Understanding the somatic consequences of depression: biological mechanisms and the role of depression symptom profile

The impact of frailty on depressive disorder in later life: Findings from the Netherlands Study of depression in older persons

BACKGROUND

Physical frailty and depressive symptoms are reciprocally related in community-based studies, but its prognostic impact on depressive disorder remains unknown.

METHODS

A cohort of 378 older persons (≥60 years) suffering from a depressive disorder (DSM-IV criteria) was reassessed at two-year follow-up. Depressive symptom severity was assessed every six months with the Inventory of Depressive Symptomatology, including a mood, motivational, and somatic subscale. Frailty was assessed according to the physical frailty phenotype at the baseline examination.

RESULTS

For each additional frailty component, the odds of non-remission was 1.24 [95% CI=1.01-1.52] (P=040). Linear mixed models showed that only improvement of the motivational (P<001) subscale and the somatic subscale (P=003) of the IDS over time were dependent on the frailty severity.

CONCLUSIONS

Physical frailty negatively impacts the course of late-life depression. Since only improvement of mood symptoms was independent of frailty severity, one may hypothesize that frailty and residual depression are easily mixed-up in psychiatric treatment.

Role of Adiposity-Driven Inflammation in Depressive Morbidity

Depression and metabolic disorders, including overweight and obesity, appear tightly interrelated. The prevalence of these conditions is concurrently growing worldwide, and both depression and overweight/obesity represent substantial risk factors for multiple medical complications. Moreover, there is now multiple evidence for a bidirectional relationship between depression and increased adiposity, with overweight/obesity being associated with an increased prevalence of depression, and in turn, depression augmenting the risk of weight gain and obesity. Although the reasons for this intricate link between depression and increased adiposity remain unclear, converging clinical and preclinical evidence points to a critical role for inflammatory processes and related alterations of brain functions. In support of this notion, increased adiposity leads to a chronic low-grade activation of inflammatory processes, which have been shown elsewhere to have a potent role in the pathophysiology of depression. It is therefore highly possible that adiposity-driven inflammation contributes to the development of depressive disorders and their growing prevalence worldwide. This review will present recent evidence in support of this hypothesis and will discuss the underlying mechanisms and potential therapeutic targets. Altogether, findings presented here should help to better understand the mechanisms linking adiposity to depression and facilitate the identification of new preventive and/or therapeutic strategies.

Into the Bowels of Depression: Unravelling Medical Symptoms Associated with Depression by Applying Machine-Learning Techniques to a Community Based Population Sample

Background

Depression is commonly comorbid with many other somatic diseases and symptoms. Identification of individuals in clusters with comorbid symptoms may reveal new pathophysiological mechanisms and treatment targets. The aim of this research was to combine machine-learning (ML) algorithms with traditional regression techniques by utilising self-reported medical symptoms to identify and describe clusters of individuals with increased rates of depression from a large cross-sectional community based population epidemiological study.

Methods

A multi-staged methodology utilising ML and traditional statistical techniques was performed using the community based population National Health and Nutrition Examination Study (2009–2010) (N = 3,922). A Self-organised Mapping (SOM) ML algorithm, combined with hierarchical clustering, was performed to create participant clusters based on 68 medical symptoms. Binary logistic regression, controlling for sociodemographic confounders, was used to then identify the key clusters of participants with higher levels of depression (PHQ-9≥10, n = 377). Finally, a Multiple Additive Regression Tree boosted ML algorithm was run to identify the important medical symptoms for each key cluster within 17 broad categories: heart, liver, thyroid, respiratory, diabetes, arthritis, fractures and osteoporosis, skeletal pain, blood pressure, blood transfusion, cholesterol, vision, hearing, psoriasis, weight, bowels and urinary.

Results

Five clusters of participants, based on medical symptoms, were identified to have significantly increased rates of depression compared to the cluster with the lowest rate: odds ratios ranged from 2.24 (95% CI 1.56, 3.24) to 6.33 (95% CI 1.67, 24.02). The ML boosted regression algorithm identified three key medical condition categories as being significantly more common in these clusters: bowel, pain and urinary symptoms. Bowel-related symptoms was found to dominate the relative importance of symptoms within the five key clusters.

Conclusion

This methodology shows promise for the identification of conditions in general populations and supports the current focus on the potential importance of bowel symptoms and the gut in mental health research.

Depressive symptoms in women's midlife in relation to their body weight before, during and after childbearing years

OBJECTIVE

This study aimed to examine how weight and weight changes related to pregnancy were associated with depressive symptoms 11-16 years after childbirth.

METHOD

We followed 16,998 first-time mothers from the Danish National Birth Cohort up till 16 years after birth and estimated associations between depressive symptoms and pre-pregnancy body mass index (BMI) (kg m-2), weight changes in different time periods, and BMI-adjusted waist circumference 7 years after birth (WCBMI, cm). Depressive symptoms were estimated by the Center for Epidemiologic Studies Depression 10-item scale. Multiple logistic regression analyses were used to estimate odds ratios (OR) and 95% confidence intervals.

RESULTS

Compared with normal-weight, we found that underweight, overweight and obesity were associated with greater odds of depressive symptoms (1.29, 1.24 and 1.73, respectively). Compared with weight change ±1 BMI unit during the total follow-up period, greater odds for depressive symptoms were observed with weight loss (OR 1.14, 0.96-1.36) or gain of 2-2.99 kg m-2 (OR 1.11, 0.92-1.33) or gain of ≥3 kg m-2 (OR 1.68, 1.46-1.94). WCBMI > 2.2 cm was associated with greater odds of depressive symptoms (OR 1.16, 0.99-1.36) than waist circumference as predicted by BMI.

CONCLUSION

Low and high pre-pregnancy BMI, weight changes and WCBMI larger than predicted were associated with more depressive symptoms in midlife.

Depression and risk of type 2 diabetes: the potential role of metabolic factors

The aim of the present study was to evaluate the interaction between depressive symptoms and metabolic dysregulations as risk factors for type 2 diabetes. The sample comprised of 2525 adults who participated in a baseline and a follow-up assessment over a 4.5-year period in the Emotional Health and Wellbeing Study (EMHS) in Quebec, Canada. A two-way stratified sampling design was used, on the basis of the presence of depressive symptoms and metabolic dysregulation (obesity, elevated blood sugar, high blood pressure, high levels of triglycerides and decreased high-density lipoprotein). A total of 87 (3.5%) individuals developed diabetes. Participants with both depressive symptoms and metabolic dysregulation had the highest risk of diabetes (adjusted odds ratio=6.61, 95% confidence interval (CI): 4.86-9.01), compared with those without depressive symptoms and metabolic dysregulation (reference group). The risk of diabetes in individuals with depressive symptoms and without metabolic dysregulation did not differ from the reference group (adjusted odds ratio=1.28, 95% CI: 0.81-2.03), whereas the adjusted odds ratio for those with metabolic dysregulation and without depressive symptoms was 4.40 (95% CI: 3.42-5.67). The Synergy Index (SI=1.52; 95% CI: 1.07-2.17) suggested that the combined effect of depressive symptoms and metabolic dysregulation was greater than the sum of individual effects. An interaction between depression and metabolic dysregulation was also suggested by a structural equation model. Our study highlights the interaction between depressive symptoms and metabolic dysregulation as a risk factor for type 2 diabetes. Early identification, monitoring and a comprehensive management approach of both conditions might be an important diabetes prevention strategy.

Alteration of Heart Rate Variability in Patients of Depression

INTRODUCTION

Altered cardiac autonomic functions in form of reduced Heart Rate Variability (HRV) have been found to be associated with increased cardiovascular morbidity and mortality in depressive patients.

AIM

To investigate the relationship between HRV measures, which is a non-invasive marker of autonomic nervous system and depression.

MATERIALS AND METHODS

The study included a convenient sample size of drug naive depressive patients (n=30) diagnosed on basis of ICD-10 and compared with age and gender matched healthy volunteers (n=30). Five minute ECG recording was done for HRV analysis and frequency domain measures like LF (Low Frequency), HF (High Frequency), LF/HF ratio as well as time domain measures like SDNN (Standard Deviation of all NN interval) and RMSSD (Root Mean Square of Successive differences of NN intervals) were obtained.

RESULTS

In the frequency domain parameters, values of LF (nu) and LF/HF Ratio were found to be significantly higher (p<0.001) whereas, that of HF (nu) was significantly lower (p<0.001) in depression group as compared to control group. However, in the time domain parameters, no significant difference was observed in SDNN and RMSSD values in between the two groups.

CONCLUSION

HRV recordings showed significant changes in frequency domain parameters in the patients suffering from depression. Thus, it could be said from our study that autonomic imbalance reflecting enhanced sympathetic activation relative to parasympathetic component is associated with depression.

