Effects of perceived stress and uplifts on inflammation and coagulability

Stress-Induced Hypercoagulability: Insights from Epidemiological and Mechanistic Studies, and Clinical Integration

By integrating findings from comprehensive reviews, meta-analyses, and cutting-edge genetic studies, this article illuminates the significance of stress-induced hypercoagulability in clinical medicine. In particular, the findings from numerous prospective cohort studies indicate that stress and hemostatic factors of a hypercoagulable state are associated with increased incident risk and poor prognosis for atherosclerotic cardiovascular disease and venous thromboembolism. Mendelian randomization studies suggest that these associations are partially causal. The review synthesizes extensive research on the link between acute and chronic stress and hypercoagulability, outlining a potential pathway from stress to thrombosis risk. Consistent with the allostatic load concept, acute stress-induced hypercoagulability, initially adaptive, can turn maladaptive under chronic stress or excessive acute stress, leading to arterial or venous thrombotic events. Individuals with predisposing factors, including atherosclerosis, thrombophilia, or immobilization, may exhibit an increased risk of thrombotic disease during stress. Contextual sociodemographic characteristics, the stress experience, and coping resources additionally modulate the extent of stress-induced hypercoagulability. Research into the neuroendocrine, cellular, and molecular bases reveals how stress influences platelet activation coagulation and fibrinolysis. The activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis, along with vagal withdrawal, and the effects of catecholamines, cortisol, and vasopressin, are the central mechanisms involved. Hemoconcentration, inflammation, endothelial dysfunction, and thrombopoiesis additionally contribute to stress-induced hypercoagulability. Further research is needed to prove a causal link between chronic stress and hypercoagulability. This includes exploring its implications for the prevention and management of thrombotic diseases in stressed individuals, with a focus on developing effective psychosocial and pharmacological interventions.

Uplifts and hassles are related to worsening in chronic fatigue syndrome: a prospective study

BACKGROUND

Limited published data suggests that absence of uplifts (minor pleasant events) is associated with clinical worsening in patients with chronic fatigue syndrome (CFS). The current study aimed to assess the relation of illness worsening to the trajectories of social and non-social uplifts and hassles in a six-month prospective study in CFS.

METHODS

Participants were primarily in their 40s, female, white, and ill for over a decade. All participants (N = 128) met criteria for CFS. The interview-based global impression of change rating was used to classify individual outcomes as improved, unchanged, or worsened at six- month follow-up. Uplifts and hassles, both social and non-social, were assessed with the Combined Hassles and Uplifts Scale (CHUS). The CHUS was administered weekly in online diaries over six months. Linear mixed effect models were utilized to examine linear trends for hassles and uplifts.

RESULTS

No significant differences were found between the three global outcome groups for age, sex, or illness duration; however, work status was significantly lower for the non-improved groups (p < 0.001). Non-social hassles intensity showed an increasing slope for the worsened group (p = 0.03) and a decreasing slope (p = 0.05) for the improved group. For the worsened group, a downward trend was found for frequency of non-social (p = 0.01) uplifts.

CONCLUSION

Individuals with worsening as compared to improving illness in CFS show significantly different six-month trajectories for weekly hassles and a deficit in uplifts. This may have clinical implications for behavioral intervention. Trial registration ClinicalTrials.gov ID: NCT02948556.

Uplifts and hassles are related to worsening in chronic fatigue syndrome A prospective study

Background: Limited published data suggests that absence of uplifts (minor pleasant events) is associated with clinical worsening in patients with chronic fatigue syndrome (CFS). The current study aimed to assess the relation of illness worsening to the trajectories of social and non-social uplifts and hassles in a six-month prospective study in CFS. Methods: Participants were primarily in their 40s, female, white, and ill for over a decade. All participants (N=128) met criteria for CFS. The interview-based global impression of change rating was used to classify individual outcomes as improved, unchanged, or worsened at six- month follow-up. Uplifts and hassles, both social and non-social, were assessed with the Combined Hassles and Uplifts Scale (CHUS). The CHUS was administered weekly in online diaries over six months. Linear mixed effect models were utilized to examine linear trends for hassles and uplifts. Results: No significant differences were found between the three global outcome groups for age, sex, or illness duration; however, work status was significantly lower for the non-improved groups ( p <.001). Non-social hassles intensity showed an increasing slope for the worsened group ( p =.03) and a decreasing slope ( p =0.05) for the improved group. For the worsened group, a downward trend was found for frequency of non-social ( p =0.01) uplifts. Conclusion: Individuals with worsening as compared to improving illness in CFS show significantly different six-month trajectories for weekly hassles and a deficit in uplifts. This may have clinical implications for behavioral intervention. Trial Registration: ClinicalTrials.gov ID: NCT02948556.

