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Turner M. Neurobiological and psychological factors to depression. Int J Psychiatry Clin Pract 2024:1-14. [PMID: 39101692 DOI: 10.1080/13651501.2024.2382091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 08/06/2024]
Abstract
Major Depressive Disorder (MDD) is a common condition with complex psychological and biological background. While its aetiology is still unclear, chronic stress stands amongst major risk factors to MDD pathogenesis. When researching on MDD, it is necessary to be familiar with the neurobiological effects of several prominent contributors to the chronic stress factor experienced across hypothalamic-pituitary-adrenal (HPA) axis, neurotransmission, immune system reflexivity, and genetic alterations. Bi-directional flow of MDD pathogenesis suggests that psychological factors produce biological effects. Here, a summary of how the MDD expresses its mechanisms of action across an overactive HPA axis, the negative impacts of reduced neurotransmitter functions, the inflammatory responses and their gene x environment interactions. This paper builds on these conceptual factors and their input towards the MDD symptomatology with a purpose of synthesising the current findings and create an integrated view of the MDD pathogenesis. Finally, relevant treatment implications will be summarised, along with recommendations to a multimodal clinical practice.
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Affiliation(s)
- Malini Turner
- School of Health, University of New England, Armidale, Australia
- Biomedical Sciences, Endeavour College of Natural Health, Brisbane, Australia
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Abelson JL, Sánchez BN, Mayer SE, Briggs H, Liberzon I, Rajaram N. Do diurnal salivary cortisol curves carry meaningful information about the regulatory biology of the HPA axis in healthy humans? Psychoneuroendocrinology 2023; 150:106031. [PMID: 36801587 DOI: 10.1016/j.psyneuen.2023.106031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/22/2023] [Accepted: 01/22/2023] [Indexed: 01/26/2023]
Abstract
Salivary cortisol stress biomarkers have been extensively used in epidemiological work to document links between stress and ill health. There has been little effort to ground field friendly cortisol measures in the hypothalamic-pituitary-adrenal (HPA) axis regulatory biology that is likely relevant to delineating mechanistic pathways leading from stress exposure to detrimental health outcomes. Here, we utilized a healthy convenience sample (n = 140) to examine normal linkages between extensively collected salivary cortisol measures and available laboratory probes of HPA axis regulatory biology. Participants provided 9 saliva samples per day over 6 days within a month, while engaging in usual activities, and also participated in 5 regulatory tests (adrenocorticoptripin stimulation, dexamethasone/corticotropin-releasing-hormone stimulation, metyrapone, dexamethasone suppression, and Trier Social Stress Test). Logistical regression was used to test specific predictions linking cortisol curve components to regulatory variables and to explore widely for non-predicted associations. We found support for 2 of 3 original hypotheses, showing associations (1) between cortisol diurnal decline and feedback sensitivity as measured by dexamethasone suppression, and (2) between morning cortisol levels and adrenal sensitivity. We did not find links between central drive (metyrapone test) and end of day salivary levels. We confirmed an a priori expectation of limited linkage between regulatory biology and diurnal salivary cortisol measures, beyond those predicted. These data support an emerging focus on measures related to diurnal decline in epidemiological stress work. They raise questions about the biological meaning of other curve components, including morning cortisol levels, and perhaps CAR (Cortisol Awakening Response). If morning cortisol dynamics are linked to stress, more work on adrenal sensitivity in stress adaptation and stress-health links may be warranted.
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Affiliation(s)
- James L Abelson
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
| | - Brisa N Sánchez
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Stefanie E Mayer
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Hedieh Briggs
- Department of Psychiatry and Behavioral Sciences, Texas A&M University, College Station, TX, USA
| | - Israel Liberzon
- Department of Psychiatry and Behavioral Sciences, Texas A&M University, College Station, TX, USA
| | - Nirmala Rajaram
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Skalniak A, Krzyściak W, Śmierciak N, Szwajca M, Donicz P, Kozicz T, Pilecki M. Immunological routine laboratory parameters at admission influence the improvement of positive symptoms in schizophrenia patients after pharmacological treatment. Front Psychiatry 2023; 14:1082135. [PMID: 37032951 PMCID: PMC10073498 DOI: 10.3389/fpsyt.2023.1082135] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/20/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction The standard care of schizophrenia patients is based on the assessment of their psychotic behavior, using interview-based, subjective scales that measure symptoms severity. We aimed at defining easily accessible and inexpensive blood-derived clinical diagnostic parameters that might serve as objective markers in the prediction of the effects of pharmacological treatment of schizophrenia patients. Methods A total of 40 patients with schizophrenia diagnosis according to ICD 10 during psychotic decompensation were included in the study. Blood-based biochemical parameters, BMI and interview-based medical scales of symptom severity were determined - all at admission and after 12 weeks of standard pharmacological treatment. Results The drops in scale values were correlated with clinical parameters. All scale changes after treatment were dependent on the value of the given scale at admission, with higher initial values leading to larger drops of the values after treatment. Models based on those correlations were significantly improved when immune and metabolism parameters were included. C4 complement and C-reactive protein (CRP) level at admission were predictive of changes in Positive and Negative Syndrome Scale (PANSS) subscales related to significant disruption of thought processes, reality testing and disorganization. The pharmacological treatment-driven changes in scales representing negative symptoms were correlated with markers of the patients' thyroid status and metabolism. Discussion We show that objective markers can be obtained by testing immune and metabolic parameters from the patients' blood and may be added at a low cost to the standard care of schizophrenia patients in order to predict the outcome of pharmacological treatment.