Adjuvant thiamine improved standard treatment in patients with major depressive disorder: results from a randomized, double-blind, and placebo-controlled clinical trial

Given that antidepressants (ADs) work slowly, there is interest in means to accelerate their therapeutic effect and to reduce side effects. In this regard, thiamine (vitamin B₁) is attracting growing interest. Thiamine is an essential nutrient, while thiamine deficiency leads to a broad variety of disorders including irritability and symptoms of depression. Here, we tested the hypothesis that adjuvant thiamine would reduce depression, compared to placebo. A total of 51 inpatients (mean age: 35.2 years; 53 % females) with MDD (Hamilton Depression Rating Scale score (HDRS) at baseline: >24) took part in the study. A standardized treatment with SSRI was introduced and kept at therapeutic levels throughout the study. Patients were randomly assigned either to the thiamine or the placebo condition. Experts rated (HDRS) symptoms of depression at baseline, and after 3, 6, and 12 weeks (end of the study). Between baseline and the end of the study, depression had reduced in both groups. Compared to placebo, adjuvant thiamine improved symptoms of depression after 6 week of treatment, and improvements remained fairly stable until the end of the study, though mean differences at week 12 were not statistically significant anymore. No adverse side effects were reported in either group. Results suggest that among younger patients with MDD adjuvant thiamine alleviated symptoms of depression faster compared to placebo. Importantly, improvements were observed within 6 weeks of initiation of treatment. Thus, thiamine might have the potential to counteract the time lag in the antidepressant effects of ADs.

Impact of major depressive disorder, distinct subtypes, and symptom severity on lifestyle in the BiDirect Study

The aim of this study was to examine associations of major depressive disorder (MDD), its distinct subtypes, and symptom severity with the individual lifestyle factors smoking, diet quality, physical activity, and body mass index as well as with a combined lifestyle index measuring the co-occurrence of these lifestyle factors. A sample of 823 patients with MDD and 597 non-depressed controls was examined. The psychiatric assessment was based on a clinical interview including the Mini International Neuropsychiatric Interview and the Hamilton Depression Rating Scale. Each lifestyle factor was scored as either healthy or unhealthy, and the number of unhealthy lifestyle factors was added up in a combined lifestyle index. Cross-sectional analyses were performed using alternating logistic regression and ordinal logistic regression, adjusted for socio-demographic characteristics. After adjustment, MDD was significantly associated with smoking, low physical activity, and overweight. Likewise, MDD was significantly related to the overall lifestyle index. When stratifying for subtypes, all subtypes showed higher odds for an overall unhealthier lifestyle than controls, but the associations with the individual lifestyle factors were partly different. Symptom severity was associated with the lifestyle index in a dose-response manner. In conclusion, patients with MDD represent an important target group for lifestyle interventions.

Exploring heterogeneity and correlates of depressive symptoms in the Women and Their Children's Health (WaTCH) Study

INTRODUCTION

Oil spill exposures are associated with increased levels of depression, which is often measured using continuous scores or dichotomous cut points on screening tools in population-based studies. Latent profile analysis can overcome analytic limitations such as 1) masking of heterogeneity in outcomes among people within dichotomous categories and 2) loss of information about symptom patterns among those with the same continuous score. This study examined variation in depressive symptoms and assessed the associations between depressive symptomatology and oil spill exposure, socioeconomic risk factors, and social capital.

METHODS

Between 2012 and 2014, we interviewed 2852 women in southeastern Louisiana. We performed latent profile analysis then tested the adjusted associations between sociodemographic characteristics, oil spill exposure and latent class membership.

RESULTS

Results indicated a three-class solution in which classes varied by symptom severity as the best fit. The strongest associations were among women with the most severe depressive symptoms, who were less educated, were more economically vulnerable, and had the least social support compared to women with no depressive symptoms.

LIMITATIONS

This study is limited by its cross-sectional design and the self-reported nature of exposures and depressive symptoms, but results are consistent with prior literature.

CONCLUSIONS

Our results support the conventional use of screening tools to estimate depressive symptomatology. Nevertheless, the identification of subgroups within study participants highlights an important finding: the subgroups were comprised of characteristically different women with varying levels of depressive symptoms, a discovery that would have been overlooked if the CES-D was used conventionally.

Familial aggregation and heritability of the melancholic and atypical subtypes of depression

BACKGROUND

The heterogeneity of mood disorders has been a challenge to our understanding of their underlying biologic and genetic pathways. This report examines the specificity of the familial aggregation of atypical and melancholic subtypes of depression and their clinical correlates in a large community based family study of affective spectrum disorders.

METHODS

The sample includes 457 probands and their directly interviewed adult first degree relatives from the National Institute of Mental Health (NIMH) Family Study of Affective Spectrum Disorder. Depression subtypes were based on best estimate diagnoses using information from semi-structured diagnostic interviews by experienced clinical interviews and multiple family history reports.

RESULTS

Atypical depression in probands was significantly associated with the atypical subtype of depression in relatives (OR 1.75 [95%CI 1.02-3.02], p=0.04), independent of proband and relative comorbid disorders. Melancholic depression in probands was not associated with melancholic depression in relatives (OR 1.25 [95%CI 0.62-2.55], p=.53). The familial heritability of the atypical subtype was 0.46 (95%CI 0.21-0.71), whereas that of the melancholic subtype was 0.33 (95%CI 0.21-0.45). Melancholic depression was associated with greater severity in terms of treatment, global functioning, suicide attempts, comorbid disorders, and an earlier age at onset of depression.

LIMITATIONS

The subsample of interviewed relatives necessary to assess specific subtypes of depression reduced the power to detect the specificity of mood disorder subtypes.

CONCLUSION

The results indicate that the atypical subtype should be incorporated in future treatment, genetic and other etiologic studies of major depression. Findings further suggest that melancholic subtype may be an indicator of clinical severity of depression.

Circulating biosignatures of late-life depression (LLD): Towards a comprehensive, data-driven approach to understanding LLD pathophysiology

There is scarce information about the pathophysiological processes underlying Late-Life Depression (LLD). We aimed to determine the neurobiological abnormalities related to LLD through a multi-modal biomarker approach combining a large, unbiased peripheral proteomic panel and structural brain imaging. We examined data from 44 LLD and 31 control participants. Plasma proteomic analysis was performed using a multiplex immunoassay. We evaluated the differential protein expression between groups with random intercept models. We carried out enrichment pathway analyses (EPA) to uncover biological pathways and processes related to LLD. Machine learning analysis was applied to the combined dataset to determine the accuracy with which specific proteins could correctly discriminate LLD versus control participants. Sixty-one proteins were differentially expressed in LLD (p < 0.05 and FDR < 0.01). EPA showed that these proteins were related to abnormal immune-inflammatory control, cell survival and proliferation, proteostasis control, lipid metabolism, intracellular signaling. Machine learning analysis showed that a panel of three proteins (C-peptide, FABP-liver, ApoA-IV) discriminated LLD and control participants with 100% accuracy. The plasma proteomic profile in LLD revealed dysregulation in biological processes essential to the maintenance of homeostasis at cellular and systemic levels. These abnormalities increase brain and systemic allostatic load leading to the downstream negative outcomes of LLD, including increased risk of medical comorbidities and dementia. The peripheral biosignature of LLD has predictive power and may suggest novel putative therapeutic targets for prevention, treatment, and neuroprotection in LLD.

Scaffold Hopping Toward Agomelatine: Novel 3, 4-Dihydroisoquinoline Compounds as Potential Antidepressant Agents

A scaffold-hopping strategy toward Agomelatine based on in silico screening and knowledge analysis was employed to design novel antidepressant agents. A series of 3, 4-dihydroisoquinoline compounds were selected for chemical synthesis and biological assessment. Three compounds (6a-1, 6a-2, 6a-9) demonstrated protective effects on corticosterone-induced lesion of PC12 cells. Compound 6a-1 also displayed low inhibitory effects on the growth of HEK293 and L02 normal cells and it was further evaluated for its potential antidepressant effects in vivo. The forced swim test (FST) results revealed that compound 6a-1 remarkably reduced the immobility time of rats and the open field test (OFT) results indicated a better general locomotor activity of the rats treated with compound 6a-1 than those with Agomelatine or Fluoxetine. Mechanism studies implied that compound 6a-1 can significantly reduce PC12 cell apoptosis by up-regulation of GSH and down-regulation of ROS in corticosterone-induced lesion of PC12 cells. Meanwhile, the down-regulation of calcium ion concentration and up-regulation of BDNF level in PC12 cells may account for the neuroprotective effects. Furthermore, compound 6a-1 can increase cell survival and cell proliferation, promote cell maturation in the rat hippocampus after chronic treatment. The acute toxicity data in vivo indicated compound 6a-1 exhibited less hepatotoxicity than Agomelatine.

Feasibility of an interactive voice response system for monitoring depressive symptoms in a lower-middle income Latin American country

Background

Innovative, scalable solutions are needed to address the vast unmet need for mental health care in low- and middle-income countries (LMICs).

Methods

We conducted a feasibility study of a 14-week automated telephonic interactive voice response (IVR) depression self-care service among Bolivian primary care patients with at least moderately severe depressive symptoms. We analyzed IVR call completion rates, the reliability and validity of IVR-collected data, and participant satisfaction.

