Gender-dependent impact of major depression on autonomic cardiovascular modulation

Cardiac autonomic function is preserved in young adults with major depressive disorder

The prevalence of major depressive disorder (MDD) is highest in young adults and contributes to an increased risk of developing future cardiovascular disease (CVD). However, the underlying mechanisms remain unclear. The studies examining cardiac autonomic function that have included young unmedicated adults with MDD report equivocal findings, and few have considered the potential influence of disease severity or duration. We hypothesized that heart rate variability (HRV) and cardiac baroreflex sensitivity (BRS) would be reduced in young unmedicated adults with MDD (18-30 yr old) compared with healthy nondepressed young adults (HA). We further hypothesized that greater symptom severity would be related to poorer cardiac autonomic function in young adults with MDD. Heart rate and beat-to-beat blood pressure were continuously recorded during 10 min of supine rest to assess HRV and cardiac BRS in 28 HA (17 female, 22 ± 3 yr old) and 37 adults with MDD experiencing current symptoms of mild-to-moderate severity (unmedicated; 28 female, 20 ± 3 yr old). Neither HRV [root mean square of successive differences between normal heartbeats (RMSSD): 63 ± 34 HA vs. 79 ± 36 ms MDD; P = 0.14] nor cardiac BRS (overall gain, 21 ± 10 HA vs. 23 ± 7 ms/mmHg MDD; P = 0.59) were different between groups. In young adults with MDD, there was no association between current depressive symptom severity and either HRV (RMSSD, R2 = 0.004, P = 0.73) or cardiac BRS (overall gain, R2 = 0.02, P = 0.85). Taken together, these data suggest that cardiac autonomic dysfunction may not contribute to elevated cardiovascular risk factor profiles in young unmedicated adults with MDD of mild-to-moderate severity.NEW & NOTEWORTHY This study investigated cardiac autonomic function in young unmedicated adults with major depressive disorder (MDD). The results demonstrated that both heart rate variability and cardiac baroreflex sensitivity were preserved in young unmedicated adults with MDD compared with healthy nondepressed young adults. Furthermore, in young adults with MDD, current depressive symptom severity was not associated with any indices of cardiac autonomic function.

Heart rate variability status at rest in adult depressed patients: a systematic review and meta-analysis

Purposes

A meta-analysis was conducted to examine the differences in heart rate variability (HRV) between depressed patients and healthy individuals, with the purpose of providing a theoretical basis for the diagnosis of depression and the prevention of cardiovascular diseases.

Methods

To search China National Knowledge Infrastructure (CNKI), WanFang, VIP, PubMed, Web of Science, Science Direct, and Cochrane Library databases to collect case-control studies on HRV in depressed patients, the retrieval date is from the establishment of the database to December 2022. Effective Public Health Practice Project (EPHPP) scale was used to evaluate literature quality, and Stata14.0 software was used for meta-analysis.

Results

This study comprised of 43 papers, 22 written in Chinese and 21 in English, that included 2,359 subjects in the depression group and 3,547 in the healthy control group. Meta-analysis results showed that compared with the healthy control group, patients with depression had lower SDNN [Hedges' g = -0.87, 95% CI (-1.14, -0.60), Z = -6.254, p < 0.01], RMSSD [Hedges' g = -0.51, 95% CI (-0.69,-0.33), Z = -5.525, p < 0.01], PNN50 [Hedges' g = -0.43, 95% CI (-0.59, -0.27), Z = -5.245, p < 0.01], LF [Hedges' g = -0.34, 95% CI (-0.55, - 0.13), Z = -3.104, p < 0.01], and HF [Hedges' g = -0.51, 95% CI (-0.69, -0.33), Z = -5.669 p < 0.01], and LF/HF [Hedges' g = -0.05, 95% CI (-0.27, 0.18), Z = -0.410, p = 0.682] showed no significant difference.

Conclusion

This research revealed that HRV measures of depressed individuals were lower than those of the healthy population, except for LF/HF, suggesting that people with depression may be more at risk of cardiovascular diseases than the healthy population.

Investigating the effects of beta-blockers on circadian heart rhythm using heart rate variability in ischemic heart disease with preserved ejection fraction

Heart failure is characterized by sympathetic activation and parasympathetic withdrawal leading to an abnormal autonomic modulation. Beta-blockers (BB) inhibit overstimulation of the sympathetic system and are indicated in heart failure patients with reduced ejection fraction. However, the effect of beta-blocker therapy on heart failure with preserved ejection fraction (HFpEF) is unclear. ECGs of 73 patients with HFpEF > 55% were recruited. There were 56 patients in the BB group and 17 patients in the without BB (NBB) group. The HRV analysis was performed for the 24-h period using a window size of 1,4 and 8-h. HRV measures between day and night for both the groups were also compared. Percentage change in the BB group relative to the NBB group was used as a measure of difference. RMSSD (13.27%), pNN50 (2.44%), HF power (44.25%) and LF power (13.53%) showed an increase in the BB group relative to the NBB group during the day and were statistically significant between the two groups for periods associated with high cardiac risk during the morning hours. LF:HF ratio showed a decrease of 3.59% during the day. The relative increase in vagal modulated RMSSD, pNN50 and HF power with a decrease in LF:HF ratio show an improvement in the parasympathetic tone and an overall decreased risk of a cardiac event especially during the morning hours that is characterized by a sympathetic surge.

When Heart Beats Differently in Depression: Review of Nonlinear Heart Rate Variability Measures

BACKGROUND

Disturbed heart dynamics in depression seriously increases mortality risk. Heart rate variability (HRV) is a rich source of information for studying this dynamics. This paper is a meta-analytic review with methodological commentary of the application of nonlinear analysis of HRV and its possibility to address cardiovascular diseases in depression.

OBJECTIVE

This paper aimed to appeal for the introduction of cardiological screening to patients with depression, because it is still far from established practice. The other (main) objective of the paper was to show that nonlinear methods in HRV analysis give better results than standard ones.

METHODS

We systematically searched on the web for papers on nonlinear analyses of HRV in depression, in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 framework recommendations. We scrutinized the chosen publications and performed random-effects meta-analysis, using the esci module in jamovi software where standardized effect sizes (ESs) are corrected to yield the proof of the practical utility of their results.

