Low levels of docosahexaenoic acid identified in acute coronary syndrome patients with depression

Efficacy of omega-3 supplementation on sertraline continuous therapy to reduce depression or anxiety symptoms: A systematic review and meta-analysis

We aimed to synthesize the evidence from randomized controlled trials (RCTs) that determined the efficacy of adding omega-3 supplementation to the continuous sertraline therapy in adults with depression. Meta-analyses were performed using random effects. We used the Revised Cochrane risk of bias tool for randomized trials version 2.0. to assess the risk of bias. Four RCTs were included. The follow-up ranged from eight to 12 weeks. Regarding the Beck Depression Inventory, the pooled SMD was 0.50 (95% CI: -0.51, 1.50; I²: 94.1%). A subgroup analysis was performed regarding the presence of coronary disease: SMD -0.17 (95% CI: -0.41, 0.07; I²: 0.0%). Regarding the Beck Anxiety Inventory, the pooled MD was 0.03 (95% CI: -2.22, 2.28; I²: 0.0%). Regarding the Hamilton Depression Rating Scale, the pooled MD was 0.42 (95% CI: -1.44, 2.29; I²: 35.7%). All pooled outcomes presented a very low certainty of the evidence. Three RCTs presented a low risk of bias in all domains; however, one study presented some concerns in two domains. No essential reductions in the outcomes were found. A subgroup analysis suggested that may be better not to provide the supplementation in patients with coronary disease. The evidence is not enough to make recommendations.

Serum polyunsaturated fatty acids and risk of psychiatric disorder at 6 months after acute coronary syndrome: A prospective cohort study

Cardiovascular disease is a known risk factor for the development of psychiatric disorder and about 20% of patients with acute coronary syndrome (ACS) develop depression. Our previous prospective study showed that serum linoleic acid (LA) level at baseline (admission) is a risk factor for the development of psychiatric disorder 3 months later. However, it was unclear whether serum LA could predict psychiatric disorders after 3 months. Thus, we examined the effects of polyunsaturated fatty acid (PUFA) levels at ACS onset on comorbid psychiatric disorders at 6 months. The study involved a follow-up investigation of the previous prospective cohort study of ACS patients. The sample with complete participant data at 6 months post-ACS comprised 100 patients. On admission, serum n-3 and n-6 PUFA levels were measured by gas chromatography and patients were interviewed to obtain medical information. Eight patients (8%) showed psychiatric disorder at 6 months. The association between psychiatric disorder and serum PUFA concentrations at ACS onset was examined by multivariable logistic regression analysis. Psychiatric disorders were predicted by baseline serum LA level (odds ratio = 7.27, 95% confidence interval = 1.11-47.76), indicating that it is a significant risk factor for the development of psychiatric disorder at 6 months. Thus, dietary education to reduce the intake of LA-containing foods might be useful for preventing psychiatric disorder in the population at high risk for ACS. However, the prevalence of psychiatric disorder, particularly depressive disorder, may have been too low to identify significant differences in PUFA analysis.

Serum polyunsaturated fatty acids and risk of psychiatric disorder after acute coronary syndrome: A prospective cohort study

BACKGROUND

Around 20% of patients with acute coronary syndrome (ACS) develop depression. Furthermore, some observational studies revealed baseline polyunsaturated fatty acids (PUFAs) may affect the prognosis of depression after ACS. This prospective cohort study examined the association between psychiatric disorder and PUFAs after ACS.

METHODS

Subjects were ACS patients admitted to a Tokyo teaching hospital. Psychiatric morbidity as a primary endpoint was measured using structured interview 3 months after admission. At admission, serum n-3 and n-6 PUFAs were measured by gas chromatography and patients were interviewed to evaluate medical information. Multiple logistic regression analysis was performed to calculate odds ratios (ORs) and 95% confidence intervals to examine the association between PUFAs at baseline and psychiatric disorder after ACS.

RESULTS

Between March 2014 and August 2016, 100 patients completed the follow-up assessment. Eleven patients (11%) showed some form of new-onset psychiatric disorder at 3 months, mainly depressive episode (major, 5; minor, 1) and PTSD (full, 1; partial, 2). Psychiatric disorder was predicted by serum linoleic acid level (OR=3.96) and Hospital Anxiety and Depression Scale total score (OR=1.34) at baseline. No significant associations were seen with other PUFAs.

LIMITATIONS

The results were obtained from a single hospital and based on a small number of participants. There might be some patients with new-onset psychiatric disorder among the refused patients.

CONCLUSIONS

Psychiatric disorder incidence in ACS patients might be lower in Japan than in Western countries. Reduced intake of linoleic acid-containing foods might prevent depression or PTSD after ACS.

There is No Association Between the Omega-3 Index and Depressive Symptoms in Patients With Heart Disease Who Are Low Fish Consumers

BACKGROUND

Long chain Omega-3 polyunsaturated fatty acids (LCn3PUFAs) may improve cardiovascular health and depression. This study investigated the relationships between erythrocyte membrane LCn3PUFA status, depression and angina symptoms in patients with heart disease.

METHODS

We recruited 91 patients (65 males and 26 females, mean age 59.2±10.3 years) with heart disease and depressive symptoms (Center for Epidemiological Studies Depression Scale, CES-D ≥ 16) and low fish/fish oil intakes. The Omega-3 Index (EPA+DHA) of erythrocyte membranes (as a percentage of total fatty acids) was assessed by gas chromatography. Depression status was measured by both self-report and clinician-report scales; CES-D and the Hamilton depression scale (HAM-D). Angina symptoms were measured using the Seattle Angina Questionnaire and the Canadian Cardiovascular Society Classification for Angina Pectoris.