Results

Of the 32 participants, the majority were women (78 % or 25/32) and non-indigenous (75 % or 24/32). Participants had moderate depressive symptoms at baseline (PHQ-8 score mean 13.3, SD = 3.5) and reported good or fair general health status (88 % or 28/32). Fifty-four percent of weekly IVR calls (approximately 7 out of 13 active call-weeks) were completed. Neither PHQ-8 scores nor IVR call completion differed significantly by ethnicity, education, self-reported depression diagnosis, self-reported overall health, number of chronic conditions, or health literacy. The reliability for IVR-collected PHQ-8 scores was good (Cronbach’s alpha = 0.83). Virtually every participant (97 %) was “mostly” or “very” satisfied with the program. Many described the program as beneficial for their mood and self-care, albeit limited by some technological difficulties and the lack of human interaction.

Conclusion

Findings suggest that IVR could feasibly be used to provide monitoring and self-care education to depressed patients in Bolivia. An expanded stepped-care service offering contact with lay health workers for more depressed individuals and expanded mHealth content may foster greater patient engagement and enhance its therapeutic value while remaining cost-effective.

Trial registration ISRCTN ISRCTN 18403214. Registered 14 September 2016. Retrospectively registered

Major depressive disorder

Major depressive disorder (MDD) is a debilitating disease that is characterized by depressed mood, diminished interests, impaired cognitive function and vegetative symptoms, such as disturbed sleep or appetite. MDD occurs about twice as often in women than it does in men and affects one in six adults in their lifetime. The aetiology of MDD is multifactorial and its heritability is estimated to be approximately 35%. In addition, environmental factors, such as sexual, physical or emotional abuse during childhood, are strongly associated with the risk of developing MDD. No established mechanism can explain all aspects of the disease. However, MDD is associated with alterations in regional brain volumes, particularly the hippocampus, and with functional changes in brain circuits, such as the cognitive control network and the affective-salience network. Furthermore, disturbances in the main neurobiological stress-responsive systems, including the hypothalamic-pituitary-adrenal axis and the immune system, occur in MDD. Management primarily comprises psychotherapy and pharmacological treatment. For treatment-resistant patients who have not responded to several augmentation or combination treatment attempts, electroconvulsive therapy is the treatment with the best empirical evidence. In this Primer, we provide an overview of the current evidence of MDD, including its epidemiology, aetiology, pathophysiology, diagnosis and treatment.

Association between major depression and cardiovascular risk: the role of antidepressant medication

RATIONALE AND OBJECTIVES

Major depressive disorder (MDD) is associated with an increased risk for cardiovascular disease (CVD). Apart from biological and life style factors, the use of antidepressants and their potentially adverse effects might contribute to the increased CVD risk. Therefore, we compared cardiovascular risk profiles between relatively young depressed patients without CVD with and without antidepressant medication and healthy participants.

METHODS

We investigated 44 depressed patients (with antidepressants N = 20 (13 women), mean age 43.2 years; without antidepressants N = 24 (15 women), mean age 40.0) and 41 healthy participants (matched for sex, age, education). As markers of CVD risk, blood pressure, body mass index (BMI), and plasma levels of fasting glucose, cholesterol, low density lipoprotein (LDL), high density lipoprotein (HDL), and high sensitivity C-reactive protein (h-CRP) were measured.

RESULTS

We found significant differences between groups for BMI (p < .01), systolic (p = .02) and diastolic blood pressure (p < .01), and glucose (p < .001). Post hoc analyses indicated differences between both patient groups compared to the healthy control group, but not between patients groups. Further controlling for BMI diminished the effect of diagnosis on blood pressure; however, this was not the case for glucose level. There were no between-group differences in cholesterol, LDL, HDL, and h-CRP.

CONCLUSIONS

We found a clearly increased CVD risk in this group of rather young depressed patients. Importantly, there was no significant difference in CVD risk between patients with vs. without antidepressants. This suggests that major depression per se and not antidepressant medication is associated with increased CVD risk.

Geriatric characteristics in randomised controlled trials on antidepressant drugs for older adults: a systematic review

OBJECTIVE

Meta-analyses of antidepressant drug treatment trials have found that increasing age is associated with a less favourable outcome. Because the prevalence of geriatric characteristics, like disability, medical co-morbidity, malnutrition, cognitive (dys)function and frailty increase with age and are associated with depression, these characteristics are likely to modify the treatment outcome of antidepressant drugs in late-life depression. This review examines how these five characteristics are taken into account in randomised controlled trials (RCTs) with antidepressant drugs for major depressive disorder in patients aged 60 years or above.

DESIGN

A systematic search in PubMED, PsychInfo and EMBASE, from the year 2000 onwards, yielded 27 RCTs, with a total of 6356 subjects with a median age of 71 years. Two reviewers independently assessed whether each characteristic was considered as inclusion or exclusion criterion, descriptive variable, stratification variable, co-variable, outcome measure, or in adverse effect monitoring.

RESULTS

Malnutrition and frailty were not taken into account in any study. Disability was used as an outcome measure in five studies. Two studies explicitly included a population with possibly serious medical co-morbidity. Cognitive status was the only condition taken into account as co-variable (n = 3) or stratifying variable (n = 1) and was used as outcome measure in seven studies.

CONCLUSIONS

We conclude that geriatric characteristics are rarely taken into account in RCTs on antidepressant drugs in late-life depression, and studies including the oldest adults are underrepresented. This warrants recruitment of the oldest adults and adjustment of treatment strategies in future studies. Copyright © 2016 John Wiley & Sons, Ltd.

The Association Between Psychiatric Disorders and Telomere Length: A Meta-Analysis Involving 14,827 Persons

OBJECTIVE

This study examined the relationship between leukocyte telomere length (LTL), a marker of cell aging, and psychiatric disorders in adults compared with controls using meta-analytic methods.

METHODS

Data were abstracted from studies examining the relationship between LTL and adult psychiatric disorders. In addition to an overall estimate of effect size, subgroup analyses and meta-regression were performed to examine whether covariates (including psychiatric diagnoses) moderated the estimate.

RESULTS

A significant overall effect size showing LTL shortening was found across all psychiatric disorders (Hedge g = -0.50, p < .001). Subgroup analyses did not demonstrate significant differences in effect size based on individual covariates (psychiatric disorder, sex, age, or assay method). The meta-regression indicated that although type of disorder and, likely, age moderate the overall effect size, the heterogeneity between studies could not be explained by a model that included these variables as well as sex and assay method. Although not significantly different, posttraumatic stress disorder, anxiety disorders, and depressive disorders had comparatively larger effect sizes (-1.27, -0.53, and -0.55), and psychotic and bipolar disorders had comparatively smaller ones (-0.23 and -0.26).

CONCLUSIONS

We observed a robust effect size of LTL shortening for psychiatric disorders as a whole compared with controls. The results were less straightforward regarding relative differences in the strength of this association by specific disorder. Future studies should focus on mechanisms explaining accelerated cell aging with psychiatric illness, defining directions (if any) of causality and elucidating possible differences in this association between disorders.

Predicting depressed patients with suicidal ideation from ECG recordings

Globally suicidal behavior is the third most common cause of death among patients with major depressive disorder (MDD). This study presents multi-lag tone-entropy (T-E) analysis of heart rate variability (HRV) as a screening tool for identifying MDD patients with suicidal ideation. Sixty-one ECG recordings (10 min) were acquired and analyzed from control subjects (29 CONT), 16 MDD subjects with (MDDSI+) and 16 without suicidal ideation (MDDSI-). After ECG preprocessing, tone and entropy values were calculated for multiple lags (m: 1-10). The MDDSI+ group was found to have a higher mean tone value compared to that of the MDDSI- group for lags 1-8, whereas the mean entropy value was lower in MDDSI+ than that in CONT group at all lags (1-10). Leave-one-out cross-validation tests, using a classification and regression tree (CART), obtained 94.83 % accuracy in predicting MDDSI+ subjects by using a combination of tone and entropy values at all lags and including demographic factors (age, BMI and waist circumference) compared to results with time and frequency domain HRV analysis. The results of this pilot study demonstrate the usefulness of multi-lag T-E analysis in identifying MDD patients with suicidal ideation and highlight the change in autonomic nervous system modulation of the heart rate associated with depression and suicidal ideation.

Depressive and anxiety disorders and short leukocyte telomere length: mediating effects of metabolic stress and lifestyle factors

BACKGROUND

Depressive and anxiety disorders are associated with shorter leukocyte telomere length (LTL), an indicator of cellular aging. It is, however, unknown which pathways underlie this association. This study examined the extent to which lifestyle factors and physiological changes such as inflammatory or metabolic alterations mediate the relationship.

METHOD

We applied mediation analysis techniques to data from 2750 participants of the Netherlands Study of Depression and Anxiety. LTL was assessed using quantitative polymerase chain reaction. Independent variables were current depressive (30-item Inventory of Depressive Symptoms - Self Report) and anxiety (21-item Beck's Anxiety Inventory) symptoms and presence of a depressive or anxiety disorder diagnosis based on DSM-IV; mediator variables included physiological stress systems, metabolic syndrome components and lifestyle factors.