RESULTS

In all, 26 publications on the connection of nonlinear HRV measures and depression meeting our inclusion criteria were selected, examining a total of 1537 patients diagnosed with depression and 1041 healthy controls (N=2578). The overall ES (unbiased) was 1.03 (95% CI 0.703-1.35; diamond ratio 3.60). We performed 3 more meta-analytic comparisons, demonstrating the overall effectiveness of 3 groups of nonlinear analysis: detrended fluctuation analysis (overall ES 0.364, 95% CI 0.237-0.491), entropy-based measures (overall ES 1.05, 95% CI 0.572-1.52), and all other nonlinear measures (overall ES 0.702, 95% CI 0.422-0.982). The effectiveness of the applied methods of electrocardiogram analysis was compared and discussed in the light of detection and prevention of depression-related cardiovascular risk.

CONCLUSIONS

We compared the ESs of nonlinear and conventional time and spectral methods (found in the literature) and demonstrated that those of the former are larger, which recommends their use for the early screening of cardiovascular abnormalities in patients with depression to prevent possible deleterious events.

Simultaneous monitoring of activity and heart rate variability in depressed patients: A pilot study using a wearable monitor for 3 consecutive days

INTRODUCTION

Reduced activity and sleep-wake rhythm disturbances are essential features of depressive episodes. In addition, alterations in heart rate variability (HRV) have been implicated in depression. By using a wearable sensor that monitors 3-dimensional acceleration and HRV simultaneously, we examined the activity and HRV indices in depressive episode of mood disorders.

METHODS

Participants were 19 patients (13 major depressive disorder [MDD] and 6 bipolar depression; 11 females) and 18 controls (9 females) matched for age and ethnicity (all Japanese) who completed 3 consecutive days of all-day monitoring by a small and light device attached to the chest.

RESULTS

Activity magnitude was significantly reduced while lying/resting time was increased in depressed patients, compared with controls. When males and females were examined separately, male, but not female, patients showed significant reduction in activity. HRV indices such as R-R interval and high-frequency power (a parameter for the parasympathetic system) were significantly decreased in patients than in controls. Significant differences in activity and HRV indices were seen only in males. Sympathetic load during sleep significantly correlated with damped rest-activity rhythm in depressed patients.

LIMITATIONS

The number of participants was small, and the majority of the participants were taking psychotropic medications.

CONCLUSIONS

We obtained evidence for reduced activity, increased lying/resting time, and reduced HRV indices in male depressed patients. The simultaneous monitoring for activity and HRV suggested greater sympathetic load during sleep is associated with damped rest-activity rhythm (increased activity during sleep and decreased daytime activity), which might be a characteristic pathology of depression.

Heart-brain interactions in cardiac and brain diseases: why sex matters

Cardiovascular disease and brain disorders, such as depression and cognitive dysfunction, are highly prevalent conditions and are among the leading causes limiting patient's quality of life. A growing body of evidence has shown an intimate crosstalk between the heart and the brain, resulting from a complex network of several physiological and neurohumoral circuits. From a pathophysiological perspective, both organs share common risk factors, such as hypertension, diabetes, smoking or dyslipidaemia, and are similarly affected by systemic inflammation, atherosclerosis, and dysfunction of the neuroendocrine system. In addition, there is an increasing awareness that physiological interactions between the two organs play important roles in potentiating disease and that sex- and gender-related differences modify those interactions between the heart and the brain over the entire lifespan. The present review summarizes contemporary evidence of the effect of sex on heart-brain interactions and how these influence pathogenesis, clinical manifestation, and treatment responses of specific heart and brain diseases.

Impact of Meditation-Based Lifestyle Modification on HRV in Outpatients With Mild to Moderate Depression: An Exploratory Study

BACKGROUND

The scientific evaluation of mind-body-interventions (MBI), including yoga and meditation, has increased significantly in recent decades. However, evidence of MBI's efficacy on biological parameters is still insufficient.

OBJECTIVES

In this study, we used HRV analysis to evaluate a novel MBI as a treatment of outpatients with mild to moderate depressive disorder. The Meditation-Based Lifestyle Modification (MBLM) program incorporates all major elements of classical yoga, including ethical principles of yoga philosophy, breathing exercises, postural yoga, and meditation.

METHODS

In this exploratory randomized controlled trial, we compared the changes in HRV indices of a MBLM group (N = 22) and a minimal treatment group (MINIMAL, drugs only, N = 17) with those of a multimodal treatment-as-usual group (TAU, according to best clinical practice, N = 22). Electrocardiogram (ECG) recordings were derived from a Holter monitoring device, and HRV indices have been extracted from nearly stationary 20-min periods.

RESULTS

Short-term HRV analysis revealed statistically significant differences in the pre-to-post changes between MBLM and TAU. In particular, the vagal tone mediating RMSSD and the Rényi entropy of symbolic dynamics indicated HRV gains in MBLM participants compared with TAU. Almost no alterations were observed in the MINIMAL group.

CONCLUSIONS

Our results suggest a benefit in selected HRV parameters for outpatients with mild to moderate depression participating in the MBLM program. For further investigations, we propose analysis of complete 24-h HRV recordings and additional continuous pulse wave or blood pressure analysis to assess long-term modulations and cardiovascular effects.

Susceptibility of Women to Cardiovascular Disease and the Prevention Potential of Mind-Body Intervention by Changes in Neural Circuits and Cardiovascular Physiology

Women have been reported to be more vulnerable to the development, prognosis and mortality of cardiovascular diseases, yet the understanding of the underlying mechanisms and strategies to overcome them are still relatively undeveloped. Studies show that women's brains are more sensitive to factors affecting mental health such as depression and stress than men's brains. In women, poor mental health increases the risk of cardiovascular disease, and conversely, cardiovascular disease increases the incidence of mental illness such as depression. In connection with mental health and cardiovascular health, the presence of gender differences in brain activation, cortisol secretion, autonomic nervous system, vascular health and inflammatory response has been observed. This connection suggests that strategies to manage women's mental health can contribute to preventing cardiovascular disease. Mind-body interventions, such as meditation, yoga and qigong are forms of exercise that strive to actively manage both mind and body. They can provide beneficial effects on stress reduction and mental health. They are also seen as structurally and functionally changing the brain, as well as affecting cortisol secretion, blood pressure, heart rate variability, immune reactions and reducing menopausal symptoms, thus positively affecting women's cardiovascular health. In this review, we investigate the link between mental health, brain activation, HPA axis, autonomic nervous system, blood pressure and immune system associated with cardiovascular health in women and discuss the effects of mind-body intervention in modulating these factors.