RESULTS

The mean Omega-3 Index was 4.8±1.0% (±SD). Depression scores measured by CES-D and HAM-D were 29.2±8.8 (moderate to severe) and 11.0±5.7 (mild) (arbitrary units) respectively reflecting a different perception of depressive symptoms between patients and clinicians. Angina status was inversely associated with depression scores (r>-0.26, P<0.03). There were no significant relationships between individual LCn3PUFA or the Omega-3 Index and either the depression scores or the angina symptoms.

CONCLUSION

Worse angina status was associated with worse depression, but the Omega-3 Index was not associated with symptoms of depression or angina in patients with heart disease.

Baseline blood levels of omega-3 and depression remission: a secondary analysis of data from a placebo-controlled trial of omega-3 supplements

OBJECTIVE

Depression is associated with low red blood cell (RBC) levels of 2 omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), suggesting that omega-3 supplements might improve depression. However, clinical trials have produced mixed results. The purpose of this secondary analysis of data from a randomized controlled trial was to determine whether baseline blood levels of omega-3, which are known to vary widely among individuals, predict depression outcomes.

METHOD

The percentages of EPA, DHA, and the omega-6 arachidonic acid (AA) were measured in RBCs at baseline and posttreatment in 122 participants with DSM-IV major depression who were randomly assigned between May 2005 and December 2008 to receive either 50 mg/d of sertraline and a daily dosage of 930 mg EPA/750 mg DHA or sertraline plus placebo. Associations between baseline omega-3 RBC levels and remission of depression (17-item Hamilton Depression Rating Scale score ≤ 7) were analyzed by treatment arm.

RESULTS

Among participants in the omega-3 arm, baseline RBC levels of EPA + DHA (P = .002) and the EPA + DHA:AA ratio (P = .003) were significantly higher among those whose depression subsequently remitted compared with those whose depression did not remit. No associations were detected in the sertraline plus placebo arm. Baseline levels of EPA (P = .03) and the EPA + DHA:AA ratio (P = .04) moderated the relationship between treatment arm and depression outcomes.

CONCLUSIONS

High baseline RBC levels of EPA and DHA and a high EPA + DHA:AA ratio predict favorable depression outcomes in patients receiving omega-3 supplements. Omega-3 supplementation may be an effective treatment for depression, but the requisite dosage and duration of treatment may depend on the patient's baseline level of omega-3 fatty acids.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00116857.

Characterising acute coronary syndrome-associated depression: Let the data speak

Depression in the context of acute coronary syndrome (ACS) is understood to confer increased morbidity and mortality risk. The pathophysiological mechanisms underlying this association remain poorly understood, although several candidates including inflammation, cardiac autonomic dysregulation, and behavioural factors are viewed as of key importance. No single bio-behavioural explanatory model of ACS-associated depression has emerged, likely due the substantial heterogeneity across both conditions. We studied 344 patients with ACS; 45 fulfilled diagnostic (DSM-IV) criteria for a major depressive episode occurring within 1-month of ACS, and 13 had ongoing major depression that pre-dated ACS and continued through to 1 month post-ACS. We employed two statistical methods (multinomial logistic regression; and latent class analysis) and a range of immunological, autonomic and nutritional markers in an attempt to characterise a biological basis for ACS-associated depression. Regression modelling failed to accurately predict categorical group membership of ACS-associated depression. An alternative data-driven approach produced a three-class solution, with the derived classes differing on measure of C-reactive protein, vitamin D, omega-6:omega-3 ratio, heart rate variability, and age (all p⩽0.004). The majority of participants with ACS-associated and ongoing depression were members of the class characterised by the greatest biological disturbance. Patients with depression differed from those without depression on a range of psychological trait and state variables; additionally reporting poorer sleep quality, higher levels of social isolation, and functional impairment, but had similar biological profiles. Patients with ongoing depression generally had higher scores on these psychological/behavioural measures. Our novel analytic approach identified a combination of biomarkers suggestive of a role for immune, autonomic, and nutritional pathways in the manifestation of depression during ACS, in the context of additional psychosocial and behavioural vulnerabilities. Further studies are required to confirm the causal role of these factors in perpetuating depression and increasing risk of poor-health outcomes.

Determination of sex-based differences in serum γ-linolenic [corrected] acid and dihomo-γ-linolenic [corrected] acid using gas chromatography-mass spectrometry

Because serum unsaturated fatty acids can provide useful information on disease diagnosis, the simultaneous determination of several fatty acids in small volumes of human serum would be beneficial for clinical applications. In the present study, serum fatty acids were extracted with n-heptane/chloroform from 10μL of serum collected from 26 healthy Japanese subjects (11 men, ages 23-37 years; 15 women, ages 18-37 years) after deproteinization with perchloric acid, derivatization to their methyl ester using p-toluenesulfonic acid as an acid catalyst, and subsequent separation and measurement by gas chromatography-mass spectrometry (GC-MS) in the selected ion monitoring mode. Nine types of fatty acids (palmitoleic acid [PLA], oleic acid [OA], linoleic [corrected] acid [LA], γ-linolenic acid [GLA], α-linolenic acid [ALA], dihomo-GLA [DGLA], arachidonic acid [AA], eicosapentaenoic acid [EPA], and docosahexaenoic acid [DHA]) were analyzed in the serum within 35 min by GC-MS. The concentrations of these fatty acids in serum ranged from 3.64±0.38μM (GLA) to 413±26.3 μM (LA). Among these nine fatty acids, GLA and DGLA levels were significantly lower in women than in men (p=0.0034 and 0.0012, respectively), suggesting that there may be sex-based differences in the biosynthetic production or metabolic processes of GLA and DGLA in humans.