RESULTS

Short LTL was associated with higher symptom severity (B = -2.4, p = 0.002) and current psychiatric diagnosis (B = -63.3, p = 0.024). C-reactive protein, interleukin-6, waist circumference, triglycerides, high-density lipoprotein cholesterol and cigarette smoking were significant mediators in the relationship between psychopathology and LTL. When all significant mediators were included in one model, the effect sizes of the relationships between LTL and symptom severity and current diagnosis were reduced by 36.7 and 32.7%, respectively, and the remaining direct effects were no longer significant.

CONCLUSIONS

Pro-inflammatory cytokines, metabolic alterations and cigarette smoking are important mediators of the association between depressive and anxiety disorders and LTL. This calls for future research on intervention programs that take into account lifestyle changes in mental health care settings.

BIDIRECTIONAL PROSPECTIVE ASSOCIATIONS OF METABOLIC SYNDROME COMPONENTS WITH DEPRESSION, ANXIETY, AND ANTIDEPRESSANT USE

BACKGROUND

Metabolic syndrome components-waist circumference, high-density lipoprotein cholesterol (HDL-C), triglycerides, systolic blood pressure and fasting glucose-are cross-sectionally associated with depression and anxiety with differing strength. Few studies examine the relationships over time or whether antidepressants have independent effects.

METHODS

Participants were from the Netherlands Study of Depression and Anxiety (NESDA; N = 2,776; 18-65 years; 66% female). At baseline, 2- and 6-year follow-up, participants completed diagnostic interviews, depression and anxiety symptom inventories, antidepressant use assessment, and measurements of the five metabolic syndrome components. Data were analyzed for the consistency of associations between psychopathology indicators and metabolic syndrome components across the three assessment waves, and whether psychopathology or antidepressant use at one assessment predicts metabolic dysregulation at the next and vice versa.

RESULTS

Consistently across waves, psychopathology was associated with generally poorer values of metabolic syndrome components, particularly waist circumference and triglycerides. Stronger associations were observed for psychopathology symptom severity than diagnosis. Antidepressant use was independently associated with higher waist circumference, triglycerides and number of metabolic syndrome abnormalities, and lower HDL-C. Symptom severity and antidepressant use were associated with subsequently increased number of abnormalities, waist circumference, and glucose after 2 but not 4 years. Conversely, there was little evidence that metabolic syndrome components were associated with subsequent psychopathology outcomes.

CONCLUSIONS

Symptom severity and antidepressant use were independently associated with metabolic dysregulation consistently over time and also had negative consequences for short-term metabolic health. This is of concern given the chronicity of depression and anxiety and prevalence of antidepressant treatment.

Depression and cardiovascular disease: Epidemiological evidence on their linking mechanisms

Depression's burden of disease goes beyond functioning and quality of life and extends to somatic health. Results from longitudinal cohort studies converge in illustrating that major depressive disorder (MDD) subsequently increases the risk of cardiovascular morbidity and mortality with about 80%. The impact of MDD on cardiovascular health may be partly explained by mediating mechanisms such as unhealthy lifestyle (smoking, excessive alcohol use, physical inactivity, unhealthy diet, therapy non-compliance) and unfavorable pathophysiological disturbances (autonomic, HPA-axis, metabolic and immuno-inflammatory dysregulations). A summary of the literature findings as well as relevant results from the large-scale Netherlands Study of Depression and Anxiety (N=2981) are presented. Persons with MDD have significantly worse lifestyles as well as more pathophysiological disturbances as compared to healthy controls. Some of these differences seem to be specific for (typical versus 'atypical', or antidepressant treated versus drug-naive) subgroups of MDD patients. Alternative explanations are also present, namely undetected confounding, iatrogenic effects or 'third factors' such as genetics.

The role of obesity measures in the development and persistence of major depressive disorder

BACKGROUND

The role of obesity with the development of major depressive disorder (MDD) requires conformation and whether obesity contributes to more chronic depression in persons with established (MDD) is unknown. This study examined the longitudinal relationship of body mass index (BMI) and waist circumference with the incidence and persistence of MDD over 2-year and 6-year periods.

METHOD

Data were sourced from the Netherlands Study of Depression and Anxiety. MDD was established with Composite International Diagnostic Interviews. The relationship of BMI and waist circumference with the development of depression two and six years later were estimated in the subsample with no current psychopathology at baseline. Associations with the persistence of depression was estimated in the subsample with current MDD.

RESULTS

Higher BMI at baseline, but not waist circumference, slightly increased the odds of the development of MDD after two years (odds ratio (OR) per standard deviation increase: 1.11; p=0.03), This relationship was not significant after adjustment for health and lifestyle variables. Conversely, over a 6-year period both BMI and waist circumference moderately increased the odds of developing MDD even after adjustment (OR:1.17; p=0.05, OR:1.20; p=0.05). Persistence of MDD in currently depressed subjects, is not related with BMI or waist circumference (adjusted OR:0.93; p=0.2, OR:0.91; p=0.15).

LIMITATIONS

Development of depression may differ in participants lost to follow-up.

CONCLUSION

Over a 6 year period, patients with higher BMI show a slightly increased risk of development of depression. However, in depressed patients there is no relationship between BMI and the persistence of depression.

Serum proteomic profiles of depressive subtypes

Depression is a highly heterogeneous disorder. Accumulating evidence suggests biological and genetic differences between subtypes of depression that are homogeneous in symptom presentation. We aimed to evaluate differences in serum protein profiles between persons with atypical and melancholic depressive subtypes, and compare these profiles with serum protein levels of healthy controls. We used the baseline data from the Netherlands Study of Depression and Anxiety on 414 controls, 231 persons with a melancholic depressive subtype and 128 persons with an atypical depressive subtype for whom the proteomic data were available. Depressive subtypes were previously established using a data-driven analysis, and 171 serum proteins were measured on a multi-analyte profiling platform. Linear regression models were adjusted for several covariates and corrected for multiple testing using false discovery rate q-values. We observed differences in analytes between the atypical and melancholic subtypes (9 analytes, q<0.05) and between atypical depression and controls (23 analytes, q<0.05). Eight of the nine markers differing between the atypical and melancholic subtype overlapped with markers from the comparison between atypical subtype and controls (mesothelin, leptin, IGFBP1, IGFBP2, FABPa, insulin, C3 and B2M), and were mainly involved in cellular communication and signal transduction, and immune response. No markers differed significantly between the melancholic subtype and controls. To conclude, although some uncertainties exist in our results as a result of missing data imputation and lack of proteomic replication samples, many of the identified analytes are inflammatory or metabolic markers, which supports the notion of atypical depression as a syndrome characterized by metabolic disturbances and inflammation, and underline the importance and relevance of subtypes of depression in biological and genetic research, and potentially in the treatment of depression.

Association between comorbidities and absence of chest pain in acute coronary syndrome with in-hospital outcome

BACKGROUND

To evaluate the impact of comorbidities on the management and outcomes of acute coronary syndrome (ACS) patients without chest pain/discomfort (i.e. ACS without typical presentation).

METHODS

Of the 11,458 ACS patients, enrolled by the International Survey of Acute Coronary Syndrome in Transitional Countries (ISACS-TC; ClinicalTrials.gov: NCT01218776), 8.7% did not have typical presentation at the initial evaluation, and 40.2% had comorbidities. The odds of atypical presentation increased proportionally with the number of comorbidities (odds ratio [OR]: 1, no-comorbid; OR: 1.64, 1 comorbidity; OR: 2.52, 2 comorbidities; OR: 4.57, ≥3 comorbidities).

RESULTS

Stratifying the study population by the presence/absence of comorbidities and typical presentation, we found a decreasing trend for use of medications and percutaneous intervention (OR: 1, typical presentation and no-comorbidities; OR: 0.70, typical presentation and comorbidities; OR: 0.23, atypical presentation and no-comorbidities; OR: 0.18, atypical presentation and comorbidities). On the opposite, compared with patients with typical presentation and no-comorbidities (OR: 1, referent), there was an increasing trend (p<0.001) in the risk of death (OR: 2.00, OR: 2.52 and OR: 4.83) in the above subgroups. However, after adjusting for comorbidities, medications and invasive procedures, atypical presentation was not a predictor of in-hospital death. Independent predictors of poor outcome were history of stroke (OR: 2.04), chronic kidney disease (OR: 1.57), diabetes mellitus (OR: 1.49) and underuse of invasive procedures.

CONCLUSIONS

In the ISACS-TC, atypical ACS presentation was often associated with comorbidities. Atypical presentation and comorbidities influenced underuse of in-hospital treatments. The latter and comorbidities are related with poor in-hospital outcome, but not atypical presentation, per se.

Differential Autonomic Nervous System Reactivity in Depression and Anxiety During Stress Depending on Type of Stressor

OBJECTIVES

It remains unclear whether depressive and anxiety disorders are associated with hyporeactivity or hyperreactivity of the autonomic nervous system (ANS) and whether deviant reactivity occurs in all types of stressors. This study compared ANS reactivity in people with current or remitted depression/anxiety with reactivity in healthy controls during two stress conditions.

