Persistence of abnormal cortisol levels in elderly persons after recovery from major depression

Biological Embedding of Early-Life Adversity and a Scoping Review of the Evidence for Intergenerational Epigenetic Transmission of Stress and Trauma in Humans

Severe or chronic stress and trauma can have a detrimental impact on health. Evidence suggests that early-life adversity can become biologically embedded and has the potential to influence health outcomes decades later. Epigenetics is one mechanism that has been implicated in these long-lasting effects. Observational studies in humans indicate that the effects of stress could even persist across generations, although whether or not epigenetic mechanisms are involved remains under debate. Here, we provide an overview of studies in animals and humans that demonstrate the effects of early-life stress on DNA methylation, one of the most widely studied epigenetic mechanisms, and summarize findings from animal models demonstrating the involvement of epigenetics in the transmission of stress across generations. We then describe the results of a scoping review to determine the extent to which the terms intergenerational or transgenerational have been used in human studies investigating the transmission of trauma and stress via epigenetic mechanisms. We end with a discussion of key areas for future research to advance understanding of the role of epigenetics in the legacy effects of stress and trauma.

Salivary cortisol in longitudinal associations between affective symptoms and midlife cognitive function: A British birth cohort study

Affective disorders are associated with accelerated cognitive ageing. However, current understanding of biological mechanisms which underlie these observed associations is limited. The aim of this study was to test: 1) Whether cortisol acts as a pathway in the association between depressive or anxiety symptoms across adulthood and midlife cognitive function; 2) Whether cortisol is associated with later depressive or anxiety symptoms, and cognitive function. Data were used from the National Child Development Study (NCDS), a sample of infants born in mainland UK during one week of 1958. A measure of the accumulation of affective symptoms was derived from data collected from age 23 to 42 using the Malaise Inventory Scale. Salivary cortisol measures were available at age 44-45. Cognitive function (memory, fluency, information processing) and affective symptoms were assessed at the age of 50. Path models were run to test whether salivary cortisol explained the longitudinal association between depressive or anxiety disorder symptoms and cognitive function. Direct effects of affective symptoms are shown across early to middle adulthood on cognitive function in midlife (memory and information processing errors). However, there were no effects of affective symptoms on cognitive function through cortisol measures. Additionally, cortisol measures were not significantly associated with subsequent affective symptoms or cognitive function at the age of 50. These results do not provide clear evidence to suggest that cortisol plays a role in the association between affective symptoms and cognitive function over this period of time. These findings contribute to our understanding of how the association between affective symptoms and cognitive function operates over time.

Towards individualised contraceptive counselling: clinical and reproductive factors associated with self-reported hormonal contraceptive-induced adverse mood symptoms

OBJECTIVE

The study aim was to establish which demographic, clinical, reproductive and psychiatric factors are associated with self-reported hormonal contraceptive (HC)-induced adverse mood symptoms.

STUDY DESIGN

We compiled baseline data from two Swedish studies: one cross-sectional study on combined oral contraceptive (COC)-induced adverse mood symptoms (n=118) and one randomised controlled trial on adverse mood symptoms on COC (n=184). Both included women eligible for COC use, aged over 18 years. All women answered a questionnaire on HC use and associated mood problems. The Mini-International Neuropsychiatric Interview (M.I.N.I.) was used to capture mood and anxiety disorders. Women who acknowledged HC-induced adverse mood symptoms, ongoing or previously (n=145), were compared with women without any such experience (n=157).

RESULTS

Compared with women without self-reported HC-induced adverse mood symptoms, women with these symptoms were younger at HC start (adjusted odds ratio (aOR) 0.83, 95% CI 0.72 to 0.95), had more often undergone induced abortion (OR 3.36, 95% CI 1.57 to 7.23), more often suffered from an ongoing minor depressive disorder (n=12 vs n=0) and had more often experienced any previous mental health problem (aOR 1.90, 95% CI 1.01 to 3.59).

CONCLUSIONS

In line with previous research, this study suggests that women with previous or ongoing mental health problems and women who are younger at HC start are more likely to experience HC-induced adverse mood symptoms. Former and current mental health should be addressed at contraceptive counselling, and ongoing mental health disorders should be adequately treated.

IMPLICATIONS

This study adds valuable knowledge for identification of women susceptible to HC-induced adverse mood symptoms. It should facilitate the assessment of whether or not a woman has an increased risk of such symptoms, and thus enable clinicians to adopt a more personalised approach to contraceptive counselling.

Comparison of inflammatory, nutrient, and neurohormonal indicators in patients with schizophrenia, bipolar disorder and major depressive disorder

Psychiatric disorders are severe, debilitating conditions with unknown etiology and are commonly misdiagnosed, when based solely on clinical interviews, because of overlapping symptoms and similar familial patterns. Until now, no valid and objective biomarkers have been used to diagnose and differentiate between psychiatric disorders. We compared clinically tested serum indicators in terms of inflammation (C-reactive protein, complement proteins C3 and C4, and serum Immunoglobulins A, M, and G), nutrients (homocysteine, folate, and vitamin B12), and neurohormones (adrenocorticotropic hormone and cortisol) in patients with schizophrenia (SCZ, n = 1659), bipolar disorder (BD, n = 1901), and major depressive disorder (MDD, n = 1521) to investigate potential biomarkers. A receiver operating characteristic (ROC) curve was used to analyze the diagnostic potential of these analytes. We found that compared with MDD, serum levels of C-reactive protein, C3, C4, and homocysteine were higher in SCZ and BD groups, and folate and vitamin B12 were lower in SCZ and BD groups. In contrast with BD, adrenocorticotropic hormone and cortisol increased in patients with MDD. Although ROC analysis suggested that they were not able to effectively distinguish between the three, these biological indicators showed different patterns in the three disorders. As such, more specific biomarkers should be explored in the future.

Factors associated with recurrent transient global amnesia: systematic review and pathophysiological insights

The examination of the risk factors that affect the recurrence of transient global amnesia (TGA) may shed light on the pathophysiological substrate of the disease. A systematic review was performed to identify the factors associated with the recurrence of TGA. MEDLINE, EMBASE, CENTRAL and PsycINFO were meticulously searched. Observational controlled studies involving patients with single (s-TGA) and recurrent TGA (r-TGA) according to Hodges and Warlow's criteria were retrieved. Differences in the demographic characteristics, personal and family medical history, previous exposure to precipitating events and laboratory findings were examined. Retrieved evidence was assessed in the context of the individual article validity, based on the numerical power and methodological quality of each study. Nine cohort studies with retrospective, prospective or mixed design were retrieved. In total, 1989 patients with TGA were included, 269 of whom suffered from r-TGA (13.5%). R-TGA presented an earlier age of onset. Evidence was suggestive of a relationship between recurrence and a family or personal history of migraine, as well as a personal history of depression. There was weaker evidence that associated recurrence with a positive family history of dementia, a personal history of head injury and hippocampal lesions in diffusion-weighted MRI. On the other hand, no connection was found between recurrence and electroencephalographic abnormalities, impaired jugular venous drainage, cardiovascular risk factors, atrial fibrillation, previous cerebrovascular events, exposure to precipitating events, a positive family history of TGA and hypothyroidism. Important pathophysiological insights that arised from these findings were discussed.