Role of omega-3 fatty acids in the treatment of depressive disorders: a comprehensive meta-analysis of randomized clinical trials

Background

Despite omega-3 polyunsaturated fatty acids (PUFA) supplementation in depressed patients have been suggested to improve depressive symptomatology, previous findings are not univocal.

Objectives

To conduct an updated meta-analysis of randomized controlled trials (RCTs) of omega-3 PUFA treatment of depressive disorders, taking into account the clinical differences among patients included in the studies.

Methods

A search on MEDLINE, EMBASE, PsycInfo, and the Cochrane Database of RCTs using omega-3 PUFA on patients with depressive symptoms published up to August 2013 was performed. Standardized mean difference in clinical measure of depression severity was primary outcome. Type of omega-3 used (particularly eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) and omega-3 as mono- or adjuvant therapy was also examined. Meta-regression analyses assessed the effects of study size, baseline depression severity, trial duration, dose of omega-3, and age of patients.

Results

Meta-analysis of 11 and 8 trials conducted respectively on patients with a DSM-defined diagnosis of major depressive disorder (MDD) and patients with depressive symptomatology but no diagnosis of MDD demonstrated significant clinical benefit of omega-3 PUFA treatment compared to placebo (standardized difference in random-effects model 0.56 SD [95% CI: 0.20, 0.92] and 0.22 SD [95% CI: 0.01, 0.43], respectively; pooled analysis was 0.38 SD [95% CI: 0.18, 0.59]). Use of mainly EPA within the preparation, rather than DHA, influenced final clinical efficacy. Significant clinical efficacy had the use of omega-3 PUFA as adjuvant rather than mono-therapy. No relation between efficacy and study size, baseline depression severity, trial duration, age of patients, and study quality was found. Omega-3 PUFA resulted effective in RCTs on patients with bipolar disorder, whereas no evidence was found for those exploring their efficacy on depressive symptoms in young populations, perinatal depression, primary disease other than depression and healthy subjects.

Conclusions

The use of omega-3 PUFA is effective in patients with diagnosis of MDD and on depressive patients without diagnosis of MDD.

Omega-3 fatty acids and depression: scientific evidence and biological mechanisms

The changing of omega-6/omega-3 polyunsaturated fatty acids (PUFA) in the food supply of Western societies occurred over the last 150 years is thought to promote the pathogenesis of many inflammatory-related diseases, including depressive disorders. Several epidemiological studies reported a significant inverse correlation between intake of oily fish and depression or bipolar disorders. Studies conducted specifically on the association between omega-3 intake and depression reported contrasting results, suggesting that the preventive role of omega-3 PUFA may depend also on other factors, such as overall diet quality and the social environment. Accordingly, tertiary prevention with omega-3 PUFA supplement in depressed patients has reached greater effectiveness during the last recent years, although definitive statements on their use in depression therapy cannot be yet freely asserted. Among the biological properties of omega-3 PUFA, their anti-inflammatory effects and their important role on the structural changing of the brain should be taken into account to better understand the possible pathway through which they can be effective both in preventing or treating depression. However, the problem of how to correct the inadequate supply of omega-3 PUFA in the Westernized countries' diet is a priority in order to set food and health policies and also dietary recommendations for individuals and population groups.

Effects of n-3 polyunsaturated fatty acids on depressive symptoms, anxiety and emotional state in patients with acute myocardial infarction

BACKGROUND

Our aim was to assess whether an early introduced n-3 polyunsaturated fatty acids (n-3 PUFA) supplementation affects depression symptoms, anxiety and emotional state in patients with acute myocardial infarction (AMI) and no history of mental disorders.

METHODS

Fifty two patients with AMI were enrolled into the study and randomized to the study group (group P; n=26; standard therapy+n-3 PUFA 1 g daily) or the control group (group C; n=26; standard therapy). The following psychological tests were used at the baseline (3rd day of AMI) and after one month (30±1 days): Beck Depression Inventory (BDI), State-Trait Anxiety Inventory in a specific situation (STAI-S) and as a general trait (STAI-T), Emotional State Questionnaire (ESQ).

RESULTS

The baseline characteristics, pharmacotherapy and BDI, STAI-S/T and ESQ were similar between both groups. The mean test scores assessed for all patients (group P and C) during the one-month observation were significantly lower for BDI (p=0.04), STAI-T (p=0.03), STAI-S (p=0.01) and harm/loss emotions (p=0.005). After adjusting for age, sex, body mass index, coronary artery disease severity, ejection fraction, serum troponin level and the baseline tests results, n-3 PUFA intervention revealed additional significant decrease in BDI (p=0.046), STAI-S (p=0.03) and harm/loss emotions (p=0.04).

CONCLUSIONS

Our study provides novel and preliminary observations--n-3 PUFA supplementation reveals additional decreasing effects on depressive and anxiety symptoms in early post-MI patients.

Lower docosahexaenoic acid concentrations in the postmortem prefrontal cortex of adult depressed suicide victims compared with controls without cardiovascular disease

BACKGROUND

A growing body of evidence suggests that deficits in long-chain omega-3 (LCn-3) fatty acids may contribute to major depressive disorder (MDD) and principal causes of excess mortality including suicide and cardiovascular disease. In the present study we compared concentrations of docosahexaenoic acid (DHA, 22:6n-3), the principal LCn-3 fatty acid in brain, in the postmortem prefrontal cortex (BA10) of adult depressed suicide victims and controls with and/or without cardiovascular disease.

METHODS

DHA concentrations (μmol/g) in the prefrontal cortex (PFC, BA10) of adult male and female suicide victims (n = 20) and controls with (n = 8) or without (n = 12) cardiovascular disease were determined by gas chromatography.