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Affiliation(s)
- Anna Skalniak
- Department of Endocrinology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Wirginia Krzyściak
- Department of Medical Diagnostics, Faculty of Pharmacy, Jagiellonian University Medical College, Kraków, Poland
- *Correspondence: Wirginia Krzyściak,
| | - Natalia Śmierciak
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Marta Szwajca
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Paulina Donicz
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Tamas Kozicz
- Department of Clinical Genomics, Mayo Clinic, Rochester, MN, United States
| | - Maciej Pilecki
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
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Beydoun HA, Beydoun MA, Maldonado AI, Fanelli-Kuczmarski MT, Weiss J, Evans MK, Zonderman AB. Allostatic Load and Cognitive Function Among Urban Adults in the Healthy Aging in Neighborhoods of Diversity across the Life Span Study. J Alzheimers Dis 2023; 92:425-443. [PMID: 36776055 PMCID: PMC10896260 DOI: 10.3233/jad-220888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND Cross-sectional studies have linked cognition to allostatic load (AL) which reflects multisystem dysregulation from life course exposure to stressors. OBJECTIVE To examine baseline and changes in AL and their relationships with 11 cognitive function test scores, while exploring health disparities according to sex and race. METHODS Longitudinal [Visit 1 (2004-2009) and Visit 2 (2009-2013)] data were analyzed from 2,223 Healthy Aging in Neighborhoods of Diversity across the Life Span participants. We calculated AL total score using cardiovascular, metabolic, and inflammatory risk indicators, and applied group-based trajectory modeling to define AL change. RESULTS Overall and stratum-specific relationships were evaluated using mixed-effects linear regression models that controlled for socio-demographic, lifestyle, and health characteristics. Baseline AL was significantly associated with higher log-transformed Part A Trail Making Test score [Loge (TRAILS A)] (β= 0.020, p = 0.004) and increasing AL was associated with higher Benton Visual Retention Test score [BVRT] (β= 0.35, p = 0.002) at baseline, in models that controlled for age, sex, race, poverty status, education, literacy, smoking, drug use, the 2010 healthy eating index and body mass index. Baseline AL and AL change were not related to change in cognitive function between visits. There were no statistically significant interaction effects by sex or race in fully-adjusted models. CONCLUSION At baseline, AL was associated with worse attention or executive functioning. Increasing AL was associated with worse non-verbal memory or visuo-constructional abilities at baseline. AL was not related to change in cognitive function over time, and relationships did not vary by sex or race.
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Affiliation(s)
- Hind A. Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, VA, USA
| | - May A. Beydoun
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, Baltimore, MD, USA
| | - Ana I. Maldonado
- Department of Psychology, University of Maryland Baltimore County, Baltimore, MD, USA
| | - Marie T. Fanelli-Kuczmarski
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, Baltimore, MD, USA
| | - Jordan Weiss
- Stanford Center on Longevity, Stanford University, Stanford, CA, USA
| | - Michele K. Evans
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, Baltimore, MD, USA
| | - Alan B. Zonderman
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, Baltimore, MD, USA
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Kanes SJ, Dennie L, Perera P. Targeting the Arginine Vasopressin V 1b Receptor System and Stress Response in Depression and Other Neuropsychiatric Disorders. Neuropsychiatr Dis Treat 2023; 19:811-828. [PMID: 37077711 PMCID: PMC10106826 DOI: 10.2147/ndt.s402831] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/23/2023] [Indexed: 04/21/2023] Open
Abstract
A healthy stress response is critical for good mental and overall health and promotes neuronal growth and adaptation, but the intricately balanced biological mechanisms that facilitate a stress response can also result in predisposition to disease when that equilibrium is disrupted. The hypothalamic-pituitary-adrenal (HPA) axis neuroendocrine system plays a critical role in the body's response and adaptation to stress, and vasopressinergic regulation of the HPA axis is critical to maintaining system responsiveness during chronic stress. However, exposure to repeated or excessive physical or emotional stress or trauma can shift the body's stress response equilibrium to a "new normal" underpinned by enduring changes in HPA axis function. Exposure to early life stress due to adverse childhood experiences can also lead to lasting neurobiological changes, including in HPA axis function. HPA axis impairment in patients with depression is considered among the most reliable findings in biological psychiatry, and chronic stress has been shown to play a major role in the pathogenesis and onset of depression and other neuropsychiatric disorders. Modulating HPA axis activity, for example via targeted antagonism of the vasopressin V1b receptor, is a promising approach for patients with depression and other neuropsychiatric disorders associated with HPA axis impairment. Despite favorable preclinical indications in animal models, demonstration of clinical efficacy for the treatment of depressive disorders by targeting HPA axis dysfunction has been challenging, possibly due to the heterogeneity and syndromal nature of depressive disorders. Measures of HPA axis function, such as elevated cortisol levels, may be useful biomarkers for identifying patients who may benefit from treatments that modulate HPA axis activity. Utilizing clinical biomarkers to identify subsets of patients with impaired HPA axis function who may benefit is a promising next step in fine-tuning HPA axis activity via targeted antagonism of the V1b receptor.