METHODS

From the Netherlands Study of Depression and Anxiety, data of 804 individuals with current depression/anxiety, 913 individuals with remitted depression/anxiety, and 466 healthy controls (mean age = 44.1 years; 66.4% female) were available. Two conditions were used to evoke stress: a) an n-back task, a cognitively challenging stressor, and 2) a psychiatric interview, evoking personal-emotional stress related to the occurrence of symptoms of depression/anxiety. Indicators of ANS activity were heart rate (HR), root mean square of differences between successive interbeat intervals (RMSSD), respiratory sinus arrhythmia (RSA), and preejection period.

RESULTS

As compared with controls, participants with psychopathology had significant hyporeactivity of HR (controls = 4.1 ± 4.2 beats/min; remitted = 3.5 ± 3.5 beats/min; current psychopathology = 3.1 ± 3.4 beats/min), RMSSD (controls = -6.2 ± 14.5 milliseconds; remitted = -5.4 ± 17.8 milliseconds; current psychopathology = -3.5 ± 15.4 milliseconds), and RSA (controls = -9.3 ± 17.0 milliseconds; remitted = -7.4 ± 16.5 milliseconds; current psychopathology = -6.9 ± 15.0 milliseconds) during the n-back task. In contrast, during the psychiatric interview, they showed significant hyperreactivity of HR (controls = 2.7 ± 3.4 beats/min; remitted = 3.5 ± 3.4 beats/min; current psychopathology = 4.0 ± 3.3 beats/min), RMSSD (controls = -3.4 ± 12.2 milliseconds; remitted = -4.1 ± 12.1 milliseconds; current psychopathology = -5.6 ± 11.8 milliseconds), and RSA (controls = -3.8 ± 8.1 milliseconds; remitted = -4.3 ± 7.9 milliseconds; current psychopathology = -5.0 ± 7.9 milliseconds). The lack of group differences in preejection period reactivity suggests that the found effects were driven by altered cardiac vagal reactivity in depression/anxiety.

CONCLUSIONS

The direction of altered ANS reactivity in depressed/anxious patients is dependent on the type of stressor, and only the more ecologically valid stressors may evoke hyperreactivity in these patients.

Perinatal maternal depression and cortisol function in pregnancy and the postpartum period: a systematic literature review

BACKGROUND

Perinatal depression has a significant impact on both mother and child. However, the influence of hormonal changes during pregnancy and the postpartum period remains unclear. This article provides a systematic review of studies examining the effects of maternal cortisol function on perinatal depression.

METHOD

A systematic search was conducted of six electronic databases for published research on the relationship between cortisol and perinatal depression. The databases included; MEDLINE complete, PsychINFO, SCOPUS, Psychology and Behavioural Sciences, Science Direct and EBSCO, for the years 1960 to May 2015. Risk of bias was assessed and data extraction verified by two investigators.

RESULTS

In total, 47 studies met criteria and studies showed considerable variation in terms of methodology including sample size, cortisol assays, cortisol substrates, sampling processes and outcome measures. Those studies identified as higher quality found that the cortisol awakening response is positively associated with momentary mood states but is blunted in cases of major maternal depression. Furthermore, results indicate that hypercortisolemia is linked to transient depressive states while hypocortisolemia is related to chronic postpartum depression.

DISCUSSION AND CONCLUSION

Future research should aim to improve the accuracy of cortisol measurement over time, obtain multiple cortisol samples in a day and utilise diagnostic measures of depression. Future studies should also consider both antenatal and postnatal depression and the differential impact of atypical versus melancholic depression on cortisol levels, as this can help to further clarify the relationship between perinatal depression and maternal cortisol function across pregnancy and the postpartum period.

Risk of Diabetes in Older Adults with Co-Occurring Depressive Symptoms and Cardiometabolic Abnormalities: Prospective Analysis from the English Longitudinal Study of Ageing

High depressive symptoms and cardiometabolic abnormalities are independently associated with an increased risk of diabetes. The purpose of this study was to assess the association of co-occurring depressive symptoms and cardiometabolic abnormalities on risk of diabetes in a representative sample of the English population aged 50 years and older. Data were from the English Longitudinal Study of Ageing. The sample comprised of 4454 participants without diabetes at baseline. High depressive symptoms were based on a score of 4 or more on the 8-item binary Centre for Epidemiologic Studies–Depression scale. Cardiometabolic abnormalities were defined as 3 or more cardiometabolic risk factors (hypertension, impaired glycemic control, systemic inflammation, low high-density lipoprotein cholesterol, high triglycerides, and central obesity). Cox proportional hazards regressions assessed the association between co-occurring depressive symptoms and cardiometabolic abnormalities with incidence of diabetes. Multiple imputation by chained equations was performed to account for missing data. Covariates included age, sex, education, income, smoking status, physical activity, alcohol consumption, and cardiovascular comorbidity. The follow-up period consisted of 106 months, during which 193 participants reported a diagnosis of diabetes. Diabetes incidence rates were compared across the following four groups: 1) no or low depressive symptoms and no cardiometabolic abnormalities (reference group, n = 2717); 2) high depressive symptoms only (n = 338); 3) cardiometabolic abnormalities only (n = 1180); and 4) high depressive symptoms and cardiometabolic abnormalities (n = 219). Compared to the reference group, the hazard ratio for diabetes was 1.29 (95% CI 0.63, 2.64) for those with high depressive symptoms only, 3.88 (95% CI 2.77, 5.44) for those with cardiometabolic abnormalities only, and 5.56 (95% CI 3.45, 8.94) for those with both high depressive symptoms and cardiometabolic abnormalities, after adjusting for socio-demographic, lifestyle and clinical variables. These findings suggest that those with high depressive symptoms and cardiometabolic abnormalities are at a particularly increased risk of type 2 diabetes.

Behavioral effects and CRF expression in brain structures of high- and low-anxiety rats after chronic restraint stress

The aim of our study was to investigate the influence of chronic restraint stress (5 weeks, 3h/day) on behavior and central corticotropin-releasing factor (CRF) expression in rats selected for high (HR) and low anxiety (LR). The conditioned freezing response was used as a discriminating variable. Moreover, we assessed the influence of acute restraint on CRF expression in the brain in HR and LR rats. We found that chronic restraint induced symptoms of anhedonia (decreased consumption of 1% sucrose solution) in HR rats. In addition, HR restraint rats showed an increased learned helplessness behavior (immobility time in the Porsolt test) as well as neophobia in the open field test vs. LR restraint and HR control rats. These behavioral changes were accompanied by a decreased expression of CRF in the paraventricular nucleus of the hypothalamus (pPVN) and the dentate gyrus of the hippocampus (DG) compared to the HR control and LR restraint rat groups, respectively. The acute restraint condition increased the expression of CRF in the pPVN of HR rats compared to the HR control group, and enhanced the expression of CRF in the CA1 area and DG of LR restraint animals compared to the HR restraint and LR control rats, respectively. The present results indicate that chronic restraint stress in high anxiety rats attenuated CRF expression in the pPVN and DG, which was probably due to detrimental actions on the hippocampus-hypothalamus-pituitary-adrenal gland feedback mechanism, thus modulating the stress response and inducing anhedonia and depressive-like symptoms.

Cytokine production capacity in depression and anxiety

Recent studies have suggested that immune function may be dysregulated in persons with depressive and anxiety disorders. Few studies examined the expression of cytokines in response to ex vivo stimulation of blood by lipopolysaccharide (LPS) to study the innate production capacity of cytokines in depression and anxiety. To investigate this, baseline data from the Netherlands Study of Depression and Anxiety (NESDA) were used, including persons (18-65 years; 66% women) with current (that is, past month; N=591) or remitted (N=354) DSM-IV depressive or anxiety disorders and healthy controls (N=297). Depressive and anxiety symptoms were measured by means of the Inventory of Depressive Symptomatology (IDS) and the Beck Anxiety Inventory (BAI). Using Multi-Analyte Profiling technology, plasma levels of 13 cytokines were assayed after whole blood stimulation by addition of LPS. Basal plasma levels of C-reactive protein, interleukin-6 and tumor necrosis factor-α were also available. A basal and a LPS summary index were created. Results show that LPS-stimulated inflammation was associated with increased odds of current depressive/anxiety disorders (odds ratio (OR)=1.28, P=0.009), as was the case for basal inflammation (OR=1.28, P=0.001). These associations were no longer significant after adjustment for lifestyle and health (OR=1.13, P=0.21; OR=1.07, P=0.45, respectively). After adjustment for lifestyle and health, interleukin-8 was associated with both remitted (OR=1.25, P=0.02) and current (OR=1.28, P=0.005) disorders. In addition, LPS-stimulated inflammation was associated with more severe depressive (β=0.129, P<0.001) and anxiety (β=0.165, P<0.001) symptoms, as was basal inflammation. Unlike basal inflammation, LPS-stimulated inflammation was still associated with (anxiety) symptom severity after adjustment for lifestyle and health (IDS: interleukin (IL)-8, MCP-1, MMP2; BAI: LPS index, IL-6, IL-8, IL-10, IL-18, MCP-1, MMP2, TNF-β). To conclude, lifestyle and health factors may partly explain higher levels of basal, as well as LPS-stimulated inflammation in persons with depressive and anxiety disorders. However, production capacity of several cytokines was positively associated with severity of depressive and in particular anxiety symptoms, even while taking lifestyle and health factors into account. Elevated IL-8 production capacity in both previously and currently depressed and anxious persons might indicate a genetic vulnerability for these disorders.