RESULTS

There was a non-significant trend for lower DHA concentrations in suicide victims compared with all controls (-10%, p = 0.06, d = 0.5). Significantly lower DHA concentrations were observed in suicide victims compared with controls without cardiovascular disease (-14%, p = 0.03, d = 0.7) but not controls with cardiovascular disease (-4%, p = 0.71, d = 0.1). There was a non-significant trend for lower DHA concentrations in controls with cardiovascular disease compared with controls without cardiovascular disease (-11%, p = 0.1, d = 0.6).

CONCLUSIONS

Adult depressed suicide victims exhibit lower postmortem PFC DHA concentrations compared with controls without cardiovascular disease. These data add to a growing body of evidence implicating DHA deficits in the pathophysiology of MDD, suicide, and cardiovascular disease.

Meta-analysis of the effects of eicosapentaenoic acid (EPA) in clinical trials in depression

OBJECTIVE

Randomized trials of omega-3 polyunsaturated fatty acid (PUFA) treatment for depression have differed in outcome. Recent meta-analyses ascribe discrepancies to differential effects of eicosapentaenoic acid (EPA) versus docosahexaenoic acid (DHA) and to diagnostic heterogeneity. This meta-analysis tests the hypothesis that EPA is the effective component in PUFA treatment of major depressive episodes.

DATA SOURCES

PubMed/MeSH was searched for studies published in English from 1960 through June 2010 using the terms fish oils (MeSH) AND (depressive disorder [MeSH] OR bipolar depression) AND randomized controlled trial (publication type). The search was supplemented by manual bibliography review and examination of relevant review articles.

STUDY SELECTION

The search yielded 15 trials involving 916 participants. Studies were included if they had a prospective, randomized, double-blinded, placebo-controlled study design; if depressive episode was the primary complaint (with or without comorbid medical conditions); if omega-3 PUFA supplements were administered; and if appropriate outcome measures were used to assess depressed mood.

DATA EXTRACTION

Extracted data included study design, sample sizes, doses and percentages of EPA and DHA, mean ages, baseline and endpoint depression ratings and standard deviations for PUFA and placebo groups, and P values. The clinical outcome of interest was the standardized mean difference in the change from baseline to endpoint scores on a depression rating scale in subjects taking PUFA supplements versus subjects taking placebo.

DATA SYNTHESIS

In a mixed-effect model, percentage of EPA in the supplements was the fixed-effect predictor, dichotomized into 2 groups: EPA < 60% or EPA ≥ 60% of the total EPA + DHA. Secondary analyses explored the relevance of treatment duration, age, and EPA dose.

RESULTS

Supplements with EPA ≥ 60% showed benefit on standardized mean depression scores (effect size = 0.532; 95% CI, 0.277-0.733; t = 4.195; P < .001) versus supplements with EPA < 60% (effect size = -0.026; 95% CI, -0.200 to 0.148; t = -0.316; P = .756), with negligible contribution of random effects or heteroscedasticity and with no effects of treatment duration or age. Supplements with EPA < 60% were ineffective. Exploratory analyses supported a nonlinear model, with improvement determined by the dose of EPA in excess of DHA, within the range of 200 to 2,200 mg/d of EPA.

CONCLUSIONS

Supplements containing EPA ≥ 60% of total EPA + DHA, in a dose range of 200 to 2,200 mg/d of EPA in excess of DHA, were effective against primary depression. Translational studies are needed to determine the mechanisms of EPA's therapeutic benefit.

The effect of low-dose omega 3 fatty acids on the treatment of mild to moderate depression in the elderly: a double-blind, randomized, placebo-controlled study

Due to the rise in the social and economic costs of depression, new antidepressant medication with fewer side effects should be found. Several studies have shown that an association exists between ω-3 polyunsaturated fatty acids (ω-3 PUFAs) and depression. However, this association has not been clear enough in the elderly with mild to moderate depression. Sixty-six inhabitants of Kahrizak Charity Foundation participated in this double-blind, randomized, placebo-controlled study. Each participant was ≥ 65 years of age, had a Mini Mental State Exam of ≥ 22, and had scores ranging from 5 to 11 on the Geriatric Depression Scale-15 (GDS-15). During the 6 months, the drug group was treated daily with one gram of fish oil capsule containing 300 mg of both eicosapentaenoic acid and docosahexaenoic acid. No significant differences were noted between the groups in regard to level of education, use of antidepressant drugs, alcohol, tobacco use, history of chronic diseases, age, body mass index (BMI), high-sensitive C-reactive protein (hs-CRP), total cholesterol, and GDS-15 scores at baseline. After adjusting for cholesterol, BMI, and history of thyroid dysfunctions, a statistically significant difference was seen in GDS-15 scores between both groups. Furthermore, treatment with ω-3 PUFAs was clinically more effective in treating depression in comparison with the placebo. In this study, low-dose ω-3 PUFAs had some efficacy in the treatment of mild to moderate depression in elderly participants.

Effects of n-3 fatty acids on depressive symptoms and dispositional optimism after myocardial infarction

BACKGROUND

In patients who have experienced a myocardial infarction (MI), n-3 (omega-3) PUFA status is low, whereas the risk of depression is increased.

OBJECTIVE

The objective was to assess whether the plant-derived α-linolenic acid (ALA) and the fish fatty acids EPA and DHA would improve affective states.

DESIGN

In a secondary analysis of the randomized, double-blind, placebo-controlled Alpha Omega Trial, 4116 of 4837 (85.1%) patients (aged 60-80 y; 79.2% men) who had experienced an MI were included. Margarine spreads were used to deliver 400 mg EPA-DHA/d, 2 g ALA/d, both EPA-DHA and ALA, or a placebo for 40 mo. At 40 mo, the endpoints of depressive symptoms (15-item Geriatric Depression Scale) and dispositional optimism (a 4-item questionnaire and the Life Orientation Test-Revised) were analyzed by using a posttest-only design.