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Affiliation(s)
- Stephen J Kanes
- EmbarkNeuro, Oakland, CA, USA
- Correspondence: Stephen J Kanes, EmbarkNeuro, Inc, 1111 Broadway, Suite 1300, Oakland, CA, 94607, USA, Tel +1 610 757 7821, Email
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Ortiz R, Kluwe B, Lazarus S, Teruel MN, Joseph JJ. Cortisol and cardiometabolic disease: a target for advancing health equity. Trends Endocrinol Metab 2022; 33:786-797. [PMID: 36266164 PMCID: PMC9676046 DOI: 10.1016/j.tem.2022.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/29/2022] [Indexed: 11/05/2022]
Abstract
Stress, in both intrinsic psychosocial and extrinsic physical environmental forms, can impact the development of, and outcomes in, cardiovascular disease (CVD) through allostatic load. Cortisol is a core hormonal mediator of allostatic load produced in response to various stresses. Alterations in morning serum cortisol and daily diurnal cortisol have been associated with adiposity, dyslipidemia, incident diabetes, and CVDs such as hypertension. The review examines the role of cortisol as a key mechanistic link between stress physiology and cardiometabolic disease. Importantly, we discuss the role of targeting cortisol through pharmacological, behavioral, and environmental interventions to advance health equity in cardiometabolic disease.
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Affiliation(s)
- Robin Ortiz
- Department of Pediatrics, NYU Grossman School of Medicine, New York, NY, USA; Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA; Institute for Excellence of Health Equity, NYU Langone Health, New York, NY, USA
| | - Bjorn Kluwe
- Division of Endocrinology, Diabetes and Metabolism, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sophie Lazarus
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Mary N Teruel
- Department of Biochemistry and the Drukier Institute for Children's Health, Weill Cornell Medicine, New York, NY, USA
| | - Joshua J Joseph
- Division of Endocrinology, Diabetes and Metabolism, The Ohio State University College of Medicine, Columbus, OH, USA.
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Holleman J, Adagunodo S, Kåreholt I, Hagman G, Aspö M, Udeh-Momoh CT, Solomon A, Kivipelto M, Sindi S. Cortisol, cognition and Alzheimer's disease biomarkers among memory clinic patients. BMJ Neurol Open 2022; 4:e000344. [PMID: 36277478 PMCID: PMC9582323 DOI: 10.1136/bmjno-2022-000344] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/05/2022] [Indexed: 11/03/2022] Open
Abstract
Objective This study aims to investigate the relationship between diurnal cortisol patterns, cognition and Alzheimer's disease (AD) biomarkers in memory clinic patients. Method Memory clinic patients were recruited from Karolinska University Hospital in Sweden (n=155). Diurnal cortisol patterns were assessed using five measures: awakening levels, cortisol awakening response, bedtime levels, the ratio of awakening to bedtime levels (AM/PM ratio) and total daily output. Cognition was measured in five domains: memory, working memory, processing speed, perceptual reasoning and overall cognition. AD biomarkers Aβ42, total tau and phosphorylated tau were assessed from cerebrospinal fluid (CSF). Cognition was measured at follow-up (average 32 months) in a subsample of participants (n=57). Results In assessing the associations between cortisol and cognition, higher awakening cortisol levels were associated with greater processing speed at baseline. No relationship was found between diurnal cortisol patterns and change in cognition over time or CSF AD biomarkers in the total sample. After stratification by CSF Aβ42 levels, higher awakening cortisol levels were associated with worse memory performance in amyloid-positive participants. In amyloid-negative participants, higher bedtime cortisol levels and a lower AM/PM ratio were associated with lower overall cognition, greater awakening cortisol levels were associated with better processing speed, and a higher AM/PM ratio was associated with better perceptual reasoning. Additionally, higher awakening cortisol levels were associated with lower CSF Aβ42 levels in amyloid-positive participants, while higher bedtime cortisol levels and a lower AM/PM ratio were associated with higher CSF total tau in amyloid-negative participants. Conclusions Our findings suggest that diurnal cortisol patterns are associated with cognitive function and provide new insights into the association between diurnal cortisol patterns and AD-related CSF biomarkers. Further research is needed to examine the complex relationship between cortisol, cognition and brain pathology.