Corticosterone Induced the Increase of proBDNF in Primary Hippocampal Neurons Via Endoplasmic Reticulum Stress

Major depression disorder is one of the most common psychiatric disorders that greatly threaten the mental health of a large population worldwide. Previous studies have shown that endoplasmic reticulum (ER) stress plays an important role in the pathophysiology of depression, and current research suggests that brain-derived neurotrophic factor precursor (proBDNF) is involved in the development of depression. However, the relationship between ER and proBDNF in the pathophysiology of depression is not well elucidated. Here, we treated primary hippocampal neurons of mice with corticosterone (CORT) and evaluated the relationship between proBDNF and ERS. Our results showed that CORT induced ERS and upregulated the expression of proBDNF and its receptor, Follistatin-like protein 4 (FSTL4), which contributed to significantly decreased neuronal viability and expression of synaptic-related proteins including NR2A, PSD95, and SYN. Anti-proBDNF neutralization and ISRIB (an inhibitor of the ERS) treatment, respective ly, protected neuronal viabilities and increased the expression of synaptic-related proteins in corticosterone-exposed neurons. ISRIB treatment reduced the expression of proBDNF and FSTL4, whereas anti-proBDNF treatment did not affect ERS markers (Grp78, p-PERK, ATF4) expression. Our study presented evidence that CORT-induced ERS negatively regulated the neuronal viability and the level of synaptic-related protein of primary neurons via the proBDNF/FSTL4 pathway.

The extent to which childhood adversity and recent stress influence all-cause mortality risk in older adults

BACKGROUND

Psychological stress is recognized as a major risk factor for a range of non-communicable diseases and possibly mortality. The extent to which the type and timing of stress exposure influences mortality, and potential differences between genders, remains unknown.

OBJECTIVE

To examine the association between early-life and recent stressful experiences and mortality risk in later life, and to determine possible gender differences in these associations.

METHOD

Data were obtained from 2152 French community-dwelling participants (aged ≥65). Questionnaires were used to evaluate recent stress, as well as retrospective reporting of childhood adversity. Mortality status was determined through death registries. Adjusted Cox proportional hazards models were used to determine the association between stress and 16-year mortality risk.

RESULTS

Over a mean 12.9 years, 850 people died. Having a childhood home environment with very serious conflicts was associated with a 54% increased mortality risk (95%CI:1.21-1.96), and childhood abuse/maltreatment with a 34% increased risk (95% CI:1.05-1.70). For females, specific childhood events (serious illness HR:1.91, 95%CI:1.40-2.60; war/natural disaster HR:1.47, 95%CI:1.14-1.88) and the number of events (≥5 adverse events HR:1.91, 95%CI:1.25-2.32), also increased mortality risk. In terms of recent events, mortality risk increased by 66% (95%CI:1.39-2.00) in participants reporting a recent serious illness or physical trauma and by 86% for those reporting problems with the police/justice (95%CI:1.05-3.30). Among males specifically, mortality risk also increased with major financial problems (HR:1.92, 95%CI:1.14-3.21), and when they had a relative with a serious illness (HR:1.26, 95%CI:1.01-1.55).

CONCLUSIONS

Stressful life experiences are associated with all-cause mortality however the associations varied between early-life adversities and recent stress, and were different across the genders. Among females, certain types of childhood adversity continue to predict mortality risk in later life, while in males specific recent stress significantly increased mortality risk.

Neuroendocrine abnormalities associated with untreated first episode patients with major depressive disorder and bipolar disorder

There are few studies that explore simultaneously the relationship of neuroendocrine hormones of the HPA, HPT and HPG axes with major depressive disorder (MDD) and bipolar disorder (BD). The aim of this study is to examine the relationship of neuroendocrine pathways with affective disorders by comparing the differences in measures of neuroendocrine function between untreated first episode patients with MDD and BD. A cohort of 679 MDD and 83 BD patients was recruited. Thyroid stimulating hormone (TSH), triiodothyronine (T3), free triiodothyronine (FT3), thyroxine (T4), free thyroxin (FT4), cortisol (COR), adrenocorticotropic hormone (ACTH), estradiol (E2) and testosterone (T) were determined by chemiluminesent immunoassay for all patients. COR and ACTH were both significantly higher in the MDD group than those in BD group. The incidences of high secretion of ACTH and COR, and low thyroid hormone secretion were significantly greater in MDD patients than in BD patients. Decreased T secretion was more common in BD than MDD patients. ACTH was significantly positively correlated with HAMD total score and negatively correlated with FT3 in MDD patients. FT3 and FT4 levels were significantly negatively correlated with the somatoform factor score of HAMD in MDD patients. Untreated first episode patients with MDD have a hyperactivity of the HPA axis, lower HPT compared with BD patients. BD patients had reduced testosterone secretion. These findings indicate that ACTH, FT3 and FT4 could be used as markers for severity and symptoms of untreated first episode patients with MDD.

Glucocorticoid Negative Feedback in Regulation of the Hypothalamic-Pituitary-Adrenal Axis in Rhesus Monkeys With Various Types of Adaptive Behavior: Individual and Age-Related Differences

The study of the mechanisms underlying the increased vulnerability of the individual to stressful environmental factors in different age periods is of great relevance for prevention and effective treatment of stress-dependent diseases that are widespread in the population of aging individuals. The purpose of our study was to investigate the individual and age-related features of the glucocorticoid negative feedback in regulation of the hypothalamic-pituitary-adrenal (HPA) axis, the key adaptive neuroendocrine system, in experiments with physically healthy young and old female rhesus monkeys with administration of mineracorticoid receptor (fludrocortisone) and glucocorticoid receptor (dexamethasone) agonists. We studied the monkeys with increased trait anxiety and depression-like behavior (DAB) characterized, as previously was shown, by the increased vulnerability to acute stress and the animals with normal standard behavior (SB) as the control. The pronounced individual differences in the reaction of HPA axis to fludrocortisone and dexamethasone in young animals were found. Young animals with DAB showed a lower sensitivity of HPA axis to the inhibitory effect of both fludrocortisone and dexamethasone compared with young animals with SB. At the same time, there were no significant intergroup differences in the concentration of ACTH and cortisol in response to placebo injection, i.e., in basal conditions. The old individuals with DAB demonstrated the essential relative resistance of HPA axis to fludrocortisone test and higher basal plasma levels of cortisol and ACTH in the evening (the period of HPA axis low circadian activity) compared to old SB animals. In the same time, the intergroup differences in the response of HPA axis to dexamethasone administration were leveled due to age-related increase in sensitivity of HPA axis to dexamethasone in animals with DAB. These data testify the pronounced intergroup and age differences in the feedback regulation of HPA axis, presumably resulting from unequal individual, and age-related changes in the activity of mineralcorticoid and glucocorticoid receptors in the brain structures supporting the functions of HPA axis. The maximum age disorders in functioning of the negative feedback mechanism in the regulation of HPA axis are characteristic of animals with DAB, which, apparently, underlie the increased vulnerability of these animals to stress exposure.