RESULTS

The 4 randomly assigned groups did not differ in baseline characteristics. ALA supplementation significantly increased plasma cholesteryl ester concentrations of ALA by 69%, and EPA-DHA supplementation increased plasma cholesteryl ester concentrations of EPA and DHA by 61% and 30%, respectively. Depressive symptoms or dispositional optimism did not differ between groups with the use of n-3 fatty acids compared with placebo at the 40-mo follow-up. The standardized mean (±SE) differences in depressive symptoms were as follows: for EPA-DHA plus ALA (n = 1009) compared with placebo (n = 1030), -0.025 ± 0.044 (P = 0.57); for EPA-DHA (n = 1007) compared with placebo, -0.048 ± 0.044 (P = 0.28); and for ALA (n = 1022) compared with placebo, -0.047 ± 0.044 (P = 0.29).

CONCLUSIONS

In patients who had experienced an MI, low-dose EPA-DHA supplementation, ALA supplementation, or a combination of both did not affect depressive symptoms and dispositional optimism. These findings are in accord with those from previous trials in individuals without psychopathology or without severe depressive symptoms. This trial was registered at clinicaltrials.gov as NCT00127452.

Contribution of diet and major depression to incidence of acute myocardial infarction (AMI)

BACKGROUND

Despite significant improvements in the treatment of coronary heart disease (CHD), it is still a major cause of mortality and morbidity among the Iranian population. Epidemiological studies have documented that risk factors including smoking and the biochemical profile are responsible for the development of acute myocardial infarction (AMI). Psychological factors have been discussed as potential risk factors for coronary heart disease. Among emotional factors, depression correlates with coronary heart disease, particularly myocardial infarction.

METHODS

This case-control study was conducted on 120 cases (69 males and 51 females) of acute myocardial infarction (AMI) and 120 controls, with a mean age of 62.48 ± 15.39 years. Cases and controls were matched by age, residence and sex.

RESULTS

The results revealed that severe depression was independently associated with the risk of AMI (P = 0.025, OR = 2.6, 95% CI 1.1-5.8). The analysis of variables indicated that risk factors for developing depression were unmarried, low levels of polyunsaturated fatty acids (PUFAs), total dietary fiber (TDF) and carbohydrates. The levels of these dietary factors were lowest in severely depressed patients compared to those categorised as moderate or mild cases. Furthermore, severely depressed subjects were associated with higher levels of total cholesterol, high systolic blood pressure (SBP) and WHR. Age, income, a family history of coronary heart disease, education level, sex, employment and smoking were not associated with severe depression.

CONCLUSION

The present study demonstrated that severe depression symptoms are independent risk factors for AMI. Furthermore, severe depression was associated with an unhealthy diet and AMI risk factors.

Effect of omega-3 fatty acids on heart rate variability in depressed patients with coronary heart disease

OBJECTIVE

To determine whether omega-3 fatty acid (FA) increases the natural log of very low frequency (lnVLF) power, an index of heart rate variability (HRV), and reduces 24-hour heart rate (HR) in depressed patients with coronary heart disease (CHD). Low intake of omega-3 FAs is associated with depression and with low HRV, and all three are associated with an increased risk of death in patients with CHD.

METHODS

Thirty-six depressed patients with CHD randomized to receive 50 mg of sertraline and 2 g of omega-3/day, and 36 randomized to sertraline and a placebo, had 24-hour HRV measured at baseline and after 10 weeks of treatment.

RESULTS

There was a significant treatment × time interaction for covariate adjusted lnVLF (p = .009), for mean 24-hour HR (p = .03), and for 1-minute resting HR (p = .02). The interaction was not significant for three other measures of HRV. LnVLF did not change over time in the omega-3 arm but decreased in the placebo arm (p = .002), suggesting that omega-3 may have prevented or slowed deterioration in cardiac autonomic function.

CONCLUSIONS

The effects of omega-3 FAs on lnVLF and HR, although modest, were detected after only 10 weeks of treatment with 2 g per day of omega-3. Whether a longer course of treatment or a higher dose of omega-3 would further decrease HR, improve other indices of HRV, or reduce mortality in depressed CHD patients should be investigated.

Associations between diet quality and depressed mood in adolescents: results from the Australian Healthy Neighbourhoods Study

OBJECTIVE

Adolescence frequently coincides with the onset of psychiatric illness and depression is commonly observed in adolescents. Recent data suggest a role for diet quality in adult depression. Given the importance of adequate nutrition for brain development, it is of interest to examine whether diet quality is also related to depression in adolescents.

METHODS

The study examined 7114 adolescents, aged 10-14 years, who participated in the Australian Healthy Neighbourhoods Study. Healthy and unhealthy diet quality scores were derived from a dietary questionnaire. The Short Mood and Feelings Questionnaire for adolescents measured depression. Adjustments were made for age, gender, socioeconomic status, parental education, parental work status, family conflict, poor family management, dieting behaviours, body mass index, physical activity, and smoking.

RESULTS

Compared to the lowest category of the healthy diet score, the adjusted odds ratios (95% confidence interval) for symptomatic depression across categories (C) was: C2 = 0.61 (0.45-0.84); C3 = 0.58 (0.43-0.79); C4 = 0.47 (0.35-0.64); and C5 = 0.55 (0.40-0.77). Compared to the lowest quintile, the adjusted odds ratios (95% confidence interval) for symptomatic depression across increasing quintiles of the unhealthy diet score were: Q2 = 1.03 (0.87-1.22); Q3 = 1.22 (1.03-1.44); Q4 = 1.29 (1.12-1.50); and Q5 = 1.79 (1.52-2.11).