Diabetes and subclinical hypothyroidism on heart rate variability

BACKGROUND

We aimed to analyse if the effects of coexistent diabetes and subclinical hypothyroidism extend to the cardio autonomic nervous system, using heart rate variability baseline data from the Brazilian Longitudinal Study of Adult Health.

MATERIALS AND METHODS

Heart rate variability analyses were performed by linear time and frequency domains in 5-minute time series collected in the supine position. The associations of diabetes and subclinical hypothyroidism with the lowest quartile group for heart rate and the highest quartile group for each heart rate variability parameter were analysed using additive and multiplicative terms in logistic models. For the first approach, the subsample was categorized into four groups: subjects without diabetes and normal thyroid function (controls); subjects without diabetes and subclinical hypothyroidism; patients with diabetes and normal thyroid function; and patients with diabetes and subclinical hypothyroidism. For the interaction alnalysis, diabetes and subclinical hypothyroidism diagnoses were included in separate, along with a multiplicative interaction term between them.

RESULTS

Point odds ratio estimates for the 4th quartiles of heart rate, and 1st quartiles of all heart rate variability measurements were higher for subjects with combined diabetes and subclinical hypothyroidism than for diabetes only, independently of main sociodemographic and clinical variables (HR: 8.33 vs 2.63; SDNN: 2.59 vs 1.61; RMSSD: 2.37 vs 1.42; LF: 2.83 vs 1.71; HF: 3.06 vs 1.39), but not independently of HbA1c and TSH. Only the interaction term for the association with heart rate, adjusted for sociodemographic and clinical variables, had borderline statistical significance.

CONCLUSION

Diabetes and subclinical hypothyroidism exert a potential joint impact on cardiac autonomic control, showed by additive effects between diabetes and subclinical hypothyroidism, as well as a significant interaction term for the association with heart rate.

A meta-analysis of heart rate variability in major depression

BACKGROUND

Major depression (MD) is a risk factor for cardiovascular disease. Reduced heart rate variability (HRV) has been observed in MD. Given the predictive value of HRV for cardiovascular health, reduced HRV might be one physiological factor that mediates this association.

METHODS

The purpose of this study was to provide up-to-date random-effects meta-analyses of studies which compare resting-state measures of HRV between unmedicated adults with MD and controls. Database search considered English and German literature to July 2018.

RESULTS

A total of 21 studies including 2250 patients and 1982 controls were extracted. Significant differences between patients and controls were found for (i) frequency domains such as HF-HRV [Hedges' g = -0.318; 95% CI (-0.388 to -0.247)], LF-HRV (Hedges' g = -0.195; 95% CI (-0.332 to -0.059)], LF/HF-HRV (Hedges' g = 0.195; 95% CI (0.086-0.303)] and VLF-HRV (Hedges' g = -0.096; 95% CI (-0.179 to -0.013)), and for (ii) time-domains such as IBI (Hedges' g = -0.163; 95% CI (-0.304 to -0.022)], RMSSD (Hedges' g = -0.462; 95% CI (-0.612 to -0.312)] and SDNN (Hedges' g = -0.266; 95% CI (-0.431 to -0.100)].

CONCLUSIONS

Our findings demonstrate that all HRV-measures were lower in MD than in healthy controls and thus strengthens evidence for lower HRV as a potential cardiovascular risk factor in these patients.

Depression and cardiovascular disease: The deep blue sea of women's heart

Cardiovascular disease (CVD) constitutes a leading worldwide health problem, with increasing evidence of differences between women and men both in epidemiology, pathophysiology, clinical management, and outcomes. Data from the literature suggest that women experience a doubled incidence of CVD related deaths, while angina, heart failure and stroke are increasingly prevalent in females. About 20-25% of women go through depression during their life, and depressive symptoms have been considered a relevant emergent, non-traditional risk factor for CVD in this part of the general population. Underlying mechanisms explaining the link between depression and CVD may range from behavioral to biological risk factors, including sympathetic nervous system hyperactivity and impairment in hypothalamic-pituitary-adrenal function. However, the neuroendocrine-driven background could only partially explain the differences mentioned above for chronic systemic inflammation, altered hemostasis and modulation of cardiac autonomic control. In addition, some evidence also suggests the existence of gender-specific differences in biological responses to mental stress. Given these premises, we here summarize the current knowledge about depression and CVD relationship in women, highlighting the sex differences in physiopathology, clinical presentation and treatments.

Cardiorespiratory Coupling Analysis Based on Entropy and Cross-Entropy in Distinguishing Different Depression Stages

Aims

This study used entropy- and cross entropy-based methods to explore the cardiorespiratory coupling of depressive patients, and thus to assess the values of those entropy methods for identifying depression patients with different disease severities.

Methods

Electrocardiogram (ECG) and respiration signals from 69 depression patients were recorded simultaneously for 5 min. Patients were classified into three groups according to the Hamilton Depression Rating Scale (HDRS) scores: group Non-De (HDRS 0–7), Mid-De (HDRS 8–17), and Con-De (HDRS >17). Sample entropy (SEn), fuzzy measure entropy (FMEn) and high-frequency power (HF) were computed on the original RR interval time series and breath-to-breath interval time series. Cross sample entropy (CSEn) and cross fuzzy measure entropy (CFMEn) were computed on interval time series resampled at 2 Hz and 4 Hz, respectively. The difference among three patient groups and correlation between entropy values and HDRS scores were analyzed by statistical analysis. Surrogate data were also employed to confirm the validation of entropy measures in this study.