Association between DNA methylation of the KITLG gene and cortisol levels under stress: a replication study

A recent study reported for the first time, that DNA methylation of the KITLG gene mediates the association between childhood trauma and cortisol stress reactivity. Our study aimed to provide the first independent replication of these findings. ESPRIT is a prospective study of community-dwelling participants (age ≥ 65), randomly selected from the electoral rolls of the Montpellier district, in France. Clinical depression was assessed using the Mini-International Neuropsychiatric Interview (MINI, French version 5.00), and the Centre for Epidemiological Studies Depression Scale (CES-D). Experiences of childhood adversity were ascertained via a 25-item questionnaire. Morning, evening, and diurnal salivary cortisol was measured under basal and stress conditions and determined using direct radioimmunoassay analysis. DNA methylation of the KITLG gene was quantified in whole blood using the SEQUENOM MassARRAY EpiTYPER platform. A significant negative association was observed between KITLG DNA methylation and both morning cortisol (β = -1.846 ± 0.666, p = .007) and diurnal cortisol (area under curve [AUC]) (β = -19.429 ± 8.868, p = .031) under a stress condition. However, only the former association was significant after correcting for multiple testing. Further, this association remained after adjusting for age, sex, and depression status. No significant association was observed between childhood trauma and KITLG DNA methylation in this older population. This study provides support for an association between KITLG methylation and stress cortisol levels, suggesting that DNA methylation of this gene may play a role in the longer term regulation of the stress system. Lay summary   The significant negative association between KITLG DNA methylation and morning cortisol, measured under a stressful condition, suggests that individuals with higher KITLG methylation will secrete lower levels of cortisol whilst under stress.

Age-related differences in stress responsiveness of the hypothalamic-pituitary-adrenal axis of nonhuman primates with various types of adaptive behavior

Aging is characterized by disturbances in the functioning of the hypothalamic-pituitary-adrenal (HPA) axis, associated with disturbances in the adaptation processes and increase of the probability of the onset of post-stress syndrome. However, the individual features of age-related disorders stress reactivity of HPA axis have not been studied. The purpose was to study individual characteristics of the HPA axis responsiveness to acute psycho-emotional stress exposure (restraint, ASE) at different age periods on the model of the young adult and old physically healthy female rhesus monkeys that differ in their behavioral responses to stress, i.e., with depression-like and anxiety-like behavior (DAB) on the one hand and healthy standard (control) adaptive behavior (SB) on the other hand. No significant intergroup differences were observed in HPA axis responses to ASE in young animals. During aging the monkeys with SB showed reduced ACTH response to the ASE, whereas the monkeys with DAB demonstrated its increase. The old animals with DAB in response to ASE demonstrated the most pronounced HPA axis disorders, such as the highest levels of corticotrophin (ACTH), the lowest levels of dehydroepiandrosterone sulfate (DHEAS), reduced cortisol (F) levels and the highest values of the F/DHEAS molar ratio. The ratio F/DHEAS positively correlates with the malondialdehyde concentration in erythrocytes that is considered as the biomarker of oxidative stress. Thus, these data allow us to consider the old monkeys with DAB as individuals with higher vulnerability to the adverse effects of ASE. In addition, depression-like and anxiety-like behavior of aged primates under mild/moderate stress along with reduced DHEAS plasma concentration and increased values of F/DHEAS ratio can be used to identify individuals with increased vulnerability to ASE and accelerated aging.

DNA methylation and genetic variation of the angiotensin converting enzyme (ACE) in depression

BACKGROUND

Depression is one of the most prevalent psychiatric disorders, and in older persons is associated with high levels of comorbidity and under-treatment. Dysfunction of the hypothalamic-pituitary-adrenal (HPA) stress axis is consistently observed in the older population as well as depressed patients, with the angiotensin converting enzyme (ACE) a key regulator of the stress response. Epigenetic regulation of ACE may play an important role in HPA axis (dys)regulation.

OBJECTIVE

To investigate ACE promoter methylation as a biomarker of late-life depression, and its association with genetic variation and cortisol secretion.

METHOD

The longitudinal general population ESPRIT study is aimed at investigating psychiatric disorders in older persons (n=1863, average age=73). Depression was assessed using the Mini International Neuropsychiatric Interview according to DSM-IV criteria and the Centre for Epidemiologic Studies Depression Scale (CES-D). Genotype information for seven polymorphisms across the ACE gene was also available. Blood and saliva samples collected at baseline and used to extract DNA and measure cortisol, respectively. Sequenom MassARRAY was used to measure promoter DNA methylation of the ACE gene (n=552).

RESULTS

There was no evidence of an association between ACE promoter methylation and depression. However, there was evidence that ACE genetic variants influenced methylation, and modified the association between depression and methylation (Δ at various sites; -2.05% to 1.74%; p=0.019 to 0.039). Multivariate analyses were adjusted for participants' lifestyle, health and medical history. Independent of depression status, ACE methylation was inversely correlated with cortisol levels (r=-0.336, p=0.042).

CONCLUSION

This study provides evidence that associations between ACE methylation and depression are genotype-dependent, suggesting that the development of reliable depression biomarkers may need to consider methylation levels in combination with underlying genetic variation. ACE methylation may also be a suitable biomarker of cortisol and/or HPA axis activity.

The effect of an adverse psychological environment on salivary cortisol levels in the elderly differs by 5-HTTLPR genotype

BACKGROUND

An adverse psychological environment (e.g. stressful events or depression) has been shown to influence basal cortisol levels and cortisol response to stress. This differs depending on the adverse stimuli, but also varies across individuals and may be influenced by genetic predisposition. An insertion/deletion polymorphism in the serotonin transporter gene (5-HTTLPR) is a strong candidate in this regard.

OBJECTIVE

To investigate how stressful life events and depression are associated with diurnal cortisol levels in community-dwelling elderly and determine whether this varies according to genetic variability in the 5-HTTLPR.

METHODS

This population-based study included 334 subjects aged 65 and older (mean (SD) = 76.5 (6.3)). Diurnal cortisol was measured on two separate days, under quiet (basal) and stressful conditions. The number of recent major stressful events experienced during the past year was assessed from a 12-item validated questionnaire as an index of cumulative recent stressful events. Lifetime trauma was evaluated using the validated Watson's PTSD inventory, which evaluates the most severe traumatic or frightening experience according to DSM criteria. Depression was defined as having a Mini-International Neuropsychiatric Interview (MINI) diagnosis of current major depressive disorder or high levels of depressive symptoms (Center for Epidemiologic Studies-Depression Scale ≥16). 5-HTTLPR genotyping was performed on blood samples.

RESULTS

Exposure to stressful life events was associated with lower basal evening cortisol levels overall, and in the participants with the 5-HTTLPR L allele but not the SS genotype. The greatest effects (over 50% decrease, p < 0.001) were observed for the LL participants having experienced multiple recent stressful events or severe lifetime traumas. Participants with the L allele also had higher evening cortisol stress response. Conversely, depression tended to be associated with a 42% higher basal morning cortisol in the SS participants specifically, but did not modify the association between stressful events and cortisol levels.

CONCLUSION

An adverse psychological environment is associated with basal cortisol levels and cortisol stress response, but this differs according to 5-HTTLPR genotype.