CONCLUSIONS

Our results demonstrate an association between diet quality and adolescent depression that exists over and above the influence of socioeconomic, family, and other potential confounding factors.

Association of n-3 long-chain PUFA and fish intake with depressive symptoms and low dispositional optimism in older subjects with a history of myocardial infarction

Individuals with CHD are at increased risk of poor mental well-being. Dietary intake of EPA and DHA, the main n-3 fatty acids from fish, may be beneficial to mental well-being. We examined the association of EPA+DHA and fish intake with mental well-being in 644 participants, aged 60–80 years, with a history of myocardial infarction. Habitual food intake was assessed with a 203-item FFQ. Depressive symptoms were assessed with the self-report geriatric depression scale, and dispositional optimism was assessed with the revised life orientation test (LOT-R) and a four-item questionnaire (4Q). In Cox-regression models modified for cross-sectional analyses, we adjusted for sex, age, energy intake, BMI, family history of depression, education, marital status, smoking, physical activity and intake of saturated fat, alcohol and fibre. Compared with the lower tertile, subjects in the higher tertile of EPA+DHA intake had a lower prevalence of depressive symptoms, but this association was not statistically significant (prevalence ratio (PR) 0·78; 95 % CI 0·50, 1·22, P-trend 0·27). The higher tertile of EPA+DHA intake was positively associated with dispositional optimism measured with the 4Q (PR 0·69; 95 % CI 0·46, 1·03, P-trend 0·05), but not according to the LOT-R. Fish intake was not related to either depressive symptoms or dispositional optimism. In conclusion, intake of EPA+DHA was positively associated with dispositional optimism assessed with the 4Q, but not with optimism assessed with the LOT-R or with depressive symptoms.

Omega-3 augmentation of sertraline in treatment of depression in patients with coronary heart disease: a randomized controlled trial

CONTEXT

Studies of depressed psychiatric patients have shown that antidepressant efficacy can be increased by augmentation with omega-3 fatty acids.

OBJECTIVE

To determine whether omega-3 improves the response to sertraline in patients with major depression and coronary heart disease (CHD).

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial. Between May 2005 and December 2008, 122 patients in St Louis, Missouri, with major depression and CHD were randomized.

INTERVENTIONS

After a 2-week run-in period, all patients were given 50 mg/d of sertraline and randomized in double-blind fashion to receive 2 g/d of omega-3 acid ethyl esters (930 mg of eicosapentaenoic acid [EPA] and 750 mg of docosahexaenoic acid [DHA]) (n=62) or to corn oil placebo capsules (n=60) for 10 weeks.

MAIN OUTCOME MEASURES

Scores on the Beck Depression Inventory (BDI-II) and the Hamilton Rating Scale for Depression (HAM-D).

RESULTS

Adherence to the medication regimen was 97% or more in both groups for both medications. There were no differences in weekly BDI-II scores (treatment x time interaction = 0.02; 95% confidence interval [CI], -0.33 to 0.36; t(112) = 0.11; P = .91), pre-post BDI-II scores (placebo, 14.8 vs omega-3, 16.1; 95% difference-in-means CI, -4.5 to 2.0; t(116) = -0.77; P = .44), or HAM-D scores (placebo, 9.4 vs omega-3, 9.3; 95% difference-in-means CI, -2.2 to 2.4; t(115) = 0.12; P = .90). The groups did not differ on predefined indicators of depression remission (BDI-II < or = 8: placebo, 27.4% vs omega-3, 28.3%; odds ratio [OR], 0.96; 95% CI, 0.43-2.15; t(113) = -0.11; P = .91) or response (> 50% reduction in BDI-II from baseline: placebo, 49.0% vs omega-3, 47.7%; OR, 1.06; 95% CI, 0.51-2.19; t(112) = 0.15; P = .88).

CONCLUSIONS

Treatment of patients with CHD and major depression with sertraline and omega-3 fatty acids did not result in superior depression outcomes at 10 weeks, compared with sertraline and placebo. Whether higher doses of omega-3 or sertraline, a different ratio of EPA to DHA, longer treatment, or omega-3 monotherapy can improve depression in patients with CHD remains to be determined.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00116857.

Nutrition, mood and behaviour: a review

OBJECTIVE

To conduct a critical review of recent empirical research regarding mood, behaviour and nutrition factors including essential fatty acids, macronutrients, micronutrients and food additives.

METHOD

A literature search of databases Medline, PsycInfo, CINAHL and Embase up to October 2008. The search emphasised empirical research published in the last 10 years and also included older literature. Studies in both adults and children were addressed.

RESULTS

Research into omega-3 fatty acids has been substantial but evidence for their potential in treating mood and behaviour is modest. In comparison, there has been much less research into carbohydrate and protein intakes and little evidence for their ability to influence mood and behaviour. Recent trials with food additives suggest their removal from the diet may benefit susceptible children with hyperactivity disorders. Micronutrient supplementation appears to improve mood only in those who were initially deficient in micronutrients.

CONCLUSIONS

More stringent research designs such as longitudinal studies and the use of biologically inert placebos within randomised controlled trials are needed before supplemental use of omega-3 fatty acids to treat disorders of mood and behaviour can be recommended. Caution is advised regarding the indiscriminate use of diets free of artificial food additives in managing hyperactivity disorders, as they may place an undue burden on individuals and their families. Should omega-3 fatty acid supplementation or the elimination of certain food additives be established as effective, they may provide cost-effective, accessible and well-tolerated adjuncts to standard psychiatric treatments for mood and behavioural disturbances.