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Affiliation(s)
- Jasper Holleman
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Stockholm, Sweden
| | - Sofia Adagunodo
- Memory Clinic Zentralschweiz, Luzerner Psychiatrie, Pfaffnau-Sankt Urban, Switzerland
| | - Ingemar Kåreholt
- Institute of Gerontology, School of Health and Welfare, Aging Research Network – Jönköping (ARN-J), Jönköping University, Jonkoping, Sweden
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Göran Hagman
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Stockholm, Sweden
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Aspö
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Stockholm, Sweden
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden
| | - Chinedu T Udeh-Momoh
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Stockholm, Sweden
- Ageing Epidemiology Research Unit (AGE), School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Alina Solomon
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Stockholm, Sweden
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden
- Ageing Epidemiology Research Unit (AGE), School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- Institute of Clinical Medicine, Neurology, University of Eastern Finland, Kuopio, Finland
| | - Miia Kivipelto
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Stockholm, Sweden
- Theme Inflammation and Aging, Karolinska University Hospital, Stockholm, Sweden
- Ageing Epidemiology Research Unit (AGE), School of Public Health, Faculty of Medicine, Imperial College London, London, UK
- Institute of Clinical Medicine, Neurology, University of Eastern Finland, Kuopio, Finland
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
| | - Shireen Sindi
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Stockholm, Sweden
- Ageing Epidemiology Research Unit (AGE), School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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Lesmana MHS, Le NQK, Chiu WC, Chung KH, Wang CY, Irham LM, Chung MH. Genomic-Analysis-Oriented Drug Repurposing in the Search for Novel Antidepressants. Biomedicines 2022; 10:biomedicines10081947. [PMID: 36009493 PMCID: PMC9405592 DOI: 10.3390/biomedicines10081947] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/07/2022] [Accepted: 08/08/2022] [Indexed: 12/02/2022] Open
Abstract
From inadequate prior antidepressants that targeted monoamine neurotransmitter systems emerged the discovery of alternative drugs for depression. For instance, drugs targeted interleukin 6 receptor (IL6R) in inflammatory system. Genomic analysis-based drug repurposing using single nucleotide polymorphism (SNP) inclined a promising method for several diseases. However, none of the diseases was depression. Thus, we aimed to identify drug repurposing candidates for depression treatment by adopting a genomic-analysis-based approach. The 5885 SNPs obtained from the machine learning approach were annotated using HaploReg v4.1. Five sets of functional annotations were applied to determine the depression risk genes. The STRING database was used to expand the target genes and identify drug candidates from the DrugBank database. We validated the findings using the ClinicalTrial.gov and PubMed databases. Seven genes were observed to be strongly associated with depression (functional annotation score = 4). Interestingly, IL6R was auspicious as a target gene according to the validation outcome. We identified 20 drugs that were undergoing preclinical studies or clinical trials for depression. In addition, we identified sarilumab and satralizumab as drugs that exhibit strong potential for use in the treatment of depression. Our findings indicate that a genomic-analysis-based approach can facilitate the discovery of drugs that can be repurposed for treating depression.
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Affiliation(s)
| | - Nguyen Quoc Khanh Le
- Professional Master Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Research Center for Artificial Intelligence in Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Translational Imaging Research Center, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - Wei-Che Chiu
- Department of Psychiatry, Cathay General Hospital, Taipei 10630, Taiwan
- School of Medicine, Fu Jen Catholic University, New Taipei City 242062, Taiwan
| | - Kuo-Hsuan Chung
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Department of Psychiatry and Psychiatric Research Center, Taipei Medical University Hospital, Taipei Medical University, Taipei 11031, Taiwan
| | - Chih-Yang Wang
- Ph.D. Program for Cancer Molecular Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University and Academia Sinica, Taipei 11031, Taiwan
- Graduate Institute of Cancer Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan
| | - Lalu Muhammad Irham
- Faculty of Pharmacy, University of Ahmad Dahlan, Yogyakarta 55164, Indonesia
- Correspondence: (L.M.I.); (M.-H.C.); Tel.: +62-851-322-55-414 (L.M.I.); +886-02-2736-1661 (M.-H.C.)
| | - Min-Huey Chung
- School of Nursing, College of Nursing, Taipei Medical University, Taipei 11031, Taiwan
- Department of Nursing, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Correspondence: (L.M.I.); (M.-H.C.); Tel.: +62-851-322-55-414 (L.M.I.); +886-02-2736-1661 (M.-H.C.)
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Wen JH, Sin NL. Perceived control and reactivity to acute stressors: Variations by age, race and facets of control. Stress Health 2022; 38:419-434. [PMID: 34626157 DOI: 10.1002/smi.3103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 11/12/2022]
Abstract
Greater perceived control is associated with better health and well-being outcomes, possibly through more adaptive stress processes. Yet little research has examined whether facets of perceived control (personal mastery and perceived constraints) predict psychological and physiological stress reactivity. The present study evaluated the associations of personal mastery and perceived constraints with changes in subjective stress and cortisol in response to acute laboratory stressors, with age and race as potential moderators. In the Midlife in the United States Refresher Study (N = 633 adults aged 25-75), participants completed a baseline perceived control measure and were subsequently recruited to participate in the laboratory stress protocol. The protocol consisted of completing two mental stress tasks (mental arithmetic and Stroop) as well as providing saliva samples and subjective stress ratings. Race moderated the association between perceived constraints and subjective stress reactivity, such that higher constraints predicted greater subjective stress responses in White participants, but no association was observed in Black participants. Higher personal mastery and perceived constraints each predicted greater increases in cortisol in response to the stress tasks (AUCi ) among younger but not older adults. These findings suggest that older adults were buffered against the association between facets of control and cortisol stress reactivity. Discussion on potential racial differences in the link between constraints and stress reactivity are elaborated further, as well as considerations for future work to distinguish between facets of control and examine age and racial differences.