Depressive symptoms anticipate behavioral and emotional factors among older adults: A prospective cross-lagged panel design

This study examined the temporal relationship among depression, anxiety, insomnia, perceived stress, and physical activity in adults aged 60+ years with a history of major depressive disorder. We conducted a longitudinal study with 12 weeks of follow-up. Assessments consisted of phone or video interviews and included questionnaires evaluating depression, anxiety, insomnia, perceived stress, and physical activity. Our analytic approach consisted of a depression-focused cross-lagged panel model (CLPM) to examine week-to-week correlations among the five measures. The depression-focused CLPM identified statistically significant week-to-week self-predictive effects for each of the five measures. Higher depressive symptom burden was a strong predictor of increased stress, greater insomnia, and less physical activity the following week. No other cross-measure predictions were statistically significant. Our analytical approach clarifies the directional relationship among variables that typically co-occur with depression showing that higher depression symptom burden predisposes older adults to poor sleep, a reduced level of daytime activity, and a greater sense of stress. These findings support the need for longitudinal assessments and targeted interventions for reducing symptoms of depression in older adults.

Effects of Sodium Benzoate, a D-Amino Acid Oxidase Inhibitor, on Perceived Stress and Cognitive Function Among Patients With Late-Life Depression: A Randomized, Double-Blind, Sertraline- and Placebo-Controlled Trial

BACKGROUND

Compared with adults with depression in the general population, elderly depressive patients are prone to poor treatment response, more side effects, and early withdrawal with current antidepressants (which principally modulate monoamines). Whether N-methyl-D-aspartate receptor enhancement can benefit treatment of late-life depression deserves study. This study aims to compare sodium benzoate (a D-amino acid oxidase inhibitor and an indirect N-methyl-D-aspartate receptor enhancer), sertraline (a selective serotonin reuptake inhibitor), and placebo in the treatment of late-life depression.

METHODS

In this randomized, double-blind trial, 117 patients with major depressive disorder aged 55 years or older received 8-week treatment of 250-1500 mg/d of sodium benzoate, 25-150 mg/d of sertraline, or placebo in 2 medical centers. The primary outcome measures were Hamilton Depression Rating Scale and Perceived Stress Scale scores.

RESULTS

Three treatments similarly decreased clinicians-rated Hamilton Depression Rating Scale scores. Compared with placebo, sodium benzoate but not sertraline substantially improved Perceived Stress Scale scores and cognitive function. Sertraline, but not benzoate, significantly reduced self-report Geriatric Depression Scale scores. Benzoate and placebo showed similar safety profiles, while sertraline was more likely to raise low-density lipoprotein than benzoate and placebo. Benzoate-treated patients were less likely to drop out than sertraline or placebo recipients.

CONCLUSIONS

Sertraline can reduce subjective depressive symptoms, while benzoate can decrease perceived stress, improve cognitive function, and enhance treatment adherence in late-life depression patients. The results show promise for D-amino acid oxidase inhibition as a novel approach for perceived stress and cognitive decline among patients with late-life depression.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03414931. Registered January 2016.

High Perceived Stress May Shorten Activated Partial Thromboplastin Time and Lead to Worse Clinical Outcomes in Patients With Coronary Heart Disease

Objective: To determine the association of perceived stress with coagulation function and their predictive values for clinical outcomes. Methods: This prospective cohort study derived from a cross-sectional study for investigating the psychological status of inpatients with suspicious coronary heart disease (CHD). In this study, the 10-item Perceived Stress Scale (PSS-10) as an optional questionnaire was used to assess the severity of perceived stress. Coagulation function tests, such as activated partial thromboplastin time (APTT), prothrombin time (PT), and fibrinogen were measured within 1 h after admission. Furthermore, 241 patients with CHD out of 705 consecutive inpatients were included in the analyses and followed with a median of 26 months for the clinical outcomes. Results: The patients in high perceived stress status (PSS-10 score > 16) were with shorter APTT (36.71 vs. 38.45 s, p = 0.009). Shortened APTT ( ≤ 35.0 s) correlated with higher PSS-10 score (14.67 vs. 11.22, p = 0.003). The association of APTT with depression or anxiety was not found. Multiple linear models adjusting for PT estimated that every single point increase in PSS-10 was relevant to approximately 0.13 s decrease in APTT (p = 0.001) regardless of the type of CHD. APTT (every 5 s increase: hazard ratio (HR) 0.68 [0.47-0.99], p = 0.041) and perceived stress (every 5 points increase: HR 1.31 [1.09-1.58], p = 0.005) could predict the cardiovascular outcomes. However, both predictive values would decrease when they were simultaneously adjusted. After adjusting for the physical clinical features, the associated of perceived stress on cardiac (HR 1.25 [1.04-1.51], p = 0.020) and composite clinical outcomes (HR 1.24 [1.05-1.47], p = 0.011) persisted. Conclusions: For the patients with CHD, perceived stress strongly correlates with APTT. The activation of the intrinsic coagulation pathway is one of the mechanisms that high perceived stress causes cardiovascular events. This hints at an important role of the interaction of mental stress and coagulation function on cardiovascular prognosis. More attention needs to be paid to the patients with CHD with high perceived stress.