Long-chain n-3 fatty acid levels in baseline serum phospholipids do not predict later occurrence of depressive episodes: a nested case-control study within a cohort of middle-aged French men and women

The goal of this study was to seek the relations between baseline n-3 PUFA status and the later occurrence of depressive episodes in a French cohort of middle-aged men and women, the SU.VI.MAX study. A nested case-control study was designed within the cohort: cases with at least two depressive episodes during the 8-year follow-up were paired to non-depressed controls, antidepressant prescriptions being taken as markers of depressive episodes. The fatty acid profiles of baseline serum phospholipids have been determined. Results were analyzed using logistic regression and principal component analysis, taking into account depression history and demographic and lifestyle confounders. There was no consistent association of depression risk with any serum fatty acid, and in particular there was no association of depression risk with the long-chain n-3 PUFA eicosapentaenoic, docosapentaenoic and docosahexaenoic acids. This study does not support the hypothesis of a predictive value of n-3 PUFA status for depression in population settings.

Membrane omega-3 Fatty Acid deficiency as a preventable risk factor for comorbid coronary heart disease in major depressive disorder

Major depression disorder (MDD) significantly increases the risk for coronary heart disease (CHD) which is a leading cause of mortality in patients with MDD. Moreover, depression is frequently observed in a subset of patients following acute coronary syndrome (ACS) and increases risk for mortality. Here evidence implicating omega-3 (n-3) fatty acid deficiency in the pathoaetiology of CHD and MDD is reviewed, and the hypothesis that n-3 fatty acid deficiency is a preventable risk factor for CHD comorbidity in MDD patients is evaluated. This hypothesis is supported by cross-national and cross-sectional epidemiological surveys finding an inverse correlation between n-3 fatty acid status and prevalence rates of both CHD and MDD, prospective studies finding that lower dietary or membrane EPA+DHA levels increase risk for both MDD and CHD, case-control studies finding that the n-3 fatty acid status of MDD patients places them at high risk for emergent CHD morbidity and mortality, meta-analyses of controlled n-3 fatty acid intervention studies finding significant advantage over placebo for reducing depression symptom severity in MDD patients, and for secondary prevention of cardiac events in CHD patients, findings that n-3 fatty acid status is inversely correlated with other documented CHD risk factors, and patients diagnosed with MDD after ACS exhibit significantly lower n-3 fatty acid status compared with nondepressed ACS patients. This body of evidence provides strong support for future studies to evaluate the effects of increasing dietary n-3 fatty acid status on CHD comorbidity and mortality in MDD patients.

Considerations regarding neuropsychiatric nutritional requirements for intakes of omega-3 highly unsaturated fatty acids

BACKGROUND

Adverse neurodevelopmental and neuropsychiatric outcomes have been established as signs of nutrient deficiencies and may be applicable to insufficient dietary intakes of omega-3 highly unsaturated fatty acids (n-3 HUFAs).

OBJECTIVE

Consider if statistical definitions for Daily Reference Intakes can be applied to n-3 HUFAs intakes during pregnancy for maternal and neurodevelopmental deficiencies.

DESIGN

Data were prospectively collected from women during pregnancy and children up to age 8 years participating in the Avon Longitudinal Study of Parents and Children (ALSPAC). Statistical analyses took social and lifestyle factors into account.

RESULTS

During pregnancy, n-3 HUFA intakes from seafood that putatively meet statistical definitions of an estimated average requirement ranged from 0.05 to 0.06 en% (111-139 mg/d/2000 Cal) for suboptimal fine motor control at 42 m and 0.065-0.08 en% (114-181 mg/d/2000 Cal) for suboptimal verbal IQ at age 8 years and 0.18-0.22 en% (389-486 mg/d/2000 Cal) for maternal depression at 32 weeks. Intakes of n-3 ranging from 0.2 to 0.41 en% (445-917 mg/d/2000 Cal) prevented both increased risk of maternal depression and adverse neurodevelopmental outcomes for children among 97.5% of the population. No upper limit for safety was found.

CONCLUSION

During pregnancy, a n-3 HUFA intake of 0.40 en% (900 mg/d/2000 Cal) from seafood is likely to meet the nutritional requirements for 97.5% of the mothers and children of this population. These considerations do not constitute DRI's for docosahexaenoic acid and n-3 HUFAs, but may contribute to their formulation.

Omega-3 deficiency associated with perinatal depression: case control study

Women are depleted of omega-3 polyunsaturated fatty acids (n-3 PUFAs) during the perinatal period due to fetal diversion. An association has been shown between lowered n-3 PUFAs and depression in general. We therefore hypothesise that women with lower n-3 PUFA levels are at greater risk of depression during pregnancy. Sixteen depressed and 22 non-depressed women were recruited during the third trimester and fasting bloods were taken for plasma fatty acid analysis. High docosahexaenoic acid (DHA), high total n-3 and a low n-6:n-3 ratio were associated with significantly lower odds of depression. After adjustment for parity, age and education level, those with high DHA still had significantly lower odds of being depressed. Those with high total n-3 and a low n-6:n-3 ratio were also at significantly reduced risk of depression, although the magnitude of the difference was reduced. Study results quantified women with lower omega-3 PUFA levels as being six times more likely to be depressed antenatally, compared to women who had higher omega-3 PUFA levels. The prophylactic benefits of supplementation either prenatally or during pregnancy require close study to assess whether omega-3 PUFAs play a role in the prevention of perinatal depression.