Neuro-psychopharmacological perspective of Orphan receptors of Rhodopsin (class A) family of G protein-coupled receptors

BACKGROUND

In the central nervous system (CNS), G protein-coupled receptors (GPCRs) are the most fruitful targets for neuropsychopharmacological drug development. Rhodopsin (class A) is the most studied class of GPCR and includes orphan receptors for which the endogenous ligand is not known or is unclear. Characterization of orphan GPCRs has proven to be challenging, and the production pace of GPCR-based drugs has been incredibly slow.

OBJECTIVE

Determination of the functions of these receptors may provide unexpected insight into physiological and neuropathological processes. Advances in various methods and techniques to investigate orphan receptors including in situ hybridization and knockdown/knockout (KD/KO) showed extensive expression of these receptors in the mammalian brain and unmasked their physiological and neuropathological roles. Due to these rapid progress and development, orphan GPCRs are rising as a new and promising class of drug targets for neurodegenerative diseases and psychiatric disorders.

CONCLUSION

This review presents a neuropsychopharmacological perspective of 26 orphan receptors of rhodopsin (class A) family, namely GPR3, GPR6, GPR12, GPR17, GPR26, GPR35, GPR39, GPR48, GPR49, GPR50, GPR52, GPR55, GPR61, GPR62, GPR63, GPR68, GPR75, GPR78, GPR83, GPR84, GPR85, GPR88, GPR153, GPR162, GPR171, and TAAR6. We discussed the expression of these receptors in mammalian brain and their physiological roles. Furthermore, we have briefly highlighted their roles in neurodegenerative diseases and psychiatric disorders including Alzheimer's disease, Parkinson's disease, neuroinflammation, inflammatory pain, bipolar and schizophrenic disorders, epilepsy, anxiety, and depression.

Chronic and remitting trajectories of depressive symptoms in the elderly. Characterisation and risk factors

BACKGROUND

In elderly general population sub-syndromal clinically significant levels of depressive symptoms are highly prevalent and associated with high co-morbidity and increased mortality risk. However changes in depressive symptoms over time and etiologic factors have been difficult to characterise notably due to methodological shortcomings. Our objective was to differentiate trajectories of depressive symptoms over 10 years in community-dwelling elderly men and women using statistical modelling methods which take into account intra-subject correlation and individual differences as well as to examine current and life-time risk factors associated with different trajectories.

METHODS

Participants aged 65 and over were administered standardised questionnaires and underwent clinical examinations at baseline and after 2, 4, 7 and 10 years. Trajectories over time of the Center for Epidemiologic Studies Depression scores were modelled in 517 men and 736 women separately with latent class mixed models which include both a linear mixed model to describe latent classes of trajectories and a multinomial logistic model to characterise the latent trajectories according to baseline covariates (socio-demographic, lifestyle, clinical, genetic characteristics and stressful life events).

RESULTS

In both genders two different profiles of symptom changes were observed over the 10-year follow-up. For 9.1% of men and 25% of women a high depressive symptom trajectory was found with a trend toward worsening in men. The majority of the remaining men and women showed decreasing symptomatology over time, falling from clinically significant to very low levels of depressive symptoms. In large multivariate class membership models, mobility limitations [odds ratio (OR) = 4.5, 95% confidence interval (CI) 1.6-12.9 and OR = 4.9, 95% CI 2.3-10.7, in men and women respectively], ischemic pathologies (OR = 2.9, 95% CI 1.0-8.3 and OR = 3.1, 95% CI 1.0-9.9), and recent stressful events (OR = 4.5, 95% CI 1.1-18.5, OR = 3.2, 95% CI 1.6-6.2) were associated with a poor symptom course in both gender as well as diabetes in men (OR = 3.5, 95% CI 1.1-10.9) and childhood traumatic experiences in women (OR = 3.1, 95% CI 1.6-5.8).

CONCLUSIONS

This prospective study was able to differentiate patterns of chronic and remitting depressive symptoms in elderly people with distinct symptom courses and risk factors for men and women. These findings may inform prevention programmes designed to reduce the chronic course of depressive symptomatology.

Heterogeneity in HPA axis dysregulation and serotonergic vulnerability to depression

Variability in the serotonin transporter (5-HTTLPR) gene can influence the risk of depression associated with adversity, as well as cortisol stress reactivity, although not consistently. No study has examined the impact of both a stressful environment and corticotropic-axis dysfunction on depression, as a function of 5-HTTLPR. This population-based study included 334 subjects aged 65 and older. Depression was measured at both diagnostic (major depression according to DSM-IV) and symptomatic (subthreshold depression) levels of caseness, in addition to 5-HTTLPR and rs25531 genotyping and diurnal cortisol measures. For participants with the SS genotype, higher morning cortisol levels were associated with a 4-fold increased risk of depression. Among LL participants, both evening cortisol levels and recent stressful events increased depression risk, although only the latter remained significant after multivariable adjustment. Conversely, SL individuals appeared somewhat resilient to depression in terms of cortisol and recent stress. These findings indicate that 5-HTTLPR genetic variability appears to influence the association between stress-related factors and late-life depression, although the gene-environment interactions failed to reach statistical significance levels. Participants homozygous for the short allele appeared to have a cortisol-related neuroendocrine vulnerability to depression, while long allele homozygotes were more reactive to stressful events in terms of depression risk.

Effects of basal and acute cortisol on cognitive flexibility in an emotional task switching paradigm in men

The stress hormone cortisol is assumed to influence cognitive functions. While cortisol-induced alterations of declarative memory in particular are well-investigated, considerably less is known about its influence on executive functions. Moreover, most research has been focused on slow effects, and rapid non-genomic effects have not been studied. The present study sought to investigate the impact of acute cortisol administration as well as basal cortisol levels on cognitive flexibility, a core executive function, within the non-genomic time frame. Thirty-eight healthy male participants were randomly assigned to intravenously receive either cortisol or a placebo before performing a task switching paradigm with happy and angry faces as stimuli. Cortisol levels were measured at six points during the experiment. Additionally, before the experiment, basal cortisol measures for the cortisol awakening response were collected on three consecutive weekdays immediately following awakening and 30, 45, and 60min after. First and foremost, results showed a pronounced impact of acute and basal cortisol on reaction time switch costs, particularly for angry faces. In the placebo group, low basal cortisol was associated with minimal switch costs, whereas high basal cortisol was related to maximal switch costs. In contrast, after cortisol injection, basal cortisol levels showed no impact. These results show that cognitive flexibility-enhancing effects of acute cortisol administration are only seen in men with high basal cortisol levels. This result supports the context dependency of cortisol administration and shows the relevance of taking basal cortisol levels into account.

Prediction of anxiety and depression in general surgery inpatients: A prospective cohort study of 200 consecutive patients

INTRODUCTION

Surgery is a major stress factor for patients, and is associated with significant anxiety or depression. The Hospital Anxiety and Depression Scale is one of the most common instruments used for assessment of patients' psychological stress. Here, we aimed to identify predictors of anxiety and depression in surgical inpatients.

METHODS

The study group consisted of consecutive two-hundred patients who completed the Hospital Anxiety and Depression Scale questionnaire. A patient scoring more than cut-off values (10 for anxiety and seven for depression) was considered as being at risk of anxiety or depression. Demographical data, socioeconomic status, education level and diagnoses were recorded. The Chi-square, Fisher's exact, Mann-Whitney, Kruskal-Wallis tests and binary logistic regression analysis were used to identify the predictive parameters for anxiety and depression.