The Predictive Value of Depressive Symptoms for All-Cause Mortality: Findings From the PRIME Belfast Study Examining the Role of Inflammation and Cardiovascular Risk Markers

OBJECTIVES

To improve understanding about the potential underlying biological mechanisms in the link between depression and all-cause mortality and to investigate the role that inflammatory and other cardiovascular risk factors may play in the relationship between depressive symptoms and mortality.

METHODS

Depression and blood-based biological markers were assessed in the Belfast PRIME prospective cohort study (N = 2389 men, aged 50-59 years) in which participants were followed up for 18 years. Depression was measured using the 10-item Welsh Pure Depression Inventory. Inflammation markers (C-reactive protein [CRP], neopterin, interleukin [IL]-1 receptor antagonist [IL-1Ra], and IL-18) and cardiovascular-specific risk factors (N-terminal pro-b-type natriuretic peptide, midregion pro-atrial natriuretic peptide, midregion pro-adrenomedullin, C-terminal pro-endothelin-1 [CT-proET]) were obtained at baseline. We used Cox proportional hazards modeling to examine the association between depression and biological measures in relation to all-cause mortality and explore the mediating effects.

RESULTS

During follow-up, 418 participants died. Higher levels of depressive symptoms were associated with higher levels of CRP, IL-1Ra, and CT-proET. After adjustment for socioeconomic and life-style risk factors, depressive symptoms were significantly associated with all-cause mortality (hazard ratio = 1.10 per scale unit, 95% confidence interval = 1.04-1.16). This association was partly explained by CRP (7.3%) suggesting a minimal mediation effect. IL-1Ra, N-terminal pro-b-type natriuretic peptide, midregion pro-atrial natriuretic peptide, midregion pro-adrenomedullin, and CT-proET contributed marginally to the association between depression and subsequent mortality.

CONCLUSIONS

Inflammatory and cardiovascular risk markers are associated with depression and with increased mortality. However, depression and biological measures show additive effects rather than a pattern of meditation of biological factors in the association between depression and mortality.

The Microbiome and Mental Health: Looking Back, Moving Forward with Lessons from Allergic Diseases

Relationships between gastrointestinal viscera and human emotions have been documented by virtually all medical traditions known to date. The focus on this relationship has waxed and waned through the centuries, with noted surges in interest driven by cultural forces. Here we explore some of this history and the emerging trends in experimental and clinical research. In particular, we pay specific attention to how the hygiene hypothesis and emerging research on traditional dietary patterns has helped re-ignite interest in the use of microbes to support mental health. At present, the application of microbes and their structural parts as a means to positively influence mental health is an area filled with promise. However, there are many limitations within this new paradigm shift in neuropsychiatry. Impediments that could block translation of encouraging experimental studies include environmental forces that work toward dysbiosis, perhaps none more important than westernized dietary patterns. On the other hand, it is likely that specific dietary choices may amplify the value of future microbial-based therapeutics. Pre-clinical and clinical research involving microbiota and allergic disorders has predated recent work in psychiatry, an early start that provides valuable lessons. The microbiome is intimately connected to diet, nutrition, and other lifestyle variables; microbial-based psychopharmacology will need to consider this contextual application, otherwise the ceiling of clinical expectations will likely need to be lowered.

Polygenic dissection of major depression clinical heterogeneity

The molecular mechanisms underlying major depressive disorder (MDD) are largely unknown. Limited success of previous genetics studies may be attributable to heterogeneity of MDD, aggregating biologically different subtypes. We examined the polygenic features of MDD and two common clinical subtypes (typical and atypical) defined by symptom profiles in a large sample of adults with established diagnoses. Data were from 1530 patients of the Netherlands Study of Depression and Anxiety (NESDA) and 1700 controls mainly from the Netherlands Twin Register (NTR). Diagnoses of MDD and its subtypes were based on DSM-IV symptoms. Genetic overlap of MDD and subtypes with psychiatric (MDD, bipolar disorder, schizophrenia) and metabolic (body mass index (BMI), C-reactive protein, triglycerides) traits was evaluated via genomic profile risk scores (GPRS) generated from meta-analysis results of large international consortia. Single nucleotide polymorphism (SNP)-heritability of MDD and subtypes was also estimated. MDD was associated with psychiatric GPRS, while no association was found for GPRS of metabolic traits. MDD subtypes had differential polygenic signatures: typical was strongly associated with schizophrenia GPRS (odds ratio (OR)=1.54, P=7.8e-9), while atypical was additionally associated with BMI (OR=1.29, P=2.7e-4) and triglycerides (OR=1.21, P=0.006) GPRS. Similar results were found when only the highly discriminatory symptoms of appetite/weight were used to define subtypes. SNP-heritability was 32% for MDD, 38% and 43% for subtypes with, respectively, decreased (typical) and increased (atypical) appetite/weight. In conclusion, MDD subtypes are characterized by partially distinct polygenic liabilities and may represent more homogeneous phenotypes. Disentangling MDD heterogeneity may help the psychiatric field moving forward in the search for molecular roots of depression.

Excess Mortality in Patients with Severe Mental Disorders in 1996-2010 in Finland

Unselected population-based nationwide studies on the excess mortality of individuals with severe mental disorders are scarce with regard to several important causes of death. Using comprehensive register data, we set out to examine excess mortality and its trends among patients with severe mental disorders compared to the total population. Patients aged 25-74 and hospitalised with severe mental disorders in 1990-2010 in Finland were identified using the national hospital discharge register and linked individually to population register data on mortality and demographics. We studied mortality in the period 1996-2010 among patients with psychotic disorders, psychoactive substance use disorders, and mood disorders by several causes of death. In addition to all-cause mortality, we examined mortality amenable to health care interventions, ischaemic heart disease mortality, disease mortality, and alcohol-related mortality. Patients with severe mental disorders had a clearly higher mortality rate than the total population throughout the study period regardless of cause of death, with the exception of alcohol-related mortality among male patients with psychotic disorders without comorbidity with substance use disorders. The all-cause mortality rate ratio of patients with psychotic disorders compared to the total population was 3.48 (95% confidence interval 2.98-4.06) among men and 3.75 (95% CI 3.08-4.55) among women in the period 2008-10. The corresponding rate ratio of patients with psychoactive substance use disorders was 5.33 (95% CI 4.87-5.82) among men and 7.54 (95% CI 6.30-9.03) among women. Overall, the mortality of the total population and patients with severe mental disorders decreased between 1996 and 2010. However, the mortality rate ratio of patients with psychotic disorders and patients with psychoactive substance use disorders compared to the total population increased in general during the study period. Exceptions were alcohol-related mortality among patients with psychoactive substance use disorders and female patients with psychotic disorders, as well as amenable mortality among male patients with psychotic disorders. The mortality rate ratio of persons with mood disorders compared to the total population decreased. The markedly high mortality amenable to health care intervention among patients with severe mental disorders found in our study suggests indirectly that they may receive poorer quality somatic care. The results highlight the challenges in co-ordinating mental and somatic health services.

Depressive symptoms are associated with poor outcome for lumbar spine surgery

BACKGROUND AND AIMS

The symptoms of pain and depression often present concomitantly, but little is known as to how the different subtypes of depression affect surgical outcome. The aim of this study was to determine whether there is a difference in outcome after lumbar spine surgery between non-depressed patients and patients with different subtypes of depressive symptoms: non-melancholic (NmDS) and melancholic depression (MDS).

METHODS

This was a cross-sectional postal survey. A self-made questionnaire, the Beck Depression Inventory (BDI) and the Oswestery Low Back Disability Questionnaire (ODI) were sent to patients who had undergone lumbar spine surgery in the Oulu University Hospital between June, 2005 and May, 2008. BDI≥10 were further classified into NmDS or MDS.

RESULTS

A total of 537 patients (66%) completed the survey. Of these, 361 (67%) underwent disc surgery, 85 (16%) stabilizing surgery and 91 (17%) decompression. Participants were divided into three groups: BDI<10 N=324 (60%), NmDS N=153 (29%) and MDS N=60 (11%). The mean ODI (SD) in the BDI<10 group was 16 (15), in the NmDS group 36 (15), and in the MDS group 41 (18) (p<0.001). The ODI profiles were different between the groups (p<0.001). Pain was more frequent in depressive patients (88% of MDS, 81% in NmDS and 40% in BDI<10 patients experienced pain, p<0.001). The intensity of pain and pain-related disability was lowest among the patients in the BDI<10 group and highest among the MDS patients. Regular pain medication was used by 87% of patients in the MDS group, 93% of patients in the NmDS group, and 71% of patients in the BDI<10 group (p<0.001). Response to pain medication with NRS (0-10) was 5.6 among MDS, 5.8 among NmDS and 6.5 among BDI<10 patients (p<0.001).