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Affiliation(s)
- Jin H Wen
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Nancy L Sin
- University of British Columbia, Vancouver, British Columbia, Canada
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Diurnal dynamic range as index of dysregulation of system dynamics. A cortisol examplar using data from the Study of Midlife in the United States. Psychoneuroendocrinology 2022; 142:105804. [PMID: 35623318 PMCID: PMC9262344 DOI: 10.1016/j.psyneuen.2022.105804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 11/22/2022]
Abstract
We discuss the importance of including measures of dysregulated system dynamics in the operationalization of allostatic load. The concept of allostatic load, as originally proposed by McEwen and Stellar, included dysregulation not only in the resting state of physiological systems, but also in system dynamics. We describe previous work on cortisol diurnal dynamic range (peak to nadir spread) as an index of the health of the hypothalamic-pituitary-adrenal axis, with compression of dynamic range being a marker of dysregulation. In particular, we review the evidence for a) diurnal dynamic range compression in people from disadvantaged backgrounds, b) cross-sectional association of cortisol diurnal dynamic range compression with dysregulation in other systems' resting states, and c) cross-sectional association of cortisol diurnal dynamic range compression with lower scores on cognitive testing. Then, we present new data from the Study of Midlife in the United States (MIDUS) on longitudinal associations of cortisol dynamic range compression with subsequent cognitive decline and all-cause mortality. Briefly, each standard deviation decrement in cortisol diurnal dynamic range is associated with adjusted mortality hazard ratio of 1.35 (95% confidence interval: 1.19, 1.54). Among those who scored at median or lower in executive functioning at baseline and survive, each standard deviation decrement in cortisol dynamic range is associated with 1% greater decline in executive functioning over a decade (95% confidence interval: 0.4%, 2.0%). We conclude that including measures of system dynamics like diurnal dynamic range in the next generation of allostatic load measurement will likely advance understanding of the cumulative physiological burden of chronic stress and life experiences, and improve the prediction of future health consequences.
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Ortiz R, Joseph JJ, Branas CC, MacDonald JM, Nguemeni Tiako MJ, Oyekanmi K, South EC. Advancing health equity through integrated biology and population health research: A community-based sample cortisol feasibility and exploratory study. COMPREHENSIVE PSYCHONEUROENDOCRINOLOGY 2022; 11:100145. [PMID: 35757172 PMCID: PMC9228000 DOI: 10.1016/j.cpnec.2022.100145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/21/2022] Open
Abstract
Background Community-based research inclusive of self-assessment and objective environmental metrics can be enhanced by the collection of biomarker data in unity toward assessing the health impacts of the totality of environmental stress driven by structural racism. Cortisol dynamic range (CDR), a measure of chronic stress burden, may underpin place-based connections to health, but a gap remains in elucidating community-based CDR methodology. Purpose To 1) assess the feasibility of cortisol collection and CDR measurement in a community-based study with home-based, participant-directed specimen collection, and 2) explore the association between CDR and other individual and environmental measures in a sample of predominantly Black participants. Methods: In this cross-sectional, observational study in predominantly Black urban neighborhoods, participants (n = 73) completed health assessments and in-home, self-collected salivary cortisol. For feasibility, CDR (peak-nadir) was compared to cortisol awakening response (CAR) slope over time. Comparisons of CDR quartile by person and place variables were explored (ANOVA). Results The cohort (77% Black, 39.7% <$15 k/year income, high perceived stress) completed 98.6% of cortisol collection timepoints. CDR was calculated in all participants without interruptions to sleep-wake cycle as seen with CAR collection. Participants in the lowest quartile of CDR were the oldest (p = 0.03) with lowest reported mental health (p = 0.048) with no associations seen for CAR. Conclusion Participant-collected 10.13039/501100011622CDR is more feasible than cortisol measures dependent on slopes over time in a community-based, predominately Black cohort with exploratory findings supporting relevance to outcomes of interest to future work. Future community-based studies should integrate CDR with environment and psychosocial measures. Biological and social metrics can enhance community studies of structural racism. Cortisol dynamic range (CDR) may reflect the burden of chronic stress in a community. In-home, participant-collected salivary cortisol is feasible with in-field guidance. CDR may be more feasible in community-based study than measures dependent on time. Greatest CDR is seen with youngest age and best self-reported mental health.