Results

A consistent increasing trend has been found among most entropy measures from Non-De, to Mid-De, and to Con-De groups, and a significant (p < 0.05) difference in FMEn of RR intervals exists between Non-De and Mid-De or Con-De groups. Significant differences have been also found in all cross entropies, between Non-De and Con-De groups and between Mid-De and Con-De groups. Furthermore, significant correlations also exist between HDRS scores and FMEn of RR intervals (R = 0.24, p < 0.05), CSEn at 4 Hz (R = 0.26, p < 0.05) or 2 Hz (R = 0.28, p < 0.05) resampling, and CFMEn at 4 Hz (R = 0.31, p < 0.01) or 2 Hz (R = 0.30, p < 0.05) resampling. A significant difference of cardiorespiratory coupling parameters between different depression stages and significant correlations between entropy measures and depression severity both indicate central autonomic dysregulation in depression patients and reflect varying degrees of vagal modulation reduction among different depression levels. Analysis based on surrogate data confirms that the non-linear properties of the physiological signals played a major role in depression recognition.

Conclusion

The current study demonstrates the potential of cardiorespiratory coupling in the auxiliary diagnosis of depression based on the entropy method.

Biological markers for the effects of yoga as a complementary and alternative medicine

From the last few decades, there are increasing incidences of disorders like premature aging, cardiovascular disease, multiple sclerosis, fibromyalgia, and Alzheimer's disease In addition to medication, researchers have found that yoga, a mind-body therapy, can be used as an alternative medicine. Yoga combines specific physical postures, breathing techniques, relaxation and meditation that improve mental and physical health of the body. The purpose of this review is to collate the research evidences claiming health benefits of performing traditional yogic practices. What are the biological and other reliable indicators to suggest that doing asanas, pranayama, and meditation could reduce or treat wide range of life style disorders are discussed. Importantly, these indicators are otherwise used to assess the severity of disorders. In many of the study it has been shown that yoga improves the redox health of body whose imbalance has been well proven to cause many health complications. The impact of yoga on neurodegenerative diseases have revealed that it reverses memory loss, reduce anxiety, depression and stress, the biological indicators of disease. However, most studies have several limitations and therefore further research into yoga is needed to validate these findings.

Brain structural thickness and resting state autonomic function in adolescents with major depression

Major depressive disorder (MDD) has been associated with abnormalities in cortical thickness and autonomic function. Adolescence is a time notable for brain development and MDD onset. In healthy adolescents, greater resting state vagal activity (RVA) is associated with lower cortical thickness. The relationship between brain structural thickness and RVA in adolescents with MDD has not previously been studied. This secondary analysis drew on a sample of 37 non-depressed controls and 53 adolescents with MDD. Resting state heart rate and two indices of RVA (HF-HRV and RMSSD) were recorded during a neuroimaging session. Cortical thickness within fronto-limbic regions of interest was measured using Freesurfer analysis of T1-weighted high-resolution structural images. Self-reports of depression severity showed a significant interaction with cortical thickness of the right insula in predicting RMSSD [t = 2.22, P=0.030, β = 5.44; model fit of the interaction term as indicated by the ‘Bayes Factor’ (BF): 7.58] and HF-HRV (t = 2.09, P=0.041, β = 4.72; BF: 7.94). Clinician ratings of depression severity showed further interactions. Findings underscore the important relationships between RVA and cortical development, suggesting two possible explanations: (i) in adolescent MDD, greater fronto-limbic thickness is compensatory for deficits in autonomic regulation or (ii) increased autonomic arousal results in delayed fronto-limbic maturation. Longitudinal research is necessary to further clarify the nature of the relationship between autonomic functioning and cortical development.

Effect of gender-related depression on heart rate variability during an autonomic nervous test

Patients with depression have lower heart rate variability (HRV) compared with controls. However, studies have indicated HRV difference between male and female controls. The gender effect might be interactive with the depression effect on the HRV, resulting in a low accuracy of recognising the patients with depression from the controls. Our study explores the effect of gender-related depression on HRV. Four ANS tests including resting, deep breathing, Valsalva, and orthostatic test are employed as stimuli. HRV were collected from 182 subjects comprising 91 depressive patients (33 females/58 males) and 91 controls (33 females/58 males) in the four tests. Time and frequency domains and nonlinear parameters are employed to quantify HRV. Two-way ANOVA is applied to evaluate the effect of gender-related depression. Most HRV parameters of the patients significantly differ from those of the controls, but some parameters indicate different depression effect between the males and females in the deep breathing and Valsalva test. Some HRV parameters illustrate significant difference between the male and female controls. Therefore, the effect of depression on HRV of each gender should be investigated.

Cardiac dysautonomia in depression - heart rate variability biofeedback as a potential add-on therapy

Depressive disorders are among the most important health problems and are predicted to constitute the leading cause of disease burden by the year 2030. Aside significant impact on quality of life, psychosocial well-being and socioeconomic status of affected patients, depression is associated with impaired cardiovascular health and increased mortality. The link between affective and cardiovascular disease has largely been attributed to dysregulation of the autonomic nervous system resulting in a chronic shift toward increased sympathetic and decreased parasympathetic activity and, consecutively, cardiac dysautonomia. Among proposed surrogate parameters to capture and quantitatively analyze this shift, heart rate variability (HRV) and baroreflex sensitivity have emerged as reliable tools. Attenuation of these parameters is frequently seen in patients suffering from depression and is closely linked to cardiovascular morbidity and mortality. Therefore, diagnostic and therapeutic strategies were designed to assess and counteract cardiac dysautonomia. While psychopharmacological treatment can effectively improve affective symptoms of depression, its effect on cardiac dysautonomia is limited. HRV biofeedback is a non-invasive technique which is based on a metronomic breathing technique to increase parasympathetic tone. While some small studies observed beneficial effects of HRV biofeedback on dysautonomia in patients with depressive disorders, larger confirmatory trials are lacking. We reviewed the current literature on cardiac dysautonomia in patients suffering from depression with a focus on the underlying pathophysiology as well as diagnostic workup and treatment.