CONCLUSION

Different types of depressive symptoms are associated with poor outcome after lumbar spine surgery. The outcome was worst in patients suffering from the MDS subtype. This was observed in pain intensity, functional disability and response to pain medication.

IMPLICATION

It would be important to evaluate depression pre- and postoperatively. Offering a tailored rehabilitation programme to MDS patients should be considered.

Effectiveness of disease-specific cognitive-behavioural therapy on depression, anxiety, quality of life and the clinical course of disease in adolescents with inflammatory bowel disease: study protocol of a multicentre randomised controlled trial (HAPPY-IBD)

Introduction

Adolescents with inflammatory bowel disease (IBD) show a higher prevalence of depression and anxiety, compared to youth with other chronic diseases. The inflammation-depression hypothesis might explain this association, and implies that treating depression can decrease intestinal inflammation and improve disease course. The present multicentre randomised controlled trial aims to test the effectiveness of an IBD-specific cognitive–behavioural therapy (CBT) protocol in reducing symptoms of subclinical depression and anxiety, while improving quality of life and disease course in adolescents with IBD.

Methods and analysis

Adolescents with IBD (10–20 years) from 7 hospitals undergo screening (online questionnaires) for symptoms of depression and anxiety. Those with elevated scores of depression (Child Depression Inventory (CDI) ≥13 or Beck Depression Inventory (BDI) II ≥14) and/or anxiety (Screen for Child Anxiety Related Disorders: boys ≥26, girls ≥30) receive a psychiatric interview. Patients meeting criteria for depressive/anxiety disorders are referred for psychotherapy outside the trial. Patients with elevated (subclinical) symptoms are randomly assigned to medical care-as-usual (CAU; n=50) or CAU plus IBD-specific CBT (n=50). Main outcomes: (1) reduction in depressive and/or anxiety symptoms after 3 months and (2) sustained remission for 12 months. Secondary outcomes: quality of life, psychosocial functioning, treatment adherence. In addition, we will assess inflammatory cytokines in peripheral blood mononuclear cells and whole blood RNA expression profiles. For analysis, multilevel linear models and generalised estimating equations will be used.

Ethics and dissemination

The Medical Ethics Committee of the Erasmus MC approved this study. If we prove that this CBT improves emotional well-being as well as disease course, implementation is recommended.

Trial registration number

NCT02265588.

Are bidirectional associations of obesity and depression already apparent in childhood and adolescence as based on high-quality studies? A systematic review

Our aim was to evaluate bidirectional associations of obesity and depression in cross-sectional and longitudinal studies with initial assessments in childhood or adolescence. The clarification of these relationships may support the development of innovative interventions, e.g. based on nutrition and mental health. A systematic literature search was conducted in MEDLINE. Main inclusion criteria were (i) assessment of subjects <18 years at baseline, (ii) use of validated psychometric instruments and (iii) elicitation of objectively measured anthropometric data at least at one time point. Twenty-four studies met our inclusion criteria. Out of 19, 14 cross-sectional studies confirmed a significant association of obesity and depression. Three out of eight longitudinal studies reported associations between obesity and subsequent depression in female children and adolescents only, and three out of nine studies obtained evidence in favour of the other direction with two studies revealing significant results only for female and one only for male children and adolescents. Evidence is mixed, and secure conclusions are hampered by the methodological variance of the included studies. Relationships are seemingly more readily detectable in female children adolescents and in the cross-sectional compared with the longitudinal analyses. Possibly, the joint development of obesity and depression in predisposed subjects accounts for the latter discrepancy.

Gene expression in major depressive disorder

The search for genetic variants underlying major depressive disorder (MDD) has not yet provided firm leads to its underlying molecular biology. A complementary approach is to study gene expression in relation to MDD. We measured gene expression in peripheral blood from 1848 subjects from The Netherlands Study of Depression and Anxiety. Subjects were divided into current MDD (N=882), remitted MDD (N=635) and control (N=331) groups. MDD status and gene expression were measured again 2 years later in 414 subjects. The strongest gene expression differences were between the current MDD and control groups (129 genes at false-discovery rate, FDR<0.1). Gene expression differences across MDD status were largely unrelated to antidepressant use, inflammatory status and blood cell counts. Genes associated with MDD were enriched for interleukin-6 (IL-6)-signaling and natural killer (NK) cell pathways. We identified 13 gene expression clusters with specific clusters enriched for genes involved in NK cell activation (downregulated in current MDD, FDR=5.8 × 10(-5)) and IL-6 pathways (upregulated in current MDD, FDR=3.2 × 10(-3)). Longitudinal analyses largely confirmed results observed in the cross-sectional data. Comparisons of gene expression results to the Psychiatric Genomics Consortium (PGC) MDD genome-wide association study results revealed overlap with DVL3. In conclusion, multiple gene expression associations with MDD were identified and suggest a measurable impact of current MDD state on gene expression. Identified genes and gene clusters are enriched with immune pathways previously associated with the etiology of MDD, in line with the immune suppression and immune activation hypothesis of MDD.

Oxidative stress, anti-oxidants and the cross-sectional and longitudinal association with depressive symptoms: results from the CARDIA study

Depression may be accompanied by increased oxidative stress and decreased circulating anti-oxidants. This study examines the association between depressive symptoms, F2-isoprostanes and carotenoids in a US community sample. The study includes 3009 participants (mean age 40.3, 54.2% female) from CARDIA (Coronary Artery Risk Development in Young Adults). Cross-sectional analyses were performed on data from the year 15 examination (2000-2001) including subjects whose depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale (CES-D) and had measurements of plasma F2-isoprostanes (gas chromatography/mass spectrometry) or serum carotenoids (high-performance liquid chromatography). Carotenoids zeaxanthin/lutein, β-cryptoxanthin, lycopene, α-carotene, β-carotene were standardized and summed. Longitudinal analyses were conducted using the data from other examinations at 5-year intervals. Cross-lagged analyses investigated whether CES-D predicted F2-isoprostanes or carotenoids at the following exam, and vice versa. Regression analyses were controlled for sociodemographics, health and lifestyle factors. F2-isoprostanes were higher in subjects with depressive symptoms (CES-D ⩾ 16) after adjustment for sociodemographics (55.7 vs 52.0 pg ml(-1); Cohen's d = 0.14, P < 0.001). There was no difference in F2-isoprostanes after further adjustment for health and lifestyle factors. Carotenoids were lower in those with CES-D scores ⩾ 16, even after adjustment for health and lifestyle factors (standardized sum 238.7 vs 244.0, Cohen's d = -0.16, P < 0.001). Longitudinal analyses confirmed that depression predicts subsequent F2-isoprostane and carotenoid levels. Neither F2-isoprostanes nor carotenoids predicted subsequent depression. In conclusion, depressive symptoms were cross-sectionally and longitudinally associated with increased F2-isoprostanes and decreased carotenoids. The association with F2-isoprostanes can largely be explained by lifestyle factors, but lower carotenoids were independently associated with depressive symptoms.

[Treatment of depression in coronary heart disease]

Depression and coronary heart disease (CHD) are leading causes of disability and show a high comorbidity. Furthermore, depression is an independent risk factor for an unfavorable course and increased mortality in patients with CHD. In contrast, successful treatment of depression can reduce the risk of cardiac events. Currently, there are several treatment options for the management of depression in CHD, including self-management strategies, psychotherapy, pharmacotherapy and collaborative care models. This article provides an overview of the epidemiology of depression in CHD, the mechanisms of association and the current state of evidence with respect to the different treatment options.

The Combined Effects of Obesity, Abdominal Obesity and Major Depression/Anxiety on Health-Related Quality of Life: the LifeLines Cohort Study

BACKGROUND

Obesity and major depressive disorder (MDD)/anxiety disorders often co-occur and aggravate each other resulting in adverse health-related outcomes. As little is known about the potential effects of interaction between obesity and MDD and/or anxiety disorders on health-related quality of life (HR-QoL), this study was aimed at examining these combined effects.

METHODS

We collected data among N = 89,332 participants from the LifeLines cohort study. We categorized body weight using body mass index (kg/m2) as normal weight (18.5-24.99), overweight (25-29.9), mild obesity (30-34.9) and moderate/severe obesity (≥ 35); we measured abdominal obesity using a waist circumference of ≥102 and ≥ 88 cm for males and females, respectively. MDD and anxiety disorders were diagnosed with the Mini-International Neuropsychiatric Interview. HR-QoL was assessed using the RAND-36 questionnaire to compute physical and mental quality of life scores. We used binary logistic and linear regression analyses.