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Affiliation(s)
- Robin Ortiz
- Departments of Pediatrics and Population Health, New York University, Grossman School of Medicine, 180 Madison Ave, New York, NY, 10016, USA
- Institute for Excellence in Health Equity, New York University Langone Health, New York, Grossman School of Medicine, 180 Madison Ave, New York, NY, 10016, USA
- National Clinician Scholars Program, University of Pennsylvania Perelman School of Medicine, 1300 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
- Corresponding author. Departments of Pediatrics and Population Health, New York University, Grossman School of Medicine, 180 Madison Ave, New York, NY, 10016, USA
| | - Joshua J. Joseph
- The Ohio State University, Wexner Medical Center, Division of Endocrinology, Diabetes and Metabolism, 579 McCampbell Hall, Columbus, OH, 43210, USA
| | - Charlie C. Branas
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, Rm 1508, New York, NY, 10032, USA
| | - John M. MacDonald
- Department of Criminology, School of Arts and Sciences, University of Pennsylvania, 558 McNeil Building, Locus Walk, Philadelphia, PA, 19104, USA
| | | | - Kehinde Oyekanmi
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, 423 Guardian Drive, Philadelphia, PA, 19104, USA
- Urban Health Lab, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Eugenia C. South
- Department of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, 423 Guardian Drive, Philadelphia, PA, 19104, USA
- Urban Health Lab, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Zhang Y, Huang B, Yang W, Zhong S, Lai S, Zhao H, He J, Cai S, Lv S, Wang C, Jia Y. Correlations Between Endocrine Hormones and Cognitive Function in Patients with Obesity: a Cross-sectional Study. Obes Surg 2022; 32:2299-2308. [PMID: 35486288 DOI: 10.1007/s11695-022-06076-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Obesity not only affects physical and mental conditions, but also influences cognitive function. Endocrine hormones may influence the risk of obesity and severe obesity. Our study investigated the influences of changes in levels of endocrine hormones on cognitive function in patients with obesity and severe obesity. METHODS We used the MATRICS Consensus Cognitive Battery (MCCB) to evaluate cognitive function in the groups of healthy control (HC), obesity (OB), and severe obesity (SOB). We detected the levels of endocrine hormones and cortisol at 8:00 am in the three groups. We statistically analyzed differences in cognitive function and levels of endocrine hormones among the three groups, and performed linear correlation analysis of cortisol level and cognitive function. Using mediation analysis, we assessed the influences of body mass index (BMI) on endocrine levels and cognitive function. RESULTS Our findings revealed that OB and SOB groups exhibited a lower level of cortisol than HC group. Among the three groups, we found significant differences in verbal learning (F = 4.433, P = 0.014), social cognition (F = 4.778, P = 0.010), and total cognition (F = 2.989, P = 0.008). After post hoc Bonferroni correction, we noted that SOB group had worse scores in the above-mentioned three areas than OB and HC groups. Moreover, except for working memory and visual cognition, we identified that the degree of cognitive impairment in SOB group was more severe than that in OB group. In our study, mediation analysis showed a mediating effect of BMI on cortisol level and verbal learning. We also found correlations between cortisol level and attention/alertness (r = 0.277, P = 0.003), between cortisol level and verbal learning (r = 0.205, P = 0.030), and between BMI and verbal learning (r = - 0.192, P = 0.043). CONCLUSION In our study, patients in both OB and SOB groups experienced a widespread cognitive impairment. We also found that patients with severe obesity had more severe cognitive impairment. Cognitive impairment could be mediated by abnormal cortisol metabolism, and BMI could be a mediating factor in regulation of cortisol level.
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Affiliation(s)
- Yiliang Zhang
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Guangzhou, Guangdong, China
| | - Biao Huang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Guangzhou, Guangdong, China.,Joint Institute of Metabolic Medicine Between State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong and Jinan University, Guangzhou, China
| | - Wah Yang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Guangzhou, Guangdong, China.,Joint Institute of Metabolic Medicine Between State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong and Jinan University, Guangzhou, China
| | - Shuming Zhong
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Guangzhou, Guangdong, China
| | - Shunkai Lai
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Guangzhou, Guangdong, China
| | - Hui Zhao
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Guangzhou, Guangdong, China
| | - Jiali He
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Guangzhou, Guangdong, China
| | - Shujing Cai
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Guangzhou, Guangdong, China
| | - Sihui Lv
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Guangzhou, Guangdong, China
| | - Cunchuan Wang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Guangzhou, Guangdong, China. .,Joint Institute of Metabolic Medicine Between State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong and Jinan University, Guangzhou, China.
| | - Yanbin Jia
- Department of Psychiatry, The First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue West, Guangzhou, Guangdong, China.