Intracellular- and extracellular-derived Ca(2+) influence phospholipase A(2)-mediated fatty acid release from brain phospholipids

Docosahexaenoic acid (DHA) and arachidonic acid (AA) are found in high concentrations in brain cell membranes and are important for brain function and structure. Studies suggest that AA and DHA are hydrolyzed selectively from the sn-2 position of synaptic membrane phospholipids by Ca(2+)-dependent cytosolic phospholipase A(2) (cPLA(2)) and Ca(2+)-independent phospholipase A(2) (iPLA(2)), respectively, resulting in increased levels of the unesterified fatty acids and lysophospholipids. Cell studies also suggest that AA and DHA release depend on increased concentrations of Ca(2+), even though iPLA(2) has been thought to be Ca(2+)-independent. The source of Ca(2+) for activation of cPLA(2) is largely extracellular, whereas Ca(2+) released from the endoplasmic reticulum can activate iPLA(2) by a number of mechanisms. This review focuses on the role of Ca(2+) in modulating cPLA(2) and iPLA(2) activities in different conditions. Furthermore, a model is suggested in which neurotransmitters regulate the activity of these enzymes and thus the balanced and localized release of AA and DHA from phospholipid in the brain, depending on the primary source of the Ca(2+) signal.

Is there a role for n-3 long-chain polyunsaturated fatty acids in the regulation of mood and behaviour? A review of the evidence to date from epidemiological studies, clinical studies and intervention trials

Selected biochemical evidence suggests a potential role for n-3 long-chain PUFA (n-3PUFA) in the regulation of mood and behaviour. The present paper reviews the relevant evidence, to date, from epidemiological studies, clinical studies and intervention trials. Most evidence is available investigating a role for n-3PUFA in depression, depressive illness and suicidal behaviour, but work is also available on anxiety and anxiety-related disorders, fatigue and fatigue-related disorders, aggression, hostility and anti-social behaviour, inattention, impulsivity and attention deficit hyperactivity disorder and schizophrenic disorders. For all these aspects of mood and behaviour, the evidence available is currently limited and highly inconsistent, both in terms of study methodology and study findings. There is a clear need for further work in this area.

Acute coronary syndrome patients with depression have low blood cell membrane omega-3 fatty acid levels

OBJECTIVE

To determine the extent to which levels of membrane eicosapentaenoic (EPA)+docosahexaenoic acids (DHA) (the omega-3 index) were associated with depression in patients with acute coronary syndrome (ACS). Depression is associated with worse cardiovascular (CV) outcomes in patients with ACS. Reduced levels of blood cell membrane omega-3 (n-3) fatty acids (FAs), an emerging risk factor for both CV disease and depression, may help to explain the link between depression and adverse CV outcomes.

METHODS

We measured membrane FA composition in 759 patients with confirmed ACS. The analysis included not only EPA and DHA but also the n-6 FAs linoleic and arachidonic acids (LA and AA). Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ). Multivariable linear regression was used to adjust for demographic and clinical characteristics.

RESULTS

There was a significant inverse relationship between the n-3 index and depressive symptoms (PHQ) in the fully adjusted model (p = .034). For every 4.54% point rise in the n-3 index, there was a 1-point decline in depressive symptoms. In contrast to the n-3 FAs, membrane levels of the n-6 FAs LA and AA were not different between depressed and nondepressed ACS patients.

CONCLUSION

We found an inverse relationship between the n-3 index and the prevalence of depressive symptoms in patients with ACS. Therefore, this study supports the hypothesis that reduced n-3 FA tissue levels are a common and potentially modifiable link between depression and adverse CV outcomes.

The role of fatty acids in the development and treatment of mood disorders

PURPOSE OF REVIEW

There is increasing evidence from epidemiological, case-control and randomized clinical trials for a link between omega-3 deficiency and the development of mood disorders. This article examines recent evidence for this association.

RECENT FINDINGS

During the past year our understanding of the effect of omega-3 depletion on the structure and function of the brain has been furthered by research examining human brain tissue and by studies utilizing animal models of depression. Human and animal research has also provided further evidence for omega-3 affecting mood via its anti-inflammatory effects. Previous clinical trials indicated that omega-3 can be effective as an adjunctive treatment for those with treatment-resistant depression. More recent clinical trial data indicate that omega-3 may also be an effective monotherapy for childhood depression and for depressed mood in patients who engage in recurrent self-harm. The recent clinical trial data regarding omega-3 as a treatment for bipolar disorder are inconclusive, however, and clinical trials in postnatal depression are still lacking.

SUMMARY

This article reviews the most important recent papers in this burgeoning and interesting research area.

Long chain omega-3 fatty acids intake, fish consumption and mental disorders in the SUN cohort study

BACKGROUND

Very long chain omega-3 fatty acids (w-3 PUFA) intake and fish consumption have been suggested as protective factors against neuropsychiatric disorders but there is scarcity of large cohort studies assessing this association.

AIM OF THE STUDY

To assess the association between w-3-PUFA intake and fish consumption and mental disorders.

METHODS

A prospective cohort study was performed in 7,903 participants. W-3 PUFA intake and fish consumption were ascertained through a validated semi-quantitative food frequency questionnaire. The outcomes after 2 years of follow-up were: (1) Incident mental disorder (depression, anxiety, or stress), (2) incident depression, and (3) incident anxiety. Logistic regression models and generalized additive models were fit to assess the relationship between w-3 PUFA intake or fish consumption and the incidence of these outcomes. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated.

RESULTS

173 cases of depression, 335 cases of anxiety, and 4 cases of stress were observed during 2-year follow-up. ORs (95% CI) of mental disorder for successive quintiles of energy-adjusted w-3 PUFA intake were 1 (reference), 0.72 (0.52-0.99), 0.79 (0.58-1.08), 0.65 (0.47-0.90), and 1.04 (0.78-1.40). Subjects with a moderate consumption of fish (third and fourth quintiles of consumption: median of each quintile 83.3 and 112 g/day, respectively) had a relative risk reduction higher than 30%.

CONCLUSIONS

A potential benefit of w-3 PUFA intake on total mental disorders is suggested, although no linear trend was apparent.