RESULTS

It was found that female patients, patients older than 35 years, patients with low socioeconomic status and low education level had a relatively higher risk of anxiety. In addition, patients with low education and a hospital stay greater than seven days were at risk of depression. Logistic regression analysis revealed that socioeconomic status and education level were strongly predictive for anxiety. However, presence of anxiety was shown to be strongly predictive for depression.

CONCLUSION

Healthcare providers should be aware of their patients' psychology and, therefore, it is recommended to consider predictive factors for anxiety and depression.

Involvement of GPR50 polymorphisms in depression: independent replication in a prospective elderly cohort

INTRODUCTION

Despite the explosion in genetic association studies over the last decade, clearly identified genetic risk factors for depression remain scarce and replication studies are becoming increasingly important. G-protein-coupled receptor 50 (GPR50) has been implicated in psychiatric disorders in a small number of studies, although not consistently.

METHODS

Data were obtained from 1010 elderly men and women from the prospective population-based ESPRIT study. Logistic regression and survival models were used to determine whether three common GPR50 polymorphisms were associated with depression prevalence or the incidence of depression over 12-years. The analyses were adjusted for a range of covariates such as comorbidity and cholesterol levels, to determine independent associations.

RESULTS

All three variants showed some evidence of an association with late-life depression in women, although these were not consistent across outcomes, the overall effect sizes were relatively small, and most would not remain significant after correction for multiple testing. Women heterozygous for rs13440581, had a 1.6-fold increased risk of baseline depression, while the odds of depression comorbid with anxiety were increased fourfold for women homozygous for the minor allele of rs2072621. When depressed women at baseline were excluded from the analysis, however, neither variant was associated with the 12-year incidence of depression. In contrast, rs561077 was associated with a 1.8-fold increased risk of incident depression specifically. No significant associations were observed in men.

DISCUSSION

Our results thus provide only weak support for the involvement of GPR50 variants in late-life depression, which appear specific to certain subgroups of depressed individuals (i.e., women and those with more severe forms of depression).

C-reactive protein gene variants: independent association with late-life depression and circulating protein levels

C-reactive protein (CRP) is a heritable biomarker of systemic inflammation that is commonly elevated in depressed patients. Variants in the CRP gene that influence protein levels could thus be associated with depression but this has seldom been examined, especially in the elderly. Depression was assessed in 990 people aged at least 65 years as part of the ESPRIT study. A clinical level of depression (DEP) was defined as having a score of ⩾16 on The Center for Epidemiologic Studies Depression scale or a diagnosis of current major depression based on the Mini-International Neuropsychiatric Interview and according to Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Five single-nucleotide polymorphisms spanning the CRP gene were genotyped, and circulating levels of high-sensitivity CRP were determined. Multivariable analyses adjusted for socio-demographic characteristics, smoking, ischemic pathologies, cognitive impairment and inflammation-related chronic pathologies. The minor alleles of rs1130864 and rs1417938 were associated with a decreased risk of depression in women at Bonferroni-corrected significance levels (P=0.002). CRP gene variants were associated with serum levels in a gender-specific manner, but only rs1205 was found to be nominally associated with both an increased risk of DEP and lower circulating CRP levels in women. Variants of the CRP gene thus influence circulating CRP levels and appear as independent susceptibility factors for late-life depression.

Depressive symptoms are associated with allostatic load among community-dwelling older adults

The allostatic load model has been used to quantify the physiological costs of the body's response to repeated stressful demands and may provide a useful, integrative perspective on the various correlates of late-life depressive symptoms. We interviewed 125 Rochester, NY adults, ranging in age from 67 to 94 years. We employed an allostatic load score as a measure of multisystem dysfunction in hypothalamic–pituitary–adrenal axis function, immune function, anabolic activity, and cardiovascular activity. Overall, affective, and somatic depressive symptom scores were computed using the 20-item Center for Epidemiologic Studies Depression Scale. Multiple linear regression models were used to estimate associations between allostatic load scores and affective, somatic, and overall depressive symptoms. Among our sample of mean age 76.1 years, the one-week prevalence of clinically significant depressive symptoms was 12.8%. In models adjusting for demographic, socioeconomic, and health-related factors, higher allostatic load scores were associated with elevated scores for overall, affective, and somatic depressive symptoms: beta = 1.21 (95% CI = 0.38, 2.05); beta = 0.14 (95% CI = 0.040, 0.24); beta = 0.60 (95% CI = 0.23, 0.97), respectively. Our results suggest that allostatic load measure is associated with late-life depressive symptoms. This association appears to be of clinical significance, as the magnitude of the effect size was comparable (but opposite in direction) to that of antidepressant use. Future research should examine the inter-relationships of allostatic load, psychological stress, and late-life depressive symptoms.

Psychosocial predictors of salivary cortisol among older adults with depression

ABSTRACT Background: Previous studies have identified a number of psychosocial risk factors of dysregulated cortisol (frequently referred to as the "stress hormone") among older adults with depression. However, these studies have typically only examined a handful of risk factors at a time and have sometimes yielded inconsistent results. Method: This study aims to address this gap in the literature by simultaneously examining a range of relevant psychosocial predictors of diurnal cortisol among 54 older adults with a depressive disorder. Salivary cortisol was assessed upon awakening, at 5 PM, and at 9 PM across two consecutive days. Participants also completed measures of global psychosocial stress, current psychiatric symptomatology, pervasive distress (e.g. history of past depression), and protective factors (e.g. social support, resiliency, extent to which one has "made sense" of a significant stressor). Results: High levels of current depressive symptoms, psychiatric comorbidities, past depressive episodes, trait anxiety, and poorer ability to make sense of one's stress were found to be associated with flatter (more abnormal) cortisol slopes. However, when all of these variables were entered simultaneously in a multiple regression analysis, only history of past depression and the degree of sense made of stress emerged as unique predictors of cortisol in the model. Conclusions: These findings have important implications for identifying depressed elderly individuals with dysregulated cortisol patterns who may be most at risk for health complications. Treatments that aim to limit the chronicity of depression and help to increase the sense made of stress could potentially have a positive impact on health.

HPA axis and aging in depression: systematic review and meta-analysis

One of the most consistent findings in the biology of depression is an altered activity of the hypothalamic-pituitary-adrenal (HPA) axis. However, data concerning this issue have never been examined with a focus on the older population. Here we present a systematic review and meta-analysis, based on studies investigating levels of cortisol, adrenocorticotropic hormone (ACTH) and corticotropin-releasing hormone (CRH) in depressed participants older than 60 and compared with healthy controls. We found 20 studies, for a total of 43 comparisons on different indices of HPA axis functioning. Depression had a significant effect (Hedges' g) on basal cortisol levels measured in the morning (0.89), afternoon (0.83) and night (1.39), but a smaller effect on cortisol measured continuously (0.51). The effect of depression was even higher on post-dexamethasone cortisol levels (3.22), whereas it was non-significant on morning ACTH and CRH levels. Subgroup analyses indicated that various methodological and clinical factors can influence the study results. Overall, older participants suffering from depression show a high degree of dysregulation of HPA axis activity, with differences compared with younger adults. This might depend on several mechanisms, including physical illnesses, alterations in the CNS and immune-endocrinological alterations. Further studies are needed to clarify the implications of altered HPA axis activity in older patients suffering from depression. Novel pharmacological approaches might be effective in targeting this pathophysiological feature, thus improving the clinical outcomes.