RESULTS

The combined effect of obesity and MDD and/or anxiety disorders on physical QoL was larger than the sum of their separate effects; regression coefficients, B (95%-confidence interval, 95%-CI) were: - 1.32 (-1.75; -0.90). However, the combined effect of obesity and major depression alone on mental QoL was less than the additive effect. With increasing body weight participants report poorer physical QoL; when they also have MDD and/or anxiety disorders participants report even poorer physical QoL. In persons without MDD and/or anxiety disorders, obesity was associated with a better mental QoL.

CONCLUSIONS

Obesity and MDD and/or anxiety disorders act synergistically on physical and mental QoL. The management of MDD and/or anxiety disorders and weight loss may be important routes to improve HR-QoL.

Human dermal fibroblasts in psychiatry research

In order to decipher the disease etiology, progression and treatment of multifactorial human brain diseases we utilize a host of different experimental models. Recently, patient-derived human dermal fibroblast (HDF) cultures have re-emerged as promising in vitro functional system for examining various cellular, molecular, metabolic and (patho)physiological states and traits of psychiatric disorders. HDF studies serve as a powerful complement to postmortem and animal studies, and often appear to be informative about the altered homeostasis in neural tissue. Studies of HDFs from patients with schizophrenia (SZ), depression, bipolar disorder (BD), autism, attention deficit and hyperactivity disorder and other psychiatric disorders have significantly advanced our understanding of these devastating diseases. These reports unequivocally prove that signal transduction, redox homeostasis, circadian rhythms and gene*environment (G*E) interactions are all amenable for assessment by the HDF model. Furthermore, the reported findings suggest that this underutilized patient biomaterial, combined with modern molecular biology techniques, may have both diagnostic and prognostic value, including prediction of response to therapeutic agents.

Changes in Body Mass Index and the Trajectory of Depressive Symptoms Among Rural Men and Women

PURPOSE

This study examined the association between body mass index (BMI) changes over time and the risk of elevated depressive symptoms in a cohort of Midwestern rural adults.

METHODS

The longitudinal study used data from a telephone survey in 2005 including 1,475 men and women enrolled in the Walk the Ozarks to Wellness Project from 12 rural communities in Missouri, Arkansas, and Tennessee. Multilevel random intercept mixed models were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the association between BMI calculated from self-reported height and body weight and elevated depressive symptoms, adjusting for sociodemographic, behavioral, and medical variables.

FINDINGS

Elevated depressive symptoms were common in this rural population (17%-19%) and the mean BMI was 28 kg/m² . For each unit increase in BMI over time, representing an average increase of about 5.8 pounds from baseline weight, there was a 6% increased odds of elevated depressive symptoms (aOR: 1.06, 95% CI: 1.02-1.12).

CONCLUSIONS

Our findings hold important public health implications given the increasing rates of overweight and obesity over the past couple of decades, particularly among rural adults.

Decreased expression of heme oxygenase is associated with depressive symptoms and may contribute to depressive and hypertensive comorbidity

BACKGROUND

There is strong evidence that hypertension and depression are comorbid and oxidative stress is implicated in both pathologies. We aimed to elucidate the relationship between biochemical markers of the antioxidant-pro-oxidant equilibrium and depression in hypertension.

METHODS

Blood was collected from patients diagnosed with depression, hypertension, or comorbid depression and hypertension and healthy age- and sex-matched controls. Whole blood reduced glutathione, erythrocyte superoxide dismutase (SOD-1), glutathione peroxidase (GPx-1), glutathione reductase (GR), malondialdehyde (MDA), and plasma hydrogen peroxide (H2O2) were assayed using spectrophotometry, and heme oxygenase (HO-1) levels were determined immunoenzymatically.

RESULTS

Both hypertension and depression were associated with altered antioxidant-pro-oxidant profiles. Decreased GPx-1 and SOD-1 activities, increased GR activity, increased levels of GSH, and increased concentrations of MDA and H2O2 were observed in patients compared to controls. Inducible HO-1 was specifically decreased in patients with depression and was significantly associated with both the prevalence and severity of depressive symptoms.

CONCLUSIONS

Heme oxygenase is a biological factor that might explain the relationship between inflammation, oxidative stress, and the biological and functional changes in brain activity in depression. HO-1 is a candidate depression biomarker and provides an avenue for novel preventative and diagnostic strategies against this disease.

Exploring the Link between the Components of Metabolic Syndrome and the Risk of Depression

BACKGROUND

Metabolic syndrome (MetS) has been reported with an increased risk of depression. MetS was also associated with insulin resistance. This study aimed to evaluate whether MetS components might contribute to depression in participants with insulin resistance (IR) or not.

METHODS

This study included 3,331 participants ≥18 years in the NHANES 2009-2010. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9). MetS components were measured using blood chemistry and body measurements. IR was identified using the homeostasis model assessment method.

RESULTS

Predicted PHQ-9 scores significantly increased as the number of MetS components increased in patients with IR. The adjusted β coefficients of the predicted PHQ-9 score with 2, 4, and 5 MetS components were 1.803, 2.081, and 3.048, respectively (P for trend < 0.05). Low HDL-C levels were significantly associated with higher predicted total PHQ-9 scores in fully adjusted models in the IR group (P < 0.05).

CONCLUSION

The results indicated that the presence of a greater number of components of MetS was significantly associated with higher predicted total PHQ-9 scores in participants with IR. Among the components of MetS, the most apparent association was observed between low HDL and higher predicted total PHQ-9 scores.

Obesity and Its Potential Effects on Antidepressant Treatment Outcomes in Patients with Depressive Disorders: A Literature Review

Accumulating evidence regarding clinical, neurobiological, genetic, and environmental factors suggests a bidirectional link between obesity and depressive disorders. Although a few studies have investigated the link between obesity/excess body weight and the response to antidepressants in depressive disorders, the effect of weight on treatment response remains poorly understood. In this review, we summarized recent data regarding the relationship between the response to antidepressants and obesity/excess body weight in clinical studies of patients with depressive disorders. Although several studies indicated an association between obesity/excess body weight and poor antidepressant responses, it is difficult to draw definitive conclusions due to the variability of subject composition and methodological differences among studies. Especially, differences in sex, age and menopausal status, depressive symptom subtypes, and antidepressants administered may have caused inconsistencies in the results among studies. The relationship between obesity/excess body weight and antidepressant responses should be investigated further in high-powered studies addressing the differential effects on subject characteristics and treatment. Moreover, future research should focus on the roles of mediating factors, such as inflammatory markers and neurocognitive performance, which may alter the antidepressant treatment outcome in patients with comorbid obesity and depressive disorder.

Biological, environmental, and social influences on childhood obesity

The prevalence of childhood obesity has increased globally over the past three decades, with evidence of recent leveling off in developed countries. Reduction in the, currently high, prevalence of obesity will require a full understanding of the biological and social pathways to obesity in order to develop appropriately targeted prevention strategies in early life. Determinants of childhood obesity include individual level factors, including biological, social, and behavioral risks, acting within the influence of the child's family environment, which is, in turn, imbedded in the context of the community environment. These influences act across childhood, with suggestions of early critical periods of biological and behavioral plasticity. There is evidence of sex and gender differences in the responses of boys and girls to their environments. The evidence that determinants of childhood obesity act at many levels and at different stages of childhood is of policy relevance to those planning early health promotion and primary prevention programs as it suggests the need to address the individual, the family, the physical environment, the social environment, and social policy. The purpose of this narrative review is to summarize current, and emerging, literature in a multilevel, life course framework.

Identifying Maternal Depression in Pediatric Primary Care: Changes Over a Decade

OBJECTIVE

Maternal depression affects 10% to 40% of mothers with young children and has negative consequences for children's health and development. The American Academy of Pediatrics (AAP) recommends that pediatricians identify women with maternal depression. The authors examined trends in inquiring about (asking informal questions) or screening for (using a standardized instrument) maternal depression by pediatricians in 2004 and 2013 and identified correlates of usually inquiring/screening to identify maternal depression.

METHODS

Data were ascertained from 778 nontrainee pediatricians exclusively practicing general pediatrics who completed the 2004 (n = 457) and 2013 (n = 321) AAP Periodic Surveys. Pediatricians answered questions about physician and practice characteristics, training, attitudes, and inquiring/screening to identify maternal depression. Sample weights were used to reduce nonresponse bias. Weighted descriptive and logistic regression analyses were conducted.

RESULTS

The prevalence of usually inquiring/screening to identify maternal depression increased from 33% to 44% (p < .01). In both years, pediatricians who usually inquired about child/adolescent depression had increased odds of usually inquiring/screening to identify maternal depression. Patient race/ethnicity and training in adult Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria for depression were associated with inquiring/screening in 2004, and believing that family screening is within the scope of the pediatrician was associated with inquiring/screening in 2013.

CONCLUSION

Although inquiring/screening about maternal depression has increased since 2004, less than half of pediatricians usually screen or inquire about maternal depression, representing a missed opportunity to identify depression and manage or refer women for treatment. Further training on the importance of mental and family health to children's health may increase identification of maternal depression in pediatric primary care.