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Kiive E, Kanarik M, Veidebaum T, Harro J. Neuropeptide Y gene variants and Agreeableness: interaction effect with the birth cohort and the serotonin transporter promoter polymorphism. Acta Neuropsychiatr 2024; 36:1-8. [PMID: 37070394 DOI: 10.1017/neu.2023.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVE Neuropeptide Y (NPY) is a powerful regulator of anxious states, including social anxiety, but evidence from human genetic studies is limited. Associations of common gene variants with behaviour have been described as subject to birth cohort effects, especially if the behaviour is socially motivated. This study aimed to examine the association of NPY rs16147 and rs5574 with personality traits in highly representative samples of two birth cohorts of young adults, the samples having been formed during a period of rapid societal transition. METHODS Both birth cohorts (original n = 1238) of the Estonian Children Personality Behaviour and Health Study (ECPBHS) self-reported personality traits of the five-factor model at 25 years of age. RESULTS A significant interaction effect of the NPY rs16147 and rs5574 and birth cohort on Agreeableness was found. The T/T genotype of NPY rs16147 resulted in low Agreeableness in the older cohort (born 1983) and in high Agreeableness in the younger cohort (born 1989). The C/C genotype of NPY rs5574 was associated with higher Agreeableness in the younger but not in the older cohort. In the NPY rs16147 T/T homozygotes, the deviations from average in Agreeableness within the birth cohort were dependent on the serotonin transporter promoter polymorphism. CONCLUSIONS The association between the NPY gene variants and a personality domain reflecting social desirability is subject to change qualitatively in times of rapid societal changes, serving as an example of the relationship between the plasticity genes and environment. The underlying mechanism may involve the development of the serotonergic system.
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Affiliation(s)
- Evelyn Kiive
- Division of Special Education, Department of Education, University of Tartu, Jakobi 5, 51005 Tartu, Estonia
| | - Margus Kanarik
- Division of Neuropsychopharmacology, Department of Chemistry, University of Tartu, Ravila 14A, 50411 Tartu, Estonia
| | - Toomas Veidebaum
- Department of Chronic Diseases, National Institute for Health Development, Hiiu 42, 11619 Tallinn, Estonia
| | - Jaanus Harro
- Division of Neuropsychopharmacology, Department of Chemistry, University of Tartu, Ravila 14A, 50411 Tartu, Estonia
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Kuang X, Li K, Shi Y, Shao X, Li H, Li D. Gene-diet interaction in response to defatted flaxseed flour supplementation on obesity-related traits in Chinese overweight and obese adults: A randomized controlled trial. Nutrition 2023; 105:111870. [PMID: 36368262 DOI: 10.1016/j.nut.2022.111870] [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: 11/25/2021] [Revised: 09/23/2022] [Accepted: 10/08/2022] [Indexed: 11/09/2022]
Abstract
Effects of dietary fiber on obesity-related traits in previous studies were inconsistent. The aim of the present study was to explore whether variants in genes related to satiety and appetite can modulate the effect of dietary fiber on obesity-related traits. Fifty-one overweight or obese adults were randomly allocated to two groups to consume control biscuits (n = 24) or biscuits containing defatted flaxseed flour (n = 27) at breakfast for 8 wk. Four single-nucleotide polymorphisms related to satiety and appetite were genotyped: rs11076023 on the FTO gene, rs16147 on the NPY gene, rs155971 on the PCSK1 gene, and rs6265 on the BDNF gene. A linear regression model was used to evaluate the gene-diet interaction between obesity-related traits. Compared with control biscuits, defatted flaxseed-flour biscuits significantly reduced body weight (P = 0.001) and body mass index (BMI) (P = 0.001) in A-allele carriers (AA + AT) of rs11076023 on the FTO gene but not in non-carriers (TT) (P for the interaction = 0.005 and 0.006) and decreased fasting serum glucose in participants with CC genotype (P = 0.019) but had less effect in T-allele carriers (TT + TC) (P = 0.021) of rs16147 on the NPY gene (P for the interaction = 0.002). Compared with the control biscuits, defatted flaxseed flour significantly reduced body weight (P < 0.001) in T-allele carriers (TT + TC) of rs155971 on the PCSK1 gene but not in non-carriers (CC) (P for the interaction = 0.041) and reduced body weight (P = 0.001) and BMI (P < 0.001) in A-allele carriers (AA + AG) of rs6265 on the BDNF gene but not non-carriers (GG) (P for the interaction = 0.017 and 0.018). Variants of genes related to satiety and appetite could modulate the effect of defatted flaxseed flour on obesity-related traits.