Effects of Buddhism walking meditation on depression, functional fitness, and endothelium-dependent vasodilation in depressed elderly

OBJECTIVES

The objectives of this study were to determine the effects of the novel Buddhism-based walking meditation (BWM) and the traditional walking exercise (TWE) on depression, functional fitness, and vascular reactivity.

DESIGN

This was a randomized exercise intervention study.

SETTINGS/LOCATION

The study was conducted in a university hospital setting.

SUBJECTS

Forty-five elderly participants aged 60-90 years with mild-to-moderate depressive symptoms were randomly allocated to the sedentary control, TWE, and BWM groups.

INTERVENTIONS

The BWM program was based on aerobic walking exercise incorporating the Buddhist meditations performed 3 times/week for 12 weeks.

OUTCOME MEASURES

Depression score, functional fitness, and endothelium-dependent vasodilation as measured by the flow-mediated dilation (FMD) were the outcome measures used.

RESULTS

Muscle strength, flexibility, agility, dynamic balance, and cardiorespiratory endurance increased in both exercise groups (p<0.05). Depression score decreased (p<0.05) only in the BWM group. FMD improved (p<0.05) in both exercise groups. Significant reduction in plasma cholesterol, triglyceride, high-density lipoprotein cholesterol, and C-reactive protein were found in both exercise groups, whereas low-density lipoprotein cholesterol, cortisol, and interleukin-6 concentrations decreased only in the BWM group.

CONCLUSIONS

Buddhist walking meditation was effective in reducing depression, improving functional fitness and vascular reactivity, and appears to confer greater overall improvements than the traditional walking program.

Pretreatment cortisol levels predict posttreatment outcomes among older adults with depression in cognitive behavioral therapy

Previous studies suggest that individuals with elevated levels of cortisol (the "stress hormone") could be particularly resistant to treatment for depression. However, most of these studies have been conducted in the context of antidepressant medications, and no study has examined pretreatment cortisol levels as a predictor of treatment outcomes among older adults with depression in cognitive-behavioral therapy (CBT), despite the relevance of this population for such a research question. The current study includes 54 older adults with depression who provided salivary cortisol samples at baseline and completed measures of depression at pretreatment and posttreatment, following a 12-week course of CBT. Structural equation modeling results suggest that those with higher daily outputs of cortisol and flatter diurnal slopes were less likely to benefit from CBT-a finding which if replicated could have important implications for clinical practice and future research.

Angiotensin-converting enzyme gene variants are associated with both cortisol secretion and late-life depression

Angiotensin-converting enzyme (ACE) is assumed to influence the activity of the hypothalamic-pituitary-adrenocortical (HPA) axis, which shows hyperactivity in depressed patients. ACE could thus be a promising candidate gene for late-life depression but this has not been examined previously. Depression was assessed in 1005 persons aged at least 65 years, at baseline and over the 10-year follow-up. A clinical level of depression (DEP) was defined as having a score of > or =16 on the Centre for Epidemiology Studies-Depression scale or a diagnosis of current major depression based on the Mini International Neuropsychiatric Interview and according to DSM-IV criteria. Seven single-nucleotide polymorphisms (SNPs) in the ACE gene were genotyped and diurnal cortisol secretion, as an index of HPA axis activity, was measured. Multivariable analyses were adjusted for socio-demographic and vascular factors, cognitive impairment, and apolipoprotein E. Strong significant associations were found between all seven SNPs and DEP and, in particular, first-onset DEP in persons without a past history of depression (P-values ranging from 0.005 to 0.0004). These associations remained significant after correction for multiple testing. The genotypes that were associated with an increased risk of DEP were also significantly associated with an increase in cortisol secretion under stress conditions. Variants of the ACE gene influence cortisol secretion and appear as susceptibility factors for late-life depression in the elderly population. Whether this could represent a common pathophysiological mechanism linking HPA axis and late-life depression remains to be explored.

The association between self-reported daily hassles and cortisol levels in depression and anxiety in community living older adults

OBJECTIVES

The aim of this study was to assess whether the association, in a naturalistic setting, between daily hassles and diurnal salivary cortisol differs in the presence of depression and anxiety in older adults.

METHODS

Data were assessed in a large representative community sample of older adults (n = 1760). A multinomial analysis was used to study as an outcome variable: no disorder, depression only, anxiety only and depression and anxiety, as a function of daily hassles and cortisol levels controlling for age, gender and time of saliva collection. Multivariate regression analyses were also carried out to test the association between daily hassles and cortisol levels stratified by depression and anxiety status.

RESULTS

A significant positive association was observed between the number of daily hassles reported and cortisol levels in participants with no depression and no anxiety and in participants with anxiety. Participants without depression and anxiety, and those with depression only, had significant lower cortisol levels later in the day. This was not observed in respondents with anxiety.

CONCLUSION

Stressors such as daily hassles are associated with cortisol secretion in depression and anxiety in older adults in a large epidemiologic setting.

Anxiety and 10-year risk of incident and recurrent depressive symptomatology in older adults

BACKGROUND

Anxiety has been shown to often precede depression in children and young adults. Only a small number of investigations have examined this form of comorbidity in older adults and the temporal relationship of these syndromes remains unclear. The objective was to verify whether trait anxiety predicts incident/recurrent depressive symptomatology in older adults independently of variables susceptible to explain this relationship in this population, such as cognitive complaints, subjective health, and baseline depressive symptoms.

METHODS

A random sample of 4,649 individuals aged 65 years or older from the Three-City Study, a prospective longitudinal study with a 10-year follow-up, was used. Incident and recurrent depressive symptomatology were determined by Center for Epidemiological Studies Depression Scale cutoff scores. Anxiety was measured using the trait scale of the State-Trait Anxiety Inventory. Cox proportional hazards models were used to determine the independent risk of depressive symptomatology for baseline anxiety, cognitive complaints, subjective health, and depressive symptoms, adjusting for sociodemographic, mental health, and physical health covariates.

RESULTS

Incident depressive symptomatology was independently predicted by baseline anxiety, depressive symptoms, cognitive complaints, and subjective health. Recurrent depressive symptomatology was independently predicted by baseline anxiety and depressive symptoms, but not by cognitive complaints and subjective health. Anxiety was associated with a higher risk of incident depressive symptomatology only in participants without a history of a major depressive episode, and with a higher risk of recurrent depressive symptomatology in men than in women.

CONCLUSIONS

Trait anxiety constitutes an important independent risk factor for subsequent depressive symptomatology in older adults.

Serotonin-norepinephrine reuptake inhibitor therapy in late-life depression is associated with increased marker of bone resorption

Antidepressants are associated with bone loss and fractures in older adults. We treated depressed older adults with an antidepressant and examined its effects on bone turnover by comparing blood samples before and after treatment. Bone resorption increased after antidepressant treatment, which may increase fracture risk.