Symptoms of depression in young adulthood is associated with unfavorable clinical- and behavioral cardiovascular disease risk factors

Depression in young adults is a growing concern to public health. This study aims to investigate if depression status in young adults is related to clinical and behavioral cardiovascular disease (CVD) risk factors. Cross-sectional data from a population-based sample of young Danish adults participating in the European Youth Heart Study 2009–2010 were used to examine this (n = 644, mean age 24.3 years 47% male). Measures of cardiorespiratory fitness (CRF), body composition, blood pressure, fasting levels of high and low density lipids (HDL, LDL), insulin, and glucose were obtained. Symptoms of depression were obtained using the Major Depression Inventory scale. Information on sleep disorders; drinking and smoking habits were obtained by questionnaires. Associations of depression with CVD risk factors were examined using logistic and linear regression adjusted for age and sex. Prevalence of mild-moderate-severe depression was 8.7% (5.6% males, 11.5% females). Significant sex differences were found in the association between several CVD risk factors and depression status. Women with depression had higher odds of overweight (OR = 2.2, 95%CI: 1.01–4.0), abdominal adiposity (OR = 2.5, 95%CI: 1.2–4.8), low CRF (OR = 2.5, 95%CI: 1.2–5.5), insulin resistance (OR = 2.3, 95%CI: 1.1–4.6), low HDL (OR = 2.0, 95%CI: 1.01–4.1) and high LDL (OR = 2.2, 95%CI: 1.04–4.5) compared to women without depression. Men with depression had significantly increased odds of having high blood pressure and being smokers compared to men without depression (OR: 3.1, 95%CI: 1.1–8.8 and OR: 3.0, 95%CI: 1.1–8.4, respectively). Depression symptoms in young adulthood were related to unfavorable clinical- and behavioral CVD risk factors, particularly in women.

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Depression, starting already in young adulthood, is a challenge to public health.

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Prevalence of mild-moderate-severe depression is high in young adults.

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Already in young adulthood depression is associated to unfavorable CVD risk factors.

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Associations are predominantly present in young women with depression.

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Young adults with depression might need special attention to prevent later CVD.

Inflexibility as a Vulnerability to Depression: A Systematic Qualitative Review

The study of vulnerabilities to depression typically identifies factors that are thought to be universally maladaptive or adaptive. In contrast, researchers recently have theorized that the ability to flexibly engage in different thoughts and behaviors that fit situational demands may be most indicative of psychological health. We review empirical evidence from 147 studies reporting associations between five components of flexibility (set-shifting, affective set-shifting, cardiac vagal control, explanatory flexibility, and coping flexibility) and depression and classify studies according to strength of study design. Evidence from correlational and case-controlled studies suggests cross-sectional relationships, but few prospective studies have been conducted. We discuss limitations of existing studies, identify new directions for programmatic research, and discuss implications that flexibility has for the prevention and treatment of depression.

Sudarshan Kriya Yoga improves cardiac autonomic control in patients with anxiety-depression disorders

BACKGROUND

Several studies have demonstrated that adjuvant therapies as exercise and breathing training are effective in improving cardiac autonomic control (CAC) in patients with affective spectrum disorders. However, the effects of Sudarshan Kriya Yoga (SKY) on autonomic function in this population is unknown. Our objective was to test the hypothesis that SKY training improves CAC and cardiorespiratory coupling in patients with anxiety and/or depression disorders.

METHODS

Forty-six patients with a diagnosis of anxiety and/or depression disorders (DSM-IV) were consecutively enrolled and divided in two groups: 1) conventional therapy (Control) and 2) conventional therapy associated with SKY (Treatment) for 15 days. Anxiety and depression levels were determined using quantitative questionnaires. For the assessment of CAC and cardiorespiratory coupling, cardiorespiratory traces were analyzed using monovariate and bivariate autoregressive spectral analysis, respectively.

RESULTS

After 15-days, we observed a reduction of anxiety and depression levels only in Treatment group. Moreover, sympathetic modulation and CAC were significantly lower while parasympathetic modulation and cardiorespiratory coupling were significantly higher in the Treatment compared to Control group.

CONCLUSIONS

Intensive breathing training using SKY approach improves anxiety and/or depressive disorders as well as CAC and cardiorespiratory coupling. These finding suggest that the SKY training may be a useful non-pharmacological intervention to improve symptoms and reduce cardiovascular risk in patients with anxiety/depression disorders.

A meta-analysis of effects of selective serotonin reuptake inhibitors on blood pressure in depression treatment: outcomes from placebo and serotonin and noradrenaline reuptake inhibitor controlled trials

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) have been commonly prescribed for depression treatment. However, their effects on blood pressure are unclear.

MATERIALS AND METHODS

Effects on blood pressure of depressive patients in two groups (SSRIs versus placebo and SSRIs versus SNRIs) were evaluated. A search was conducted for double-blind, randomized controlled trials (RCTs) in PubMed, EMBASE, ISI Web of Science, PsycNET, CCRCT, and DARE (up to March 2017). The outcomes were systolic blood pressure (SBP) changes and diastolic blood pressure (DBP) changes from baseline to endpoint or to a certain period of treatment duration. Weighted mean differences (WMDs) and 95% CIs were calculated and pooled using random effects models. The χ² test and I² statistics were used to assess heterogeneity. Funnel plots, Begg's test, and Egger's test were used to estimate publication bias.

RESULTS

A total of 23 RCTs involving 13,285 participants were included. Patients on SSRIs showed no significant differences in blood pressure changes compared with placebo. In the group of SSRIs versus SNRIs, overall SBP changes and DBP changes revealed statistical significances (WMD 1.5 mmHg, 95% CI -2.15, -0.84, Z=4.46, P<0.00001 and WMD 1.34 mmHg, 95% CI -1.92, -0.75, Z=6.18, P<0.00001). Subgroup analyses on treatment duration and age further evidenced these findings.

CONCLUSION

It was established that SSRIs did not affect blood pressure, while SNRIs led to a modest increase in SBP and DBP with statistical significance compared with SSRIs.

Complexity and nonlinear biomarkers in emotional disorders: A meta-analytic study

This meta-analysis aimed at gathering and summarising the findings on nonlinear biomarkers in the field of emotional disorders under the hypothesis that diseased systems show lowered complexity and hence less flexibility to adjust daily contexts. Scientific manuscripts from 1970 to 2014 were reviewed, 58 articles were analysed, and independent meta-analyses on anxiety disorders, bipolar disorders, and depressive disorders were conducted. Results revealed that anxious patients exhibited lower complexity than controls (p<0.05) despite panic patients showed more irregular respiratory activity. Inconclusive results were found for bipolar patients but pointed to higher randomness when suffering manic episodes. Finally, depressed patients showed a loss of complexity in the cardiac system and a loss of orderliness (despite a higher complexity) in brain and stress-related hormonal systems. As a conclusion, our findings highlight that either a loss of complexity or a loss of ordered complexity characterise the physiological systems of patients with emotional disorders. Several considerations for complexity, its related measurements, and suggestions for further research are discussed.