Urban Air Pollution and Mental Stress: A Nationwide Study of University Students in China

Background: Studies exploring the relationship between air pollution levels and mental stress have rarely been done, and no studies have been done comparing university student mental stress levels based on regional air pollution levels.

Objectives: The objective of this study was to evaluate the association between air pollution and mental stress among university students.

Methods: Participants were 11,942 students, who were identified through a multistage survey sampling process conducted in 50 universities. Regional air pollution levels were retrieved from a national database, and mental stress was measured using a perceived stress scale. Both unadjusted and adjusted methods were utilized in the data analyses.

Results: Mental stress prevalence was 36.9% (95% Confidence Interval: 24.4–49.5%). The final model indicated that regional air pollution levels were positively associated with students' mental stress.

Conclusions: This study provided new and direct evidence of the health hazards of air pollution. The findings underscore the need to develop and implement stringent environmental protection policies, while simultaneously raising public awareness of environmental protection.

Association of perceived stress with health status outcomes in patients with peripheral artery disease

OBJECTIVE

To assess association of chronic self-perceived stress with health status outcomes of patients with peripheral artery disease.

METHODS

The PORTRAIT study is a prospective registry that enrolled 1275 patients with symptoms of peripheral artery disease across 16-sites in US, Netherlands, and Australia from June 2011 to December 2015. Demographics, comorbidities and diagnostic information was abstracted from chart review. Self-perceived stress was assessed using the 4-item perceived stress scale at baseline, 3- and 6-month follow-up. Scores range from 0 to 16 with higher scores indicating greater stress. Sum scores were calculated at each time point and averaged to quantify average exposure to stress from enrollment through 6 months. Disease-specific health status were assessed at baseline and 12-months using the peripheral artery disease questionnaire summary score.

RESULTS

The mean age of the analytical cohort (n = 1060) was 67.7 ± 9.3 years, 37.1% were females, and 82.3% were white. Comorbidities were highly prevalent with 80.9% having hypertension, 32.6% having diabetes, and 36.4% being smokers. In models adjusted for demographics, comorbidities, disease severity and socioeconomic status, having a higher average stress score was associated with poorer recovery (from baseline) in peripheral artery disease questionnaire summary score at 12-months (-1.4 points per +1-point increase in averaged 4-point perceived stress score, 95% CI -2.1, -0.6 p < 0.001).

CONCLUSION

In patients with peripheral artery disease, experiencing higher chronic stress throughout the 6-months following their diagnosis, was independently associated with poorer recovery in 12-month disease-specific health status outcomes. (ClinicalTrial.gov identifier: NCT01419080).

Association of Perceived Stress Levels With Long-term Mortality in Patients With Peripheral Artery Disease

IMPORTANCE

Identifying modifiable risk factors, such as stress, that could inform the design of peripheral artery disease (PAD) management strategies is critical for reducing the risk of mortality. Few studies have examined the association of self-perceived stress with outcomes in patients with PAD.

OBJECTIVE

To examine the association of high levels of self-perceived stress with mortality in patients with PAD.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data from the registry of the Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) study, a multicenter study that enrolled patients with new or worsening symptoms of PAD who presented to 16 subspecialty clinics across the US, the Netherlands, and Australia from June 2, 2011, to December 3, 2015. However, the present study included only patients in the US sites because assessments of mortality for patients in the Netherlands and Australia were not available. Data analysis was conducted from July 2019 to March 2020.

EXPOSURE

Self-perceived stress was quantified using the 4-item Perceived Stress Scale (PSS-4), with a score range of 0 to 16. A score of 6 or higher indicated high stress in this cohort. Missing scores were imputed using multiple imputation by chained equations with predictive mean matching. Stress was assessed at baseline and at 3-, 6-, and 12-month follow-up. Patients who reported high levels of stress at 2 or more follow-up assessments were categorized as having chronic stress.

MAIN OUTCOMES AND MEASURES

All-cause mortality was the primary study outcome. Such data for the subsequent 4 years after the 12-month follow-up were obtained from the National Death Index.

RESULTS

The final cohort included 765 patients, with a mean (SD) age of 68.4 (9.7) years. Of these patients, 57.8% were men and 71.6% were white individuals. High stress levels were reported in 65% of patients at baseline and in 20% at the 12-month follow-up. In an adjusted Cox proportional hazards regression model accounting for demographics, comorbidities, disease severity, treatment type, and socioeconomic status, exposure to chronic stress during the 12 months of follow-up was independently associated with increased risk of all-cause mortality in the subsequent 4 years (hazard ratio, 2.12; 95% CI, 1.14-3.94; P = .02).

CONCLUSIONS AND RELEVANCE

In thie cohort study of patients with PAD, higher stress levels in the year after diagnosis appeared to be associated with greater long-term mortality risk, even after adjustment for confounding factors. These findings suggest that, given that stress is a modifiable risk factor for which evidence-based management strategies exist, a holistic approach that includes assessment of chronic stress has the potential to improve survival in patients with PAD.