INTRODUCTION

Antidepressants have been associated with increased bone loss and fractures in older adults in observational studies, but the mechanism is unclear. We examined the effects of a serotonin-norepinephrine reuptake inhibitor, venlafaxine, on biomarkers of bone turnover in a prospective treatment study of late-life depression.

METHODS

Seventy-six individuals aged 60 years and older with current major depressive disorder received a 12-week course of venlafaxine XR 150-300 mg daily. We measured serum C-terminal cross-linking telopeptide of type I collagen (β-CTX) and N-terminal propeptide of type I procollagen (P1NP), measures of bone resorption and formation, respectively, before and after treatment. We then analyzed the change in β-CTX and P1NP within each participant. Venlafaxine levels were measured at the end of the study. We assessed depression severity at baseline and remission status after treatment.

RESULTS

After 12 weeks of venlafaxine, β-CTX increased significantly, whereas P1NP did not significantly change. The increase in β-CTX was significant only in participants whose depression did not remit (increase by 10 % in non-remitters vs. 4 % in remitters). Change in β-CTX was not correlated with serum levels of venlafaxine or norvenlafaxine.

CONCLUSION

Our findings suggest that the primary effect of serotonergic antidepressants is to increase bone resorption. However, such an increase in bone resorption seemed to depend on whether or not participants' depression remitted. Our results are in agreement with prior observational studies reporting increased bone loss in older adults taking serotonergic antidepressants. These negative effects on bone homeostasis could potentially contribute to increased fracture risk in older adults.

[Anxiety and depression in the elderly]

OBJECTIVES

This paper deals with diagnostics and prevalence of depression and anxiety in the elderly, their biological, psychological, and social risk factors, and the effectiveness of psychotherapy and pharmacotherapy.

METHODS

The results are based on an overview of the literature reflecting reviews and meta-analyses.

RESULTS

In the elderly, there is a substantial danger of confounding psychogenic with medical or drug-induced symptoms. Self-assessment scales may be useful for screening, but the results should be confirmed by an expert interview. Based on the available research, we cannot yet be sure whether the prevalence of depression and anxiety in the elderly population is in fact higher, lower, or equal to younger age groups. More women are afflicted with depression or anxiety than men. Pharmacotherapy (preferably antidepressants) and psychotherapy are effective for treating anxiety and depression in the elderly, with medium to high effect sizes. To date it is not possible to provide evidence-based treatment recommendations for the type or the setting of psychotherapy.

DISCUSSION

More research on this topic is needed.

Treatment-related alteration of cortisol predicts change in neuropsychological function during acute treatment of late-life anxiety disorder

OBJECTIVE

Older adults with anxiety disorders are burdened by impairment in neurocognition, which may be mediated by elevated circulating cortisol levels. In a randomized controlled trial of acute serotonin-reuptake inhibitor treatment for late-life anxiety disorder, we examined whether change in salivary cortisol concentrations during treatment predicted improvements in measures of memory and executive function.

METHODS

We examined 60 adults aged 60 years and older, who took part in a 12-week trial of escitalopram versus placebo for generalized anxiety disorder. All subjects had pre-treatment and post-treatment assessments that included monitoring of peak and total daily cortisol and a comprehensive neuropsychological evaluation.

RESULTS

Salivary cortisol changes during treatment showed significant associations with changes in immediate and delayed memory but no association with executive tasks (measures of working memory and set shifting). Analyses suggested that a decrease in cortisol due to serotonin-reuptake inhibitor treatment was responsible for the memory changes: memory improvement was seen with cortisol reduction among patients receiving escitalopram but not among patients receiving placebo.

CONCLUSION

Serotonin-reuptake inhibitor-induced alteration in circulating cortisol during treatment of generalized anxiety disorder predicted changes in immediate and delayed memory. This finding suggests a novel treatment strategy in late-life anxiety disorders: targeting hypothalamic-pituitary- adrenal axis dysfunction to improve memory.

A lifespan view of anxiety disorders

Neurodevelopmental changes over the lifespan, from childhood through adulthood into old age, have important implications for the onset, presentation, course, and treatment of anxiety disorders. This article presents data on anxiety disorders as they appear in older adults, as compared with earlier in life. In this article, we focus on aging-related changes in the epidemiology, presentation, and treatment of anxiety disorders. Also, this article describes some of the gaps and limitations in our understanding and suggests research directions that may elucidate the mechanisms of anxiety disorder development later in life. Finally we describe optimal management of anxiety disorders across the lifespan, in "eight simple steps" for practitioners.

The PREVENT study: a prospective cohort study to identify mid-life biomarkers of late-onset Alzheimer's disease

INTRODUCTION

Epidemiological studies indicate that significant decreases in the incidence of Alzheimer's disease (AD) may be obtained by targeting multiple middle-age risk factors. However, as dementia is unlikely to be diagnosed for decades, short-term outcome measures are required. AD biomarker changes precede clinical symptoms by many years, but their sensitivity to mid-life change remains unknown.

METHODS AND ANALYSIS

PREVENT is a prospective cohort study examining biomarker status at mid-life in at least 150 individuals genetically at high, medium or low risk of late-onset AD. Participants are children of individuals with or without a diagnosed AD allocated to high, medium and low-risk groups according to parental clinical status and ApoE genotype. The biomarkers examined over 2 years are plasma and CSF Aβ42 amyloid, Tau and pTau, proinflammatory cytokines, acute-phase proteins, medial temporal-lobe atrophy, white matter lesion volume, cognitive performance related to transentorhinal and hippocampal functioning and hypothalamic-pituitary-adrenal and sympathetic axes regulation.

ETHICS AND DISSEMINATION

Detected pathologies are communicated to the participant's general practitioner with their permission. Risk status by genotype would not be revealed. The results of the study would be published in peer-reviewed journals and validated biomarkers used to construct a randomised controlled intervention study.

Norms and associated factors of the STAI-Y State anxiety inventory in older adults: results from the PAQUID study

BACKGROUND

The latest version of the State-Trait Anxiety Inventory (STAI-Y) is commonly used in older adults, even though this anxiety scale was developed in and for young adults. Norms and associated factors of the STAI-Y are lacking for older adults in the general population. The objectives of the present study were to produce norms on the STAI-Y State scale for older adults using a large sample of older adults selected from a general population and to examine the sociodemographic and health-related factors associated with the STAI-Y State score.

METHODS

993 community-dwelling individuals aged 66 years and over from the PAQUID study were evaluated at home by a psychologist for the following variables: age, education, marital status, proximity of relatives, self-assessment of income sufficiency, occupation during active life, depressive symptomatology, objective and subjective health, objective and subjective cognitive functioning, adverse life events, activities of daily living, drug use, and cigarette consumption.

RESULTS

Norms were stratified for age, sex, and education and were produced separately for older adults with and without depressive symptomatology. Multivariate analyses revealed that younger age (66-79 years), female sex, lower education, perception of income insufficiency, depressive symptomatology, poor subjective health, subjective cognitive complaints, psychotropic drugs use, and recent adverse life events were independently associated with higher STAI-Y State score.

CONCLUSIONS

This study provides norms for the STAI-Y State anxiety inventory in a general population of older adults and indicates the specific factors linked with state anxiety. Such factors should be taken into account by clinicians in order to better understand state anxiety in older adults.