Key role of 5-HT3 receptors in the nucleus tractus solitarii in cardiovagal stress reactivity

Serotonin plays a modulatory role in central control of the autonomic nervous system (ANS). The nucleus tractus solitarii (NTS) in the medulla is an area of viscerosomatic integration innervated by both central and peripheral serotonergic fibers. Influences from different origins therefore trigger the release of serotonin into the NTS and exert multiple influences on the ANS. This major influence on the ANS is also mediated by activation of several receptors in the NTS. In particular, the NTS is the central zone with the highest density of serotonin₃ (5-HT₃) receptors. In this review, we present evidence that 5-HT₃ receptors in the NTS play a key role in one of the crucial homeostatic responses to acute and chronic stress: inhibitory modulation of the parasympathetic component of the ANS. The possible functional interactions of 5-HT₃ receptors with GABA_A and NK₁ receptors in the NTS are also discussed.

Sex differences in healthy human heart rate variability: A meta-analysis

The present meta-analysis aimed to quantify current evidence on sex differences in the autonomic control of the heart, indexed by measures of heart rate variability (HRV) in healthy human subjects. An extensive search of the literature yielded 2020 titles and abstracts, of which 172 provided sufficient reporting of sex difference in HRV. Data from 63,612 participants (31,970 females) were available for analysis. Meta-analysis yielded a total of 1154 effect size estimates (k) across 50 different measures of HRV in a cumulated total of 296,247 participants. Females showed a significantly lower mean RR interval and standard deviation of RR intervals (SDNN). The power spectral density of HRV in females is characterized by significantly less total power that contains significantly greater high- (HF) and less low-frequency (LF) power. This is further reflected by a lower LF/HF ratio. Meta-regression revealed significant effects of age, respiration control and the length of recording available for analysis. Although women showed greater mean heart rate, they showed greater vagal activity indexed by HF power of HRV. Underlying mechanisms of these findings are discussed.

Autonomic nervous system dysfunction in psychiatric disorders and the impact of psychotropic medications: a systematic review and meta-analysis

BACKGROUND

Autonomic nervous system (ANS) dysfunction is a putative underlying mechanism for increased cardiovascular disease risk in individuals with psychiatric disorders. Previous studies suggest that this risk may be related to psychotropic medication use. In the present study we systematically reviewed and analyzed published studies of heart rate variability (HRV), measuring ANS output, to determine the effect of psychiatric illness and medication use.

METHODS

We searched for studies comparing HRV in physically healthy adults with a diagnosed psychiatric disorder to controls and comparing HRV pre- and post-treatment with a psychotropic medication.

RESULTS

In total, 140 case-control (mood, anxiety, psychosis, dependent disorders, k = 151) and 30 treatment (antidepressants, antipsychotics; k = 43) studies were included. We found that HRV was reduced in all patient groups compared to controls (Hedges g = -0.583) with a large effect for psychotic disorders (Hedges g = -0.948). Effect sizes remained highly significant for medication-free patients compared to controls across all disorders. Smaller and significant reductions in HRV were observed for specific antidepressants and antipsychotics.

LIMITATIONS

Study quality significantly moderated effect sizes in case-control analyses, underscoring the importance of assessing methodological quality when interpreting HRV findings.

CONCLUSION

Combined findings confirm substantial reductions in HRV across psychiatric disorders, and these effects remained significant even in medication-free individuals. Reductions in HRV may therefore represent a significant mechanism contributing to elevated cardiovascular risk in individuals with psychiatric disorders. The negative impact of specific medications on HRV suggest increased risk for cardiovascular disease in these groups, highlighting a need for treatment providers to consider modifiable cardiovascular risk factors to attenuate this risk.

Adaption of cardio-respiratory balance during day-rest compared to deep sleep--an indicator for quality of life?

Heart rate and breathing rate fluctuations represent interacting physiological oscillations. These interactions are commonly studied using respiratory sinus arrhythmia (RSA) of heart rate variability (HRV) or analyzing cardiorespiratory synchronization. Earlier work has focused on a third type of relationship, the temporal ratio of respiration rate and heart rate (HRR). Each method seems to reveal a specific aspect of cardiorespiratory interaction and may be suitable for assessing states of arousal and relaxation of the organism. We used HRR in a study with 87 healthy subjects to determine the ability to relax during 5 day-resting periods in comparison to deep sleep relaxation. The degree to which a person during waking state could relax was compared to somatic complaints, health-related quality of life, anxiety and depression. Our results show, that HRR is barely connected to balance (LF/HF) in HRV, but significantly correlates to the perception of general health and mental well-being as well as to depression. If relaxation, as expressed in HRR, during day-resting is near to deep sleep relaxation, the subjects felt healthier, indicated better mental well-being and less depressive moods.

Comparative Study of Heart Rate Variability in Patients with Schizophrenia, Bipolar Disorder, Post-traumatic Stress Disorder, or Major Depressive Disorder

Objective

Heart rate variability (HRV) changes as a function of psychiatric illness. This study aimed to evaluate HRV among patients with various psychiatric disorders.

Methods

The present study recruited patients with schizophrenia (n=35), bipolar disorder (n=41), post-traumatic stress disorder (PTSD; n=34), or major depressive disorder (n=34) as well as healthy controls (n=27). The time-domain analysis (the standard deviation of all RR intervals [SDNN] and the square root of the mean squared differences of successive normal sinus intervals [RMSSD]), the frequency-domain analysis (very low frequency, low frequency [LF], high frequency [HF], and total power [TP]), and a non-linear complexity measure the approximate entropy were computed.

Results

SDNN and HF were significantly reduced in patients with schizophrenia compared with healthy controls. SDNN, RMSSD, TP, LF, and HF were significantly reduced in bipolar patients compared with healthy controls. HF was significantly reduced in PTSD patients compared with healthy controls.

Conclusion

Our findings indicate that HRV is not sufficiently powerful to discriminate among various psychiatric illnesses. However, our results suggest that HRV, particularly HF, could be used as a tool for discriminating between psychiatric patients and healthy controls.

Effect of pursed-lip breathing in patients with COPD: Linear and nonlinear analysis of cardiac autonomic modulation

OBJECTIVE

The aim of the present study was to evaluate the effect of pursed-lip breathing (PLB) on cardiac autonomic modulation in individuals with chronic obstructive pulmonary disease (COPD) while at rest.