Relationship between blood coagulability and sense of burden among caregivers of patients with dementia

AIM

This study aimed to examine the relationship between blood coagulability and sense of burden among caregivers of patients with senile dementia of the Alzheimer type.

METHODS

A cross-sectional study was carried out involving healthy older caregivers who lived with their patients with senile dementia of the Alzheimer type. We evaluated the Zarit Burden Interview score, levels of von Willebrand factor antigen, D-dimer, thrombin-antithrombin III complex, tissue plasminogen activator/plasminogen activator inhibitor type 1 complex, number of chronic diseases, body mass index and number of medications. A linear regression model was used to estimate adjusted associations.

RESULTS

Thrombin-antithrombin III complex levels were higher in female caregivers than in male caregivers (P = 0.07). Headaches were significantly more frequent in female caregivers than in male caregivers, as assessed by a visual analog scale (P < 0.01). The number of chronic diseases and body mass index were positively associated with levels of tissue plasminogen activator/plasminogen activator inhibitor type 1 complex (P < 0.05). Similarly, the number of medications was positively associated with levels of D-dimer (P < 0.05). However, the Zarit Burden Interview score was not associated with blood coagulability (P > 0.05).

CONCLUSIONS

The present study found that the number of chronic diseases and body mass index were associated with blood coagulability, and that female caregivers were more prone to headaches and higher blood coagulability than male caregivers. These findings highlight the essential nature of health management during caregiving. The impact of caregiver burden on blood coagulability is likely to differ depending on the long-term or short-term psychological stress associated with caregiving conditions. Geriatr Gerontol Int 2019; 19: 804-808.

End-of-day reports of daily hassles and stress in men and women with opioid-use disorder: Relationship to momentary reports of opioid and cocaine use and stress

BACKGROUND AND AIMS

Stress can be validly assessed "live" or by a summary evaluation of the very recent past. Using smartphone-based ecological momentary assessment (EMA) combined with end-of-day (EOD) entries, we assessed the association between daily hassles, stressful events and use of opioids and cocaine, in opioid- and cocaine-using men and women.

METHODS

For up to 16 weeks, 161 outpatients in opioid-agonist treatment who reported cigarette smoking carried smartphones on which they reported stressful events (SEs) and drug use (DU) and completed an EOD questionnaire to report hassles encountered throughout the day, current perceived stress, cigarettes/day, and current mood. We compared EOD responses on days with and without SE and DU reports and on days when thrice-weekly urine drug screens indicated opioid or cocaine use or abstinence.

RESULTS

Participants (N = 161) made 11,544 EOD entries; EMA SEs were reported on 861 (7.5%) days, and DUs on 1685 (14.6%) days. The most frequently reported hassles in EOD entries were "not enough money" (31.4% of daily reports) and maintaining abstinence (18.7%). Total EOD hassles showed small but statistically significant associations [odds ratios (95% CIs)] with EMA SEs [1.09 (1.06-1.13)], DUs [1.08 (1.06-1.10)], and urine-positive opioid [1.06 (1.04-1.09)] and cocaine [1.03 (1.00-1.06)] results. Men and women had similar rates (mean/day (SD)) of hassles: men 2.25 (3.55); women 2.55 (3.76) (F_1,159 = 0.53, p = 0.47).

CONCLUSIONS

Daily hassles, reported at the end of the day, are associated with both same-day stressful events and drug use. Monitoring hassles and devising specific coping strategies might be useful therapeutic targets.

Bidirectional, Temporal Associations of Sleep with Positive Events, Affect, and Stressors in Daily Life Across a Week

BACKGROUND

Sleep is intricately tied to emotional well-being, yet little is known about the reciprocal links between sleep and psychosocial experiences in the context of daily life.

PURPOSE

The aim of this study is to evaluate daily psychosocial experiences (positive and negative affect, positive events, and stressors) as predictors of same-night sleep quality and duration, in addition to the reversed associations of nightly sleep predicting next-day experiences.

METHODS

Daily experiences and self-reported sleep were assessed via telephone interviews for eight consecutive evenings in two replicate samples of US employees (131 higher-income professionals and 181 lower-income hourly workers). Multilevel models evaluated within-person associations of daily experiences with sleep quality and duration. Analyses controlled for demographics, insomnia symptoms, the previous day's experiences and sleep measures, and additional day-level covariates.

RESULTS

Daily positive experiences were associated with improved as well as disrupted subsequent sleep. Specifically, positive events at home predicted better sleep quality in both samples, whereas greater positive affect was associated with shorter sleep duration among the higher-income professionals. Negative affect and stressors were unrelated to subsequent sleep. Results for the reversed direction revealed that better sleep quality (and, to a lesser degree, longer sleep duration) predicted emotional well-being and lower odds of encountering stressors on the following day.

CONCLUSIONS

Given the reciprocal relationships between sleep and daily experiences, efforts to improve well-being in daily life should reflect the importance of sleep.