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Rnic K, Jopling E, Tracy A, LeMoult J. Emotion Regulation and Diurnal Cortisol: A Longitudinal Study of Early Adolescents. Biol Psychol 2021; 167:108212. [PMID: 34699918 DOI: 10.1016/j.biopsycho.2021.108212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 10/20/2021] [Accepted: 10/20/2021] [Indexed: 01/09/2023]
Abstract
Aberrant patterns of diurnal cortisol, a marker of stress reactivity, predict adverse physical and mental health among adolescents. However, the mechanisms underlying aberrant diurnal cortisol production are poorly understood. Thus, the objective of this study was to investigate, for the first time, whether the core emotion regulation (ER) strategies of rumination (brooding, reflection), reappraisal, and suppression were prospectively associated with individual differences in diurnal cortisol during the COVID-19 pandemic, a period of significant stress. A community sample of 48 early adolescents (Mage=13.45; 60% males) was recruited from British Columbia, Canada. Participants completed ER measures before the pandemic, and diurnal cortisol was assessed by collecting eight saliva samples over two days during the first COVID-19-related lockdown in the region. As expected, brooding predicted elevated waking cortisol and a blunted cortisol awakening response (CAR), whereas reflection predicted lower waking cortisol and suppression predicted a steeper CAR. Unexpectedly, reappraisal was not associated with diurnal cortisol production. Results indicate that ER strategies may represent a mechanism underlying individual differences in biological markers of wellbeing during stress.
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Affiliation(s)
- Katerina Rnic
- Department of Psychology, The University of British Columbia, Canada.
| | - Ellen Jopling
- Department of Psychology, The University of British Columbia, Canada
| | - Alison Tracy
- Department of Psychology, The University of British Columbia, Canada
| | - Joelle LeMoult
- Department of Psychology, The University of British Columbia, Canada
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Mikulska J, Juszczyk G, Gawrońska-Grzywacz M, Herbet M. HPA Axis in the Pathomechanism of Depression and Schizophrenia: New Therapeutic Strategies Based on Its Participation. Brain Sci 2021; 11:brainsci11101298. [PMID: 34679364 PMCID: PMC8533829 DOI: 10.3390/brainsci11101298] [Citation(s) in RCA: 103] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/24/2021] [Accepted: 09/24/2021] [Indexed: 12/27/2022] Open
Abstract
The hypothalamic-pituitary-adrenal (HPA) axis is involved in the pathophysiology of many neuropsychiatric disorders. Increased HPA axis activity can be observed during chronic stress, which plays a key role in the pathophysiology of depression. Overactivity of the HPA axis occurs in major depressive disorder (MDD), leading to cognitive dysfunction and reduced mood. There is also a correlation between the HPA axis activation and gut microbiota, which has a significant impact on the development of MDD. It is believed that the gut microbiota can influence the HPA axis function through the activity of cytokines, prostaglandins, or bacterial antigens of various microbial species. The activity of the HPA axis in schizophrenia varies and depends mainly on the severity of the disease. This review summarizes the involvement of the HPA axis in the pathogenesis of neuropsychiatric disorders, focusing on major depression and schizophrenia, and highlights a possible correlation between these conditions. Although many effective antidepressants are available, a large proportion of patients do not respond to initial treatment. This review also discusses new therapeutic strategies that affect the HPA axis, such as glucocorticoid receptor (GR) antagonists, vasopressin V1B receptor antagonists and non-psychoactive CB1 receptor agonists in depression and/or schizophrenia.
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15
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Abstract
Research documents the pernicious effects of daily stressors on well-being, but often ignored in these studies are people reporting no stressors. The current study compared adults who reported no daily stressors with adults who reported at least one stressor across 8 consecutive days on measures of well-being. Of the 2,804 respondents (age range = 25-75 years, M = 53.46) from the Midlife in the United State Survey daily diary study, 10% reported experiencing no stressors across 8 days. Those reporting no stressors were generally older, male, unmarried, and were less likely to work, provide or receive emotional support, or experience positive daily events. They reported greater daily affective well-being and fewer chronic health conditions but had lower levels of cognitive functioning. Findings suggest that daily stressors may serve as a proxy to engagement in social activities, where a lower level of engagement is related to better physical and emotional well-being but lower levels of cognitive functioning. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Susan T Charles
- Department of Psychological Science, University of California, Irvine
| | - Jacqueline Mogle
- Kurt Lewin Center for Theoretical Psychology, University of Zurich
| | - Hye Won Chai
- Department of Human Development and Family Studies, The Pennsylvania State University
| | - David M Almeida
- Department of Human Development and Family Studies, The Pennsylvania State University
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16
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Ayala-Grosso C, Torrico F, Ledezma-Ruiz M, Busolo-Pons M. Chronic Stress in Cognitive Processes: Cortisol Dynamic Range of Secretion Is Associated with Perception of Unsafety Environment in a Venezuelan Population. J Alzheimers Dis 2020; 82:S299-S312. [PMID: 33285631 DOI: 10.3233/jad-200886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Understanding diurnal secretion of cortisol in association with behavioral attitudes as a result of perception of unsafety environment is a main interest in prospective studies establishing the impact of chronic stress in cognitive processes. Adaptive secretion of cortisol, a biomarker of the hypothalamic-hypophysis-adrenal (HPA) axis, has been correlated with perception of uncertainty in surroundings as a consequence of perseverative cognition and unconscious thoughts. OBJECTIVE To determine whether diurnal secretion pattern of cortisol was associated with behavioral attitudes indexes generated from answers to standardized questionnaires from Panamerican Health Organization/World Health Organization (PAHO/WHO) agencies. METHODS Saliva cortisol dynamic range was evaluated by immuno-essay. Cortisol awakening response (CAR) and total secreted cortisol was established in a cross-sectional study of four saliva samples per day from volunteers (n = 135) between 19 and 65 years old. RESULTS Saliva cortisol dynamic range followed a significant decay along the day. Reduction of social interaction and increase of defensive behavioral attitude was associated with older groups of age. In this study, two subgroups of subjects with a steeper cortisol secretion (slope significant non-zero), and flatter cortisol secretion (slope no significant non-zero) were detected. Noticeable, we determined an association between measurements of cortisol secretion from subjects with a flatter cortisol dynamic range and behavioral defensive and inhibition of social interaction indexes. CONCLUSION These findings suggested chronical dysregulation of HPA axis as a result of perseverative cognitive perception of unsafety environment which may be precedent to cognitive impairment in the population.