METHODS

Thirty-two individuals were allocated to one of two groups: COPD (n = 17; 67.29 ± 6.87 years of age) and control (n = 15; 63.2 ± 7.96 years of age). The groups were submitted to a two-stage experimental protocol. The first stage consisted of the characterization of the sample and spirometry. The second stage comprised the analysis of cardiac autonomic modulation through the recording of R-R intervals. This analysis was performed using both nonlinear and linear heart rate variability (HRV). In the statistical analysis, the level of significance was set to 5% (p ≤ 0.05).

RESULTS

PLB promoted significant increases in the SD1, SD2, RMSSD and LF (ms(2)) indices as well as an increase in α1 and a reduction in α2 in the COPD group. A greater dispersion of points on the Poincaré plots was also observed. The magnitude of the changes produced by PLB differed between groups.

CONCLUSION

PLB led to a loss of fractal correlation properties of heart rate in the direction of linearity in patients with COPD as well as an increase in vagal activity and impact on the spectral analysis. The difference in the magnitude of the changes produced by PLB between groups may be related to the presence of the disease and alterations in the respiration rate.

Gender differences in cardiac autonomic modulation during medical internship

Medical internship is known to be a time of high stress and long working hours, which increases the risk of depression and cardiovascular disease. Gender differences in medical interns' cardiovascular risk have not been reported previously. Thirty-eight medical interns (29 males) were repeatedly tested for depressive symptoms using the Hospital Anxiety and Depression Scale and 5-min spectral analysis of heart rate variability (HRV) at 3-month intervals during their internship. Among the male interns, the variance of the heart rate decreased at 6, 9, 12 months, and a reduced high frequency, which suggests reduced cardiac parasympathetic modulation, was found at 9 and 12 months into their internship. Increased depressive symptoms were also identified at 12 months in the male group. No significant differences in depression or any of the HRV indices were identified among the female interns during their internship.

Changes in heart rate variability during TOVA testing in patients with major depressive disorder

AIM

The aim of this study was to identify major depressive disorder (MDD) based on heart rate variability (HRV) during tests of variables of attention (TOVA).

METHOD

Forty-five MDD patients without cardiovascular disease and 45 controls matched by age and gender participated in this study.

RESULTS

Compared to the controls, the MDD group had lower resting HRV parameters, more omissions and variability and longer response times on TOVA, and failure of attention employment to decrease HRV.

CONCLUSIONS

The resting HRV parameters may provide easily measured, clinically useful ways to identify patients with MDD and to monitor their progress in treatment.

Heart rate time irreversibility is impaired in adolescent major depression

We aimed to study heart rate time irreversibility--a nonlinear qualitative characteristics of heart rate variability indicating complexity of cardiac autonomic control at rest and in response to physiological stress (orthostasis) in never-treated major depressive disorder (MDD) adolescent female patients.

METHODS

We studied 20 MDD girls and 20 healthy age-matched girls at the age of 15 to 18 years. The ECG was recorded in supine position and in response to position change from lying to standing (orthostasis). Time irreversibility analysis was performed using Porta's (P%), Guzik's (G%) and Ehlers' (E) index. The depressive disorder severity was evaluated using Montgomery-Asberg Depression Rating Scale (MADRS) and Children's Depression Inventory (CDI).

RESULTS

Resting heart rate time irreversibility indices (logG%, logP%, Ehlers' index) were significantly reduced in MDD female patients without significant differences in response to orthostasis in MDD girls compared to controls. No significant correlations between time irreversibility and MDD severity were observed.

CONCLUSION

This study revealed the impaired heart rate asymmetry pattern indicating an altered complexity of cardiac autonomic regulation in adolescent female patients suffering from MDD.

Patterns of cardiorespiratory coordination in young women with recurrent major depressive disorder treated with escitalopram or venlafaxine

Evidence from previous studies suggests autonomic dysregulation in patients with major depressive disorder (MDD). Antidepressant treatment may also affect central autonomic function. We investigated whether the type of antidepressant might be associated with the pattern of cardiorespiratory coordination in non-depressed women with recurrent MDD. Resting electrocardiograms and respiratory signals were simultaneously recorded from 38 euthymic women with recurrent MDD who were treated with either escitalopram (n=19) or venlafaxine (n=19) monotherapy and from 38 healthy women. Linear measures of heart rate variability were extracted to assess cardiac autonomic control. Sample entropy (SampEn) was computed to assess the complexity of heart rate and respiratory signals, and cross-SampEn was calculated to measure the nonlinear interaction of both signals. Significant decreases in the cardiovagal tone and cardiorespiratory coupling of women with recurrent MDD receiving venlafaxine, and tendencies toward lower cardiovagal tone and cardiorespiratory coupling in women with recurrent MDD receiving escitalopram were observed when compared with healthy controls. Effect sizes for these differences were large between women receiving venlafaxine and healthy controls. We found a positive association between cardiorespiratory decoupling and venlafaxine dose. Norepinephrine-enhancement, within a therapeutic dose range, seems to be closely associated with decreased vagal tone and reduced nonlinear coupling between heart rate and respiration in euthymic women with recurrent MDD. However, the effects of serotonin enhancement on cardiovagal tone should be considered. Our results suggest that the pharmacodynamic properties of antidepressants may affect autonomic regulation of women with recurrent MDD even in euthymic state.

Cardio-respiratory coupling in untreated patients with major depression

BACKGROUND

Depressive disorders are known to be associated with higher risks of cardiovascular diseases. Several studies have reported an imbalance within the autonomic nervous system (ANS) as one putative cause. Previous investigations showed decreased cardio-respiratory coupling in depressive patients that were treated with nortriptyline. We aimed to compare parameters of heart rate variability and cardio-respiratory coupling between unmedicated patients suffering from major depressive disorder (MDD) and healthy controls in order to further understand autonomic dysfunction in the disease.

METHODS

We investigated eighteen unmedicated patients with major depressive disorder and eighteen matched healthy controls. Electrocardiogram and respiratory signals were obtained during a twenty minute resting period. Time- and frequency based parameters of HRV, respiratory sinus arrhythmia (RSA), approximate entropy of heart rate (ApEn(RR)) and respiratory rate (ApEn(Resp)) were calculated. Additionally, cross-ApEn between RR-intervals and respiration time series was determined, reflecting coupling of both signals.