Daily hassles score associates with the somatic and psychological health of patients with Crohn's disease

OBJECTIVE

To examine the associations of daily hassles with the somatic and psychological health of Crohn's disease (CD) patients.

METHOD

A cross-sectional study of 400 self-selected adult CD patients was performed with completion of demographic, medical, and psychosocial questionnaires: economic status; Patient Harvey-Bradshaw Index of disease activity; Daily Hassles Scale (DHS); Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and Short-Form Health Survey (SF-36 Physical and Mental Health) quality of life measures; Brief Symptom Inventory of psychological stress with summary Global Severity Index (GSI); Family Assessment Device; and List of Threatening Life Experiences. Analyses included correlations, regressions, and Sobel test statistic.

RESULTS

The patients were aged 38.7 ± 14.1 years, 61% female and 67% working. The Patient Harvey-Bradshaw Index was 5.52 ± 4.87. The DHS was 88.0 ± 23.2, similar in men and women, higher in smokers, and increased with greater disease activity (p < .001). The most commonly reported hassles were time, social, and work. DHS had significant negative correlations with age, disease duration, and economic status and positive correlations with GSI, SF-36, and SIBDQ. An increased Daily Hassles score was associated with reduced SIBDQ (p < .001) and SF-36 Mental Health (p < .001) and increased GSI (p < .001) and Patient Harvey-Bradshaw Index (p < .001). This effect of DHS on Patient Harvey-Bradshaw Index was mediated by GSI (Sobel t = 6.09, p < 0.001).

CONCLUSION

Daily hassles in CD patients are shown for the first time to be associated with increased psychological stress and disease activity and reduced quality of life and lower economic status. This has psychotherapeutic implications.

Daily positive events and diurnal cortisol rhythms: Examination of between-person differences and within-person variation

Growing evidence from field studies has linked daily stressors to dysregulated patterns of diurnal cortisol. Less is known about whether naturally-occurring positive events in everyday life are associated with diurnal cortisol. The objectives of this study were to evaluate daily positive events as predictors of between-person differences and within-person (day-to-day) variations in diurnal cortisol parameters, in addition to daily positive events as buffers against the associations between daily stressors and cortisol. In the National Study of Daily Experiences, 1657 adults ages 33-84 (57% female) reported daily experiences during telephone interviews on 8 consecutive evenings. Saliva samples were collected 4 times per day on 4 interview days and assayed for cortisol. Multilevel models were used to estimate associations of daily positive events with cortisol awakening response (CAR), diurnal cortisol slope, and area under the curve (AUC). At the between-person level, people who experienced more frequent positive events exhibited a steeper diurnal cortisol slope, controlling for daily stressors, daily affect, and other covariates. At the within-person level, positive events in the morning (but not prior-night or afternoon/evening events) predicted steeper decline in cortisol across that day; positive events were also marginally associated with lower same-day AUC. Associations were not mediated by daily positive affect, and positive events did not buffer against stressor-related cortisol alterations. These findings indicate that individual differences and day-to-day variations in daily positive events are associated with diurnal cortisol patterns, independent of stressors and affect.

A genetic risk score for CAD, psychological stress, and their interaction as predictors of CAD, fatal MI, non-fatal MI and cardiovascular death

Background

Psychological stress is an independent risk factor for cardiovascular disease (CVD), but the mechanism by which stress is associated with CVD is not entirely understood. Although genetic factors are implied in both stress responsivity and cardiovascular reactivity, no studies to date have investigated their interactions with stress for cardiovascular end points. The objective was to elucidate the association and interactions between a genetic risk score (GRS), individual genetic variants and stress for three cardiovascular end points: coronary artery disease (CAD), fatal myocardial infarction (MI), non-fatal MI, and cardiovascular death.

Methods and findings

18,559 participants from the Malmö Diet Cancer Study, a population-based prospective study, were included in the analyses. Cox proportional hazards regression models were used and adjusted for a large number of known predictors of cardiovascular end points. Mean follow-up time in years was 14.6 (CAD; n = 1938), 14.8 (fatal MI; n = 436), 14.8 (non-fatal MI; n = 1108), and 15.1 (cardiovascular death; n = 1071) respectively. GRS was significantly associated with increased risks of CAD (top quartile hazard ratio [HR], 1.72; 95% confidence interval [CI], 1.51–1.96), fatal MI (top quartile HR, 1.62; 95%CI, 1.23–2.15), non-fatal MI (top quartile HR, 1.55; 95%CI, 1.31–1.84), and cardiovascular death (top quartile HR, 1.29; 95%CI, 1.08–1.53). Stress was not independently associated with any end point and did not interact with GRS. Four individual genetic variants interacted unfavorably with stress for end points with mortality outcomes.

Conclusion

A GRS composed of 50 SNPs and predictive of CAD was found for the first time to also strongly predict fatal MI, non-fatal MI and cardiovascular death. A stress-sensitive component of the GRS was isolated on the basis of individual genetic variants that interacted unfavorably with stress.