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Affiliation(s)
- Xiaotong Kuang
- Institute of Nutrition and Health, Qingdao University, China; School of Public Health, Qingdao University, Qingdao, China
| | - Kelei Li
- Institute of Nutrition and Health, Qingdao University, China; School of Public Health, Qingdao University, Qingdao, China
| | - Yan Shi
- Institute of Nutrition and Health, Qingdao University, China; School of Public Health, Qingdao University, Qingdao, China
| | - Xianfeng Shao
- Institute of Nutrition and Health, Qingdao University, China; School of Public Health, Qingdao University, Qingdao, China
| | - Huiying Li
- Institute of Nutrition and Health, Qingdao University, China; School of Public Health, Qingdao University, Qingdao, China
| | - Duo Li
- Institute of Nutrition and Health, Qingdao University, China; School of Public Health, Qingdao University, Qingdao, China.
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Kienast C, Biere K, Coker RH, Genov NN, Jörres M, Maggioni MA, Mascarell-Maricic L, Schalt A, Genov M, Gunga HC, Steinach M. Adiponectin, leptin, cortisol, neuropeptide Y and profile of mood states in athletes participating in an ultramarathon during winter: An observational study. Front Physiol 2022; 13:970016. [PMID: 36579027 PMCID: PMC9791263 DOI: 10.3389/fphys.2022.970016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022] Open
Abstract
Background: The Montane® Yukon Arctic Ultra (YAU) is one of the longest (690 km) and coldest (+10.6°C-43.9°C) ultramarathons worldwide. Taking part in an ultramarathon is associated with great physiological and psychological stress, which can affect one's mood, level of hormones, and peptides. The current study aimed to identify relationships between peptides, hormones, and mood states in participants during this ultramarathon. Methods: The study cohort consisted of 36 participants (19 men, 17 women, 38.64 ± 9.12 years) split into a finisher (n = 10), non-finisher (n = 19), and control group (n = 7). Data were collected at four time points: baseline (PRE), during (D1 after 277 km, D2 after 383 km), and after the race (POST). Questionnaires were used to assess ratings of perceived exertion (RPE), total quality of recovery (TQR), and profile of mood states (POMS-SF). Serum NPY, leptin, adiponectin, and cortisol were measured. Results: Among non-finishers, scores for confusion, anger, depression, and tension-anxiety (PRE vs. D2, p < 0.05) increased, while vigor decreased (PRE vs. D1, p < 0.05). In contrast, finishers' tension-anxiety scores decreased (PRE vs. D1, p < 0.05). Fatigue increased in finishers (PRE vs. POST, p < 0.05) and non-finishers (PRE vs. D1, p < 0.05). In non-finishers, depressive mood correlated positively with leptin, anger, and confusion at several time points (p < 0.001). In finishers, NPY correlated with TQR at PRE (p < 0.05), while leptin correlated negatively with TQR at POST (p < 0.05). Tension-anxiety correlated highly with perceived exertion in non-finishers (p < 0.001) and with cortisol in finishers (p < 0.05) and non-finishers (p < 0.001). In finishers, confusion correlated negatively with NPY (p < 0.01). Conclusion: The study reveals an essential interplay between hormones and mood states affecting performance: Leptin was associated with anger and a depressive mood state in non-finishers and worse recovery in finishers. In contrast, NPY appeared linked to a lower confusion score and heightened recovery in finishers. A simultaneous increase in depressed mood, anger, tension-anxiety, and confusion might harm performance and lead to race failure.
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Affiliation(s)
- Camilla Kienast
- Charité—Universitätsmedizin Berlin, Institute of Physiology, Center for Space Medicine and Extreme Environments Berlin, Berlin, Germany,*Correspondence: Camilla Kienast,
| | - Katharina Biere
- Laboratory of Translational Research “Stress and Immunity”, Department of Anaesthesiology, University Hospital LMU Munich, Munich, Germany
| | - Robert H. Coker
- Montana Center for Work Physiology and Exercise Metabolism, University of Montana, Missoula, MT, United States
| | | | - Marc Jörres
- Charité—Universitätsmedizin Berlin, Institute of Physiology, Center for Space Medicine and Extreme Environments Berlin, Berlin, Germany
| | - Martina Anna Maggioni
- Charité—Universitätsmedizin Berlin, Institute of Physiology, Center for Space Medicine and Extreme Environments Berlin, Berlin, Germany,Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Lea Mascarell-Maricic
- Charité—Universitätsmedizin Berlin, Clinic for Psychiatry and Psychotherapy, Berlin, Germany
| | - Adriane Schalt
- Charité—Universitätsmedizin Berlin, Institute of Physiology, Center for Space Medicine and Extreme Environments Berlin, Berlin, Germany
| | - Magdalena Genov
- Charité—Universitätsmedizin Berlin, Institute of Physiology, Center for Space Medicine and Extreme Environments Berlin, Berlin, Germany
| | - Hanns-Christian Gunga
- Charité—Universitätsmedizin Berlin, Institute of Physiology, Center for Space Medicine and Extreme Environments Berlin, Berlin, Germany
| | - Mathias Steinach
- Charité—Universitätsmedizin Berlin, Institute of Physiology, Center for Space Medicine and Extreme Environments Berlin, Berlin, Germany
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Wei X, Cai F, Zhou S, Zhang J, Xu K, Shen G, Sun H, Yang F, Hong L, Zou Y, Chen YH, Liu Y, Chen L, Wang F, Wang W. The neuropeptide Y single-nucleotide polymorphism rs16147:T> C moderates the effect of alcohol dependence on depression in male Chinese Han population. Front Psychiatry 2022; 13:1012850. [PMID: 36245887 PMCID: PMC9558829 DOI: 10.3389/fpsyt.2022.1012850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/07/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Previous studies suggest that alcohol dependence is associated with depression, however, the effect of alcohol dependence varies from individual to individual, which may be due to different genetic backgrounds. The interactions between alcohol dependence and different gene polymorphisms may finally shape the onset of depression. Neuropeptide Y (NPY), which can maintain homeostasis from high-stress stimulation, may protect individuals from the onset of depression. Here, we explored whether the NPY rs16147:T>C has an association with depression in individuals with alcohol dependence during the period of alcohol dependence withdrawal. METHODS A total of 455 males with alcohol dependence were recruited. The scale of Michigan Alcoholism Screening Test (MAST) and Self-Depression Scale (SDS) were respectively used to analyze the condition of alcohol dependence and depression. Genomic DNA was extracted from each blood sample and NPY polymorphisms were genotyped. The interaction between NPY rs16147:T>C and alcohol dependence on depression was first analyzed. Then, region of significance analysis was used to confirm which model provided the best fit for the interaction (diathesis-stress or differential susceptibility). Finally, by using internal replication analyses, the accuracy and robustness of the interaction results were improved. RESULTS Alcohol dependence was positively correlated with depression. CC homozygotes of NPY rs16147:T>C exhibited less depression when exposed to low alcohol dependence, but more depression when exposed to high alcohol dependence. Individuals with the T allele showed the opposite result. CONCLUSION NPY rs16147:T>C might be correlated with susceptibility for depression in males during alcohol dependence withdrawal. The findings support the differential susceptibility model.
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Affiliation(s)
- Xiaojie Wei
- Affiliated Cixi Hospital, Wenzhou Medical University, Ningbo, China
| | - Fangfang Cai
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Siyao Zhou
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Jinjing Zhang
- Affiliated Cixi Hospital, Wenzhou Medical University, Ningbo, China
| | - Kewei Xu
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Guanghui Shen
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Huankun Sun
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Fan Yang
- School of Mental Health, Wenzhou Medical University, Wenzhou, China.,The Affiliated Kangning Hospital, Wenzhou Medical University, Wenzhou, China
| | - Liuzhi Hong
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Yang Zou
- School of Mental Health, Wenzhou Medical University, Wenzhou, China
| | - Yu-Hsin Chen
- Department of Psychology, College of Liberal Arts, Wenzhou-Kean University, Wenzhou, China
| | - Yanlong Liu
- School of Mental Health, Wenzhou Medical University, Wenzhou, China.,The Affiliated Kangning Hospital, Wenzhou Medical University, Wenzhou, China
| | - Li Chen
- School of Mental Health, Wenzhou Medical University, Wenzhou, China.,The Affiliated Kangning Hospital, Wenzhou Medical University, Wenzhou, China
| | - Fan Wang
- Beijing Hui-Long-Guan Hospital, Peking University, Beijing, China
| | - Wei Wang
- School of Mental Health, Wenzhou Medical University, Wenzhou, China.,Zhejiang Provincial Clinical Research Center for Mental Disorders, The Affiliated Wenzhou Kangning Hospital, Wenzhou Medical University, Wenzhou, China
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Cahill S, Chandola T, Hager R. Genetic Variants Associated With Resilience in Human and Animal Studies. Front Psychiatry 2022; 13:840120. [PMID: 35669264 PMCID: PMC9163442 DOI: 10.3389/fpsyt.2022.840120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/19/2022] [Indexed: 11/15/2022] Open
Abstract
Resilience is broadly defined as the ability to maintain or regain functioning in the face of adversity and is influenced by both environmental and genetic factors. The identification of specific genetic factors and their biological pathways underpinning resilient functioning can help in the identification of common key factors, but heterogeneities in the operationalisation of resilience have hampered advances. We conducted a systematic review of genetic variants associated with resilience to enable the identification of general resilience mechanisms. We adopted broad inclusion criteria for the definition of resilience to capture both human and animal model studies, which use a wide range of resilience definitions and measure very different outcomes. Analyzing 158 studies, we found 71 candidate genes associated with resilience. OPRM1 (Opioid receptor mu 1), NPY (neuropeptide Y), CACNA1C (calcium voltage-gated channel subunit alpha1 C), DCC (deleted in colorectal carcinoma), and FKBP5 (FKBP prolyl isomerase 5) had both animal and human variants associated with resilience, supporting the idea of shared biological pathways. Further, for OPRM1, OXTR (oxytocin receptor), CRHR1 (corticotropin-releasing hormone receptor 1), COMT (catechol-O-methyltransferase), BDNF (brain-derived neurotrophic factor), APOE (apolipoprotein E), and SLC6A4 (solute carrier family 6 member 4), the same allele was associated with resilience across divergent resilience definitions, which suggests these genes may therefore provide a starting point for further research examining commonality in resilience pathways.
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Affiliation(s)
- Stephanie Cahill
- Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom.,Faculty of Humanities, Cathie Marsh Institute for Social Research, The University of Manchester, Manchester, United Kingdom
| | - Tarani Chandola
- Faculty of Humanities, Cathie Marsh Institute for Social Research, The University of Manchester, Manchester, United Kingdom.,Methods Hub, Department of Sociology, Faculty of Social Sciences, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Reinmar Hager
- Evolution, Infection and Genomics, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom
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6
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[Neuropeptide Y (NPY) gene and body mass index]. NUTR HOSP 2021; 39:479-480. [PMID: 34847673 DOI: 10.20960/nh.03927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Gan Y, Chen Y, Han X, Yu NX, Wang L. Neuropeptide Y Gene × Environment Interaction Predicts Resilience and Positive Future Focus. Appl Psychol Health Well Being 2019; 11:438-458. [DOI: 10.1111/aphw.12162] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | | | | | | | - Li Wang
- Chinese Academy of Science China
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Tan CMJ, Green P, Tapoulal N, Lewandowski AJ, Leeson P, Herring N. The Role of Neuropeptide Y in Cardiovascular Health and Disease. Front Physiol 2018; 9:1281. [PMID: 30283345 PMCID: PMC6157311 DOI: 10.3389/fphys.2018.01281] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/24/2018] [Indexed: 12/20/2022] Open
Abstract
Neuropeptide Y (NPY) is an abundant sympathetic co-transmitter, widely found in the central and peripheral nervous systems and with diverse roles in multiple physiological processes. In the cardiovascular system it is found in neurons supplying the vasculature, cardiomyocytes and endocardium, and is involved in physiological processes including vasoconstriction, cardiac remodeling, and angiogenesis. It is increasingly also implicated in cardiovascular disease pathogenesis, including hypertension, atherosclerosis, ischemia/infarction, arrhythmia, and heart failure. This review will focus on the physiological and pathogenic role of NPY in the cardiovascular system. After summarizing the NPY receptors which predominantly mediate cardiovascular actions, along with their signaling pathways, individual disease processes will be considered. A thorough understanding of these roles may allow therapeutic targeting of NPY and its receptors.
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Affiliation(s)
- Cheryl M J Tan
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Peregrine Green
- Department of Physiology, Anatomy and Genetics, Burdon Sanderson Cardiac Science Centre, University of Oxford, Oxford, United Kingdom
| | - Nidi Tapoulal
- Department of Physiology, Anatomy and Genetics, Burdon Sanderson Cardiac Science Centre, University of Oxford, Oxford, United Kingdom
| | - Adam J Lewandowski
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Paul Leeson
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Neil Herring
- Department of Physiology, Anatomy and Genetics, Burdon Sanderson Cardiac Science Centre, University of Oxford, Oxford, United Kingdom
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Neurocardiology: Cardiovascular Changes and Specific Brain Region Infarcts. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5646348. [PMID: 28758117 PMCID: PMC5512017 DOI: 10.1155/2017/5646348] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 05/15/2017] [Indexed: 11/18/2022]
Abstract
There are complex and dynamic reflex control networks between the heart and the brain, including cardiac and intrathoracic ganglia, spinal cord, brainstem, and central nucleus. Recent literature based on animal model and clinical trials indicates a close link between cardiac function and nervous systems. It is noteworthy that the autonomic nervous-based therapeutics has shown great potential in the management of atrial fibrillation, ventricular arrhythmia, and myocardial remodeling. However, the potential mechanisms of postoperative brain injury and cardiovascular changes, particularly heart rate variability and the presence of arrhythmias, are not understood. In this chapter, we will describe mechanisms of brain damage undergoing cardiac surgery and focus on the interaction between cardiovascular changes and damage to specific brain regions.
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Pereira VH, Campos I, Sousa N. The role of autonomic nervous system in susceptibility and resilience to stress. Curr Opin Behav Sci 2017. [DOI: 10.1016/j.cobeha.2017.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Chang CC, Fang WH, Chang HA, Chang TC, Shyu JF, Huang SY. Serotonin 2A receptor (5-HT2A) gene promoter variant interacts with chronic perceived stress to modulate resting parasympathetic activity in humans. Psychoneuroendocrinology 2017; 76:119-126. [PMID: 27912162 DOI: 10.1016/j.psyneuen.2016.11.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 10/09/2016] [Accepted: 11/14/2016] [Indexed: 11/18/2022]
Abstract
Decreased resting vagal (parasympathetic) tone is implicated in the development of stress-related disorders, including anxiety and depression. Chronic stress elevates the expression of serotonin 2A receptors (5-HT2A), while activation of 5-HT2A leads to inhibition of parasympathetic synaptic transmission. The T allele of the promoter variant, rs6311 (C>T), of the 5-HT2A gene has been shown to increase the 5-HT2A expression in vitro and to be associated with anxiety and depressive disorders. We thus hypothesized that the 5-HT2A functional polymorphism may influence resting vagal activity among persons with chronically high levels of perceived stress. A total of 1138 well-defined healthy, medication-free Han Chinese were included for 5-HT2A genotyping. The Perceived Stress Scale (PSS) was used to measure the level of perceived stress during the last month and participants were divided into low and high PSS groups. Resting-state heart rate variability (HRV) was used to assess autonomic function. No significant between-genotype difference was found in any HRV variable in the low PSS group (n=610). However, in the high PSS group (n=528), high frequency power and root mean square of successive heartbeat interval differences (both HRV indices of parasympathetic activity) were significantly reduced in T/T genotype carriers compared to C/C homozygotes. Our findings are the first to show that individuals homozygous for the high-expressing 5-HT2A (T) allele exhibit diminished resting vagal tone-an index of stress vulnerability-when experiencing chronically elevated levels of perceived stress. The present results may advance our understanding of the genetic mechanism underlying individual differences in susceptibility to stress.
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Affiliation(s)
- Chuan-Chia Chang
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan.
| | - Wen-Hui Fang
- Department of Family and Community Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsin-An Chang
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tieh-Ching Chang
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jia-Fwa Shyu
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Biology and Anatomy, National Defense Medical Center, Taipei, Taiwan
| | - San-Yuan Huang
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
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