RESULTS

Patients showed an increased heart rate and LF/HF-ratio. Respiratory sinus arrhythmia (RSA) and ApEn(RR) were reduced in patients in comparison to controls. Breathing rate, ApEn(Resp) and cross-ApEn did not differ between the two groups.

DISCUSSION

Increased heart rate, increased LF/HF-ratio, reduced RSA and reduced ApEn(RR) indicate a decrease of cardiac vagal modulation in depressive patients. No difference of cardio-respiratory coupling was observed. Respiratory parameters and cross-ApEn did not differ between both groups, and thus we conclude that diminished vagal modulation is mainly limited to cardiac modulation.

An integrative assessment of the psychophysiologic alterations in young women with recurrent major depressive disorder

OBJECTIVE

Alterations in neuroelectrical activities coincide with major depressive disorder (MDD). This study examines the pattern of cerebral activity and cardiac autonomic parameters of euthymic women with recurrent MDD.

METHODS

Resting electroencephalograms and electrocardiograms were recorded from 20 women with MDD receiving escitalopram and 40 matched and healthy women. We computed frontal alpha asymmetry to evaluate the interhemispheric balance. Parameters of heart rate variability were extracted to assess cardiac autonomic control. Sample entropy was used to assess the complexity of neurocardiac dynamics. The relationship between cardiovagal activity and alpha electroencephalogram was examined with a coherence analysis.

RESULTS

Multivariable analysis of variance revealed a differential pattern of psychophysiologic variables between MDD patients and controls (p = .03). MDD was associated with a tendency toward lower left frontal activity (-0.06 [standard deviation = 0.14] versus 0.04 [0.17] lnμV(2), p = .04). Discriminant analysis demonstrated more right frontal activation, a lower high-frequency heart rate power spectrum, and a higher ratio of the low- to high-frequency heart rate power spectrum in patients with MDD compared with controls. Residual depressive symptoms (r = -0.09 to 0.11, p = .63-.99) and escitalopram dosage (r = -0.09 to 0.28, p = .22-.84) were not correlated with autonomic measures. Coherence between normalized high-frequency component of the heart rate power spectrum and alpha power was not significant (F3, p = .27; F4, p = .16).

CONCLUSIONS

Euthymic women with recurrent MDD have a distinctive psychophysiologic profile. This profile may reflect altered frontal activation and a reduced cardiovagal tone in depression.

Autonomic modulation and health-related quality of life among schizophrenic patients treated with non-intensive case management

BACKGROUND

Schizophrenia is associated with autonomic dysfunction and this may increase cardiovascular mortality. Past studies on autonomic modulation of schizophrenic patients focused on inpatients rather than individuals in a community setting, especially those receiving non-intensive case management (non-ICM). Besides, autonomic modulation and its association with health-related quality of life (HRQoL) in this population remain unexplored.

METHODS

A total of 25 schizophrenic patients treated by non-ICM and 40 healthy volunteers were matched by age, gender and body mass index; smokers were excluded. Between the two groups, we compared the individuals' 5 min resting assessments of heart rate variability and their HRQoL, which was measured using EuroQoL-5D (EQ-5D). Patients with schizophrenia were assessed for psychopathology using the Positive and Negative Syndrome Scale for Schizophrenia (PANSS). We examined the relationship between heart rate variability measurements, HRQoL scores, PANSS scores, and other clinical variables among the schizophrenic patients treated by non-ICM.

RESULTS

Compared to the controls, patients with schizophrenia showed a significant impairment of autonomic modulation and a worse HRQoL. Cardiovagal dysfunction among the schizophrenic patients could be predicted independently based on lower educational level and more negative symptoms. Sympathetic predominance was directly associated with anticholinergics use and EQ-5D using a visual analogue scale (EQ-VAS).

CONCLUSION

Patients with schizophrenia treated by non-ICM show a significant impairment of their autonomic function and HRQoL compared to the controls. Since the sympathovagal dysfunction is associated with more negative symptoms or higher VAS score, the treatment of the negative symptoms as well as the monitoring of HRQoL might help to manage cardiovascular risk among these individuals. In addition, EQ-VAS scores must be interpreted more cautiously in such a population.

From treating complex coronary artery disease to promoting cardiovascular health: therapeutic transitions and challenges, 2010-2020

Cardiovascular disease (CVD) has become the most common cause of mortality worldwide. Obesity, insufficient physical exercise, diabetes, and advancing age are major risk factors for developing cardiovascular disease that are currently increasing in prevalence. Nevertheless, significant progress has recently been made in the treatment of complex cardiovascular and coronary artery disease (CAD), with pharmacological management set to assume an increasingly important role. Other timely factors, such as the development of the polypill and high-level medical and political interest in advancing cardiovascular health, are driving forces that may help to make inroads into the global cardiovascular disease burden. In this article, we critically review the key challenges that we face in the coming decade as we strive to transition and apply our growing knowledge of complex CAD to promoting global cardiovascular health.

Autonomic modulation in healthy first-degree relatives of patients with major depressive disorder

BACKGROUND

Cardiac mortality is known to be increased in patients with major depression. Several studies have reported an imbalance within the autonomic nervous system (ANS) of patients with major depressive disorder (MDD) as one putative cause. Since a heritability of autonomic modulation was demonstrated in healthy subjects, we aimed to investigate autonomic modulation in first-degree relatives of patients with MDD to find potential autonomic imbalances.

METHODS

We included 30 patients with MDD, 30 of their first-degree relatives (siblings or offspring) and 30 matched healthy controls in our study. We obtained a high resolution electrocardiogram and beat to beat blood pressure measurements for 30 min at rest. Linear and nonlinear parameters of heart rate variability (HRV) and baroreflex sensitivity (BRS) were calculated.

RESULTS

Parameters of HRV and BRS did not differ significantly between relatives and controls. We found significant differences between patients and controls for some HRV and BRS parameters confirming results of previous studies.

DISCUSSION

Findings of our study suggest that an imbalance of autonomic function is related to patients with depression and not to first-degree relatives. Thus, a genetic background for autonomic dysfunction is rather unlikely.