Soluble Intracellular Adhesion Molecule-1 in Patients with Unipolar or Bipolar Affective Disorders: Results from a Pilot Trial

BACKGROUND

Immunological and vascular markers may play a role in the pathophysiology of mood disorders and mood changes.

AIM

To test whether the cell adhesion molecule soluble intracellular adhesion molecule-1 (sICAM-1) may serve as a biomarker for patients with unipolar or bipolar affective disorders when compared to a healthy control group, and whether sICAM-1 blood levels change during different mood states.

METHODS

sICAM-1 serum concentrations were compared between 20 healthy controls and 48 patients with affective disorders (unipolar, bipolar II and bipolar I disorder) during different mood states (euthymic mood state, depression or mania).

RESULTS

When compared to healthy controls, patients with affective disorders had significantly higher sICAM-1 levels during the euthymic state (p = 0.015). Differences became more pronounced during depression (p = 0.013). When unipolar and bipolar patients were analyzed separately, unipolar patients significantly differed from controls during the euthymic and depressive mood state, while bipolar II patients showed a trend towards higher sICAM-1 levels during depression. Patients with bipolar I disorders had significantly higher sICAM-1 levels during manic states when compared to controls (p = 0.007).

CONCLUSIONS

sICAM-1 elevation in unipolar and bipolar patients, independent of mood changes, might support the hypothesis of chronic immune activation and endothelial dysfunction in patients with affective disorders.

Psychological stress impairs ischemia-induced neovascularization: Protective effect of fluoxetine

BACKGROUND

Psychological stress (PS) has been associated with the development of cardiovascular diseases and adverse long-term outcomes after ischemic events. However, the precise mechanisms involved are not completely understood. Here we investigated the effect of PS on ischemia-induced neovascularization, and the potential therapeutic effect of fluoxetine in this condition.

METHODS AND RESULTS

Balb/c mice were subjected or not to chronic restraint stress. After 3 weeks, hindlimb ischemia was surgically induced by femoral artery removal. We found that blood flow recovery was significantly impaired in mice exposed to PS compared to controls (Doppler flow ratio (DFR) 0.61 ± 0.07 vs. 0.80 ± 0.07, p < 0.05). At the microvascular level, capillary density was significantly reduced in ischemic muscles of mice exposed to PS (38 ± 1 vs. 74 ± 3 capillaries per field, p < 0.001). This correlated with increased oxidative stress levels and reduced expression of VEGF and VEGF signalling molecules (p44/p42 MAPK, Akt) in ischemic muscles. We found that the number of pro-angiogenic cells (PACs) was significantly reduced in mice exposed to PS. In addition, oxidative stress levels (DCF-DA, DHE) were increased in PACs isolated from mice exposed to PS, and this was associated with impaired PAC functional activities (migration, adhesion, and integration into tubules). Importantly, treatment of mice exposed to PS with the selective serotonin reuptake inhibitor (SSRI) fluoxetine improved all the angiogenic parameters, and completely rescued PS-induced impairment of neovascularization.

CONCLUSION

PS impairs ischemia-induced neovascularization. Potential mechanisms involved include reduced activation of the VEGF pathway in ischemic tissues, increased oxidative stress levels and reduced number and functional activities of PACs. Our results suggest that fluoxetine may represent a novel therapeutic strategy to improve neovascularization and reduce ischemia in patients suffering from cardiovascular diseases and exposed to PS.

Affective reactivity to daily stressors is associated with elevated inflammation

OBJECTIVE

Inflammation increases the risk of chronic diseases, but the links between emotional responses to daily events and inflammation are unknown. We examined individual differences in affective reactivity to daily stressors (i.e., changes in positive and negative affect in response to stressors) as predictors of inflammatory markers interleukin-6 (IL-6) and C-reactive protein (CRP).

METHODS

A cross-sectional sample of 872 adults from the National Study of Daily Experiences (substudy of Midlife in the United States II) reported daily stressors and affect during telephone interviews for 8 days. Blood samples were obtained at a separate clinic visit and assayed for inflammatory markers. Multilevel models estimated trait affective reactivity slopes for each participant, which were inputted into regression models to predict inflammation.

RESULTS

People who experienced greater decreases in positive affect on days when stressors occurred (i.e., positive affect reactivity) had elevated log IL-6, independent of demographic, physical, psychological, and behavioral factors (B = 1.12, SE = 0.45, p = .01). Heightened negative affect reactivity was associated with higher log CRP among women (p = .03) but not men (p = .57); health behaviors accounted for this association in women.

CONCLUSIONS

Adults who fail to maintain positive affect when faced with minor stressors in everyday life appear to have elevated levels of IL-6, a marker of inflammation. Women who experience increased negative affect when faced with minor stressors may be at particular risk of elevated inflammation. These findings add to growing evidence regarding the health implications of affective reactivity to daily stressors.