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Affiliation(s)
- Carlos Ayala-Grosso
- Unit of Cellular Therapy, Centre of Experimental Medicine, Instituto Venezolano de Investigaciones Científicas IVIC, Caracas, Venezuela
| | - Fátima Torrico
- Unit of Molecular Biology, School of Pharmacy, Universidad Central de Venezuela, Caracas, Venezuela
| | - Margot Ledezma-Ruiz
- Unit of Molecular Biology, School of Pharmacy, Universidad Central de Venezuela, Caracas, Venezuela
| | - Maria Busolo-Pons
- Unit of Molecular Biology, School of Pharmacy, Universidad Central de Venezuela, Caracas, Venezuela
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17
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Hernández LM, Padilla GA, Koehn BW, Taylor MK. Post-awakening Cortisol in Explosive Ordnance Disposal Technicians: A Replication Study in a Novel Population. Mil Med 2020; 186:6-12. [PMID: 33005944 DOI: 10.1093/milmed/usaa245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/13/2020] [Accepted: 07/29/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Amassing evidence suggests that post-awakening salivary cortisol rhythms (changes in cortisol throughout the day) may indicate health status. We previously established summary parameters for salivary cortisol in U.S. Navy Sea, Air, and Land and reported excellent parameter stability across 2 days of repeated sampling. To confirm the generalizability of our original findings to other military populations, we replicated the procedures of our prior report in another specialized military group. The purpose of this study was to (1) establish summary parameters of daily salivary cortisol rhythms, (2) evaluate summary parameter stability, and (3) assess the impact of sampling compliance in U.S. Navy Explosive Ordnance Disposal (EOD) technicians. MATERIALS AND METHODS Seventy active duty, male Explosive Ordnance Disposal technicians (mean ± SD age; 34.9 ± 6.5 years) self-collected saliva samples in a nondeployed setting on two consecutive weekdays at WAKE, WAKE + 30 min, WAKE + 60 min, 4 p.m., and 9 p.m. For salivary cortisol, we computed summary parameters, i.e., measures of magnitude and measures of pattern, and then evaluated their stabilities via correlational analyses and Cronbach's alpha (α). Compliance was objectively and subjectively evaluated using actigraphy and self-reported data, respectively. This research was conducted under a Naval Health Research Center Institutional Review Board approved study (NHRC.2015.0013). RESULTS Average salivary cortisol concentrations increased at WAKE + 30 (mean ± SE reactivity; 48.9 + 6.8%) from WAKE, followed by a swift recovery at WAKE + 60. Approximately 10.9% of the group were classified as negative-responders (i.e., < 0% change from WAKE to WAKE + 30). The measures of magnitude demonstrated fair stability across two days (r value range: 0.37-0.45, ps < 0.01; α range: 0.54-0.62). Fifty-five percent of the sample was classified as compliant (defined as <15 min deviation from target sampling times) across both days. Compliance decreased to 31% when compliance criteria were refined to <5 min deviation; however, controlling for compliance did not overwhelmingly influence the more stable summary parameters of magnitude. CONCLUSIONS These findings demonstrate a thorough replication, with some additional refinement, of our prior study, implying generalizability across diverse military populations. Study limitations include unsupervised saliva collection in a free-living setting, which is counterbalanced by ecological validity. The noninvasive salivary sampling protocol used in this study yields stable estimations of daily cortisol rhythms in specialized military men and is recommended as an operational health surveillance tool by which to monitor chronically stressed military members.
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Affiliation(s)
- Lisa M Hernández
- Biobehavioral Sciences Lab, Warfighter Performance Department, Naval Health Research Center, San Diego, CA 92106, USA.,Leidos, San Diego, CA 92121, USA
| | - Genieleah A Padilla
- Biobehavioral Sciences Lab, Warfighter Performance Department, Naval Health Research Center, San Diego, CA 92106, USA.,Leidos, San Diego, CA 92121, USA
| | - Blake W Koehn
- Biobehavioral Sciences Lab, Warfighter Performance Department, Naval Health Research Center, San Diego, CA 92106, USA.,Leidos, San Diego, CA 92121, USA
| | - Marcus K Taylor
- Biobehavioral Sciences Lab, Warfighter Performance Department, Naval Health Research Center, San Diego, CA 92106, USA
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