Insomnia and daytime sleepiness are risk factors for depressive symptoms in the elderly

STUDY OBJECTIVES

Previous studies have reported that insomnia and excessive daytime sleepiness (EDS) may predict depression in adults. However, these associations have not been investigated in community-dwelling elderly taking into account insomnia symptoms, EDS, and sleep medication.

DESIGN

Four-year longitudinal study.

SETTING

The French Three-City Study.

PARTICIPANTS

3824 subjects aged ≥ 65 years and free of depressive symptoms at baseline.

MEASUREMENTS AND RESULTS

Questionnaires were used to evaluate "insomnia symptoms", EDS, and sleep medication at baseline. Depressive symptoms (DEP-s) were assessed using the Center for Epidemiologic Studies-Depression scale at baseline, and at 2-year and 4-year follow-up. Logistic regression models controlling for potential confounders were generated to determine whether sleep disturbances were associated with incident DEP-s and to determine the effect of individual insomnia symptoms. Insomnia symptoms and EDS independently increased the risk of incident DEP-s (OR=1.23, 95% CI=1.01-1.49 and OR=2.05, 95% CI=1.30-3.23, respectively). Poor sleep quality and difficulty in initiating and in maintaining sleep-but not early morning awakening-were identified as risk factors of DEP-s, with risk increasing with the frequency of insomnia symptoms. Sleep medication was not only a risk factor for DEP-s independent of insomnia symptoms (OR=1.62, 95% CI=1.26-2.09), but also independent of EDS (OR=1.71 95%=1.33-2.20).

CONCLUSIONS

Insomnia symptoms, EDS, and the use of medication independently increase the risk of subsequent depression in the elderly. In clinical practice, disturbed sleep and prolonged use of sleep medication may be early indicators or potentially reversible risk factors for depression, suggesting the need for further clinical interventional research.

Spiritual well-being, cortisol, and suicidality in Croatian war veterans suffering from PTSD

We present our preliminary results of work that aims to observe the relationship between the cortisol level, the level of spiritual well-being, and suicidal tendencies in Croatian war veterans suffering from PTSD. The survey was conducted on 17 PTSD veterans who completed the Spiritual Well-Being Scale and the Beck Hopelessness Scale. The plasma cortisol level was obtained by venepuction at 8.00, 12.00, 13.00, 16.00, and 22.00 h. Results showed that veterans with higher spiritual well-being scores had lower cortisol levels, and evening cortisol levels showed significant correlation with suicidal risk. The results of the present study could be a stimulus for further investigation into spiritually based interventions, exploring their impact both on mental status and physical health.

Elevated cortisol in older adults with generalized anxiety disorder is reduced by treatment: a placebo-controlled evaluation of escitalopram

BACKGROUND

Generalized anxiety disorder (GAD) is a common disorder in older adults, which has been linked to hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis in this age group. The authors examined whether treatment of GAD in older adults with a selective serotonin reuptake inhibitor (SSRI) corrects this HPA axis hyperactivity.

METHODS

The authors examined adults aged 60 years and older with GAD in a 12-week randomized controlled trial comparing the SSRI escitalopram with placebo. The authors collected salivary cortisol at six daily time points for 2 consecutive days to assess peak and total (area under the curve) cortisol, both at baseline and posttreatment.

RESULTS

Compared with placebo-treated patients, SSRI-treated patients had a significantly greater reduction in both peak and total cortisol. This reduction in cortisol was limited to patients with elevated (above the median) baseline cortisol, in whom SSRI-treated patients showed substantially greater reduction in cortisol than did placebo-treated patients. Reductions in cortisol were associated with improvements in anxiety. Additionally, genetic variability at the serotonin transporter promoter predicted cortisol changes.

CONCLUSIONS

SSRI treatment of GAD in older adults reduces HPA axis hyperactivity. Further research should determine whether these treatment-attributable changes are sustained and beneficial.

Aging of the hypothalamic-pituitary-adrenal axis in nonhuman primates with depression-like and aggressive behavior

We have investigated aging of the hypothalamic-pituitary-adrenal (HPA) axis in female rhesus monkeys that differ in adaptive behavior. Plasma cortisol (F) and dehydroepiandrosterone sulfate (DHEA-S) concentrations under basal conditions and under acute psycho-emotional stress were evaluated in blood plasma of young (6-8 years) and old (20-27 years) female rhesus monkeys with various types of adaptive behavior (aggressive, depression-like, and average). We have found that the age-related changes in the HPA axis of monkeys with depression-like behavior were accompanied by the maximal absolute and relative hypercortisolemia under both basal conditions and stress. Moreover, young aggressive monkeys, in comparison with young monkeys of other behavior groups, demonstrated the highest plasma levels of DHEA-S and the lowest molar ratios between F and DHEA-S. Thus, age-related dysfunctions of the HPA axis are associated with adaptive behavior of animals.

The moderating effect of the APOE [small element of] 4 allele on the relationship between hippocampal volume and cognitive decline in older depressed patients

OBJECTIVE

the apolipoprotein E epsilon-4 (APOE [small element of] 4) allele and depression are independently associated with increased risk for cognitive decline (CD). The authors have reported that depressed elders with an APOE [small element of]4 allele had greater CD compared with depressed elders without the allele. Depression affects the hippocampus, and reduced hippocampal volume has been associated with CD. This study sought to examine in depressed patients the relationships between hippocampal volume, the APOE [small element of] 4 allele, and their interaction on CD. Analyses were performed to examine the influence of baseline hippocampal volume, the APOE [small element of] 4 allele, and their interactions on change in cognitive functioning overtime.

DESIGN

secondary data analysis using linear regression analyses.

SETTING

clinical Research Center for the Study of Depression in Later Life conducted at Duke University.

PARTICIPANTS

depressed older patients (N = 61) followed up for 4 years.

MEASURES

At baseline, cognitive functioning (assessed by the Mini-Mental State Examination), left and right hippocampal volume (assessed by magnetic resonance imaging), and APOE genotype were obtained. At 4-year follow-up, cognitive functioning was reassessed.

RESULTS

the APOE [small element of] 4 allele and left hippocampal volume, but not right hippocampal volume, were independently associated with CD. Importantly, the authors found the APOE [small element of]4 allele to moderate the effects of left hippocampal volume on CD. The APOE [small element of]4 allele seemed to have little effect among those with larger left hippocampal volumes, whereas the allele influenced CD among those with smaller hippocampal volumes.

CONCLUSION

future studies of cognitive impairment and decline should examine both individual and conjoint effects of putative risk factors.

Biological basis of depression in adults with diabetes

Diabetes and depression are common comorbid conditions. Although certain health behaviors and risk factors partially explain the association of depression and diabetes, other potential mechanisms have yet to be elucidated. Certain neuroendocrine alterations such as activation of the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system (SNS) may contribute to the association. Additionally, presence of a proinflammatory state shown in recent literature in both diabetes and depression may contribute to this as well. The objectives of this review are to summarize and review the recent evidence showing alterations of these three biological systems-HPA axis, SNS, and inflammatory cascade--in depression, diabetes, and diabetes-related risk factors.