The Role of Gratitude in Spiritual Well-being in Asymptomatic Heart Failure Patients

Spirituality and gratitude are associated with wellbeing. Few if any studies have examined the role of gratitude in heart failure (HF) patients or whether it is a mechanism through which spirituality may exert its beneficial effects on physical and mental health in this clinical population. This study examined associations bet ween gratitude, spiritual wellbeing, sleep, mood, fatigue, cardiac-specific self-efficacy, and inflammation in 186 men and women with Stage B asymptomatic HF (age 66.5 years ±10). In correlational analysis, gratitude was associated with better sleep (r=-.25, p<0.01), less depressed mood (r=-.41, p<0.01), less fatigue (r=-.46, p<0.01), and better self-efficacy to maintain cardiac function (r=.42, p<0.01). Patients expressing more gratitude also had lower levels of inflammatory biomarkers (r=-.17, p<0.05). We further explored relationships among these variables by examining a putative pathway to determine whether spirituality exerts its beneficial effects through gratitude. We found that gratitude fully mediated the relationship between spiritual wellbeing and sleep quality (z=-2.35, SE=.03, p=.02) and also the relationship between spiritual wellbeing and depressed mood (z=-4.00, SE=.075, p<.001). Gratitude also partially mediated the relationships between spiritual wellbeing and fatigue (z=-3.85, SE=.18, p<.001), and between spiritual wellbeing and self-efficacy (z=2.91, SE=.04, p=.003). In sum, we report that gratitude and spiritual wellbeing are related to better mood and sleep, less fatigue, and more self-efficacy, and that gratitude fully or partially mediates the beneficial effects of spiritual wellbeing on these endpoints. Efforts to increase gratitude may be a treatment for improving wellbeing in HF patients' lives and be of potential clinical value.

Associations between air pollution and perceived stress: the Veterans Administration Normative Aging Study

BACKGROUND

There is mixed evidence suggesting that air pollution may be associated with increased risk of developing psychiatric disorders. We aimed to investigate the association between air pollution and non-specific perceived stress, often a precursor to development of affective psychiatric disorders.

METHODS

This longitudinal analysis consisted of 987 older men participating in at least one visit for the Veterans Administration Normative Aging Study between 1995 and 2007 (n = 2,244 visits). At each visit, participants were administered the 14-item Perceived Stress Scale (PSS), which quantifies stress experienced in the previous week. Scores ranged from 0-56 with higher scores indicating increased stress. Differences in PSS score per interquartile range increase in moving average (1, 2, and 4-weeks) of air pollution exposures were estimated using linear mixed-effects regression after adjustment for age, race, education, physical activity, anti-depressant medication use, seasonality, meteorology, and day of week. We also evaluated effect modification by season (April-September and March-October for warm and cold season, respectively).

RESULTS

Fine particles (PM2.5), black carbon (BC), nitrogen dioxide, and particle number counts (PNC) at moving averages of 1, 2, and 4-weeks were associated with higher perceived stress ratings. The strongest associations were observed for PNC; for example, a 15,997 counts/cm(3) interquartile range increase in 1-week average PNC was associated with a 3.2 point (95%CI: 2.1-4.3) increase in PSS score. Season modified the associations for specific pollutants; higher PSS scores in association with PM2.5, BC, and sulfate were observed mainly in colder months.

CONCLUSIONS

Air pollution was associated with higher levels of perceived stress in this sample of older men, particularly in colder months for specific pollutants.

Daily positive events and inflammation: findings from the National Study of Daily Experiences

BACKGROUND

Inflammation is implicated in the development of chronic diseases and increases the risk of mortality. People who experience more daily stressors than others have higher levels of inflammation, but it is unknown whether daily positive events are linked to inflammation.

OBJECTIVE

To examine the association of daily positive events with 3 inflammatory markers, interleukin-6 (IL-6), C-reactive protein (CRP), and fibrinogen.

METHOD

A cross-sectional sample of 969 adults aged 35-86 from the Midlife in the United States Study completed telephone interviews for 8 consecutive evenings. Participants reported positive experiences that occurred over the past 24h. Blood samples were obtained at a separate clinic visit and later assayed for inflammatory markers. Regression analyses evaluated the frequency of daily positive events (defined as the percent of study days with at least 1 positive event) as a predictor of each inflammatory marker. Covariates included information on demographics, physical health, depressive symptoms, dispositional and behavioral factors, and daily positive and negative affect.

RESULTS

On average, participants experienced positive events on 73% of days (SD=27%). The frequency of daily positive events was associated with lower IL-6 (p<0.001) and CRP (p=0.02) in the overall sample, and lower fibrinogen among women (p=0.01). The association remained for IL-6 in the fully adjusted model, but was no longer significant for CRP and fibrinogen after controlling for household income and race. Effects were more pronounced for participants in the lowest quartile of positive event frequency than for those in the top 3 quartiles, suggesting that lack of positivity in daily life may be particularly consequential for inflammation. Furthermore, interpersonal positive events were more predictive of lower IL-6 overall and lower fibrinogen in women than non-interpersonal positive events.

CONCLUSION

Daily positive events may serve a protective role against inflammation.

[Questionnaire development in ELSA-Brasil: challenges of a multidimensional instrument]

This article describes the development of the Brazilian Longitudinal Study for Adult Health (ELSA-Brasil) questionnaire. We first address the selection of topics whose contents have to cover the knowledge available on the complex causal network of outcomes and allow comparability with similar studies. Then we deal with the "translation and adaptation of measurement instruments" including neighborhood environment rating scales, depression and anxiety disorder rating scale and a food frequency questionnaire and discuss criteria that guided "theme block sequencing". And finally we focus on the practical importance of "pretesting and pilot studies". The ELSA may provide an original contribution regarding factors that cause or aggravate the outcomes of interest in the Brazilian population, as well as protective factors.

Evaluating the role of perceived stress on the likelihood of having a non - fatal acute coronary syndrome: a case-control study

OBJECTIVES

The aim of the current study was to evaluate the independent role of perceived stress, measured by the PSS-14, on the likelihood of having acute coronary syndrome (ACS).

CONCLUSION

This is a case-control study with individual matching by age and sex. During 2010-2012, 250 consecutive patients (60±11 years, 78% men) with a first ACS and 250 population-based, control subjects (60±8.6 years, 77.6% men), were enrolled. Perceived stress levels were evaluated with the PSS-14 scale, depression status was assessed with the Zung Depression Rating Scale, anxiety status with the STAI scale and adherence to the Mediterranean diet was assessed by the MedDietScore.

CONCLUSION

Higher perceived stress was associated with increased likelihood of having an ACS, after adjusting for various factors (OR=1.15, %CI 1.11, 1.18). STAI and ZUNG scale were positively associated with the likelihood of having an ACS (OR: 1.27 %CI 1.20-1.34, p<0.001 and OR: 1.49 %CI 1.36-1.63, p<0.001 respectively). Stratified analysis by sex showed a greater impact of perceived stress in men, compared with women (Wald test value 45.65 vs 18.56, respectively). When stratifying by depression levels, the effect of perceived stress on ACS was not significant among depressed individuals. When stratifying by level of anxiety, higher odds of having an ACS was found in the low anxiety group (OR: 1.129, %CI 1.047-1.218).

CONCLUSION

Perceived stress appears as an independent ACS risk factor, although no causal relationship can be extracted due to the nature of the study. Early recognition and treatment of perceived stress may lead to ACS risk reduction.

Do hassles and uplifts change with age? Longitudinal findings from the VA normative aging study

To examine emotion regulation in later life, we contrasted the modified hedonic treadmill theory with developmental theories, using hassles and uplifts to assess emotion regulation in context. The sample was 1,315 men from the VA Normative Aging Study aged 53 to 85 years, who completed 3,894 observations between 1989 and 2004. We computed 3 scores for both hassles and uplifts: intensity (ratings reflecting appraisal processes), exposure (count), and summary (total) scores. Growth curves over age showed marked differences in trajectory patterns for intensity and exposure scores. Although exposure to hassles and uplifts decreased in later life, intensity scores increased. Group-based modeling showed individual differences in patterns of hassles and uplifts intensity and exposure, with relative stability in uplifts intensity, normative nonlinear changes in hassles intensity, and complex patterns of individual differences in exposure for both hassles and uplifts. Analyses with the summary scores showed that emotion regulation in later life is a function of both developmental change and contextual exposure, with different patterns emerging for hassles and uplifts. Thus, support was found for both hedonic treadmill and developmental change theories, reflecting different aspects of emotion regulation in late life.

Acute painful stress and inflammatory mediator production

BACKGROUND

Proinflammatory pathways may be activated under conditions of painful stress, which is hypothesized to worsen the experience of pain and place medically vulnerable populations at risk for increased morbidity.

OBJECTIVES

To evaluate the effects of pain and subjective pain-related stress on proinflammatory activity.

METHODS

A total of 19 healthy control subjects underwent a single standard cold-pressor pain test (CPT) and a no-pain control condition. Indicators of pain and stress were measured and related to inflammatory immune responses [CD8+ cells expressing the integrin molecule CD11a (CD811a), interleukin (IL)-1 receptor agonist (IL-1RA), and IL-6] immediately following the painful stimulus and compared to responses under no-pain conditions. Heart rate and mean arterial pressure were measured as indicators of sympathetic stimulation.

RESULTS

CPT was clearly painful and generated an activation of the sympathetic nervous system. CD811a increased in both conditions, but with no statistically significantly greater increase following CPT (p<0.06). IL-1RA demonstrated a non-statistically significant increase following CPT (p<0.07). The change in IL-6 following CPT differed significantly from the response seen in the control condition (p<0.02).

CONCLUSIONS

These findings suggest that CP acute pain may affect proinflammatory pathways, possibly through mechanisms related to adrenergic activation.

Targeting activation of specific NF-κB subunits prevents stress-dependent atherothrombotic gene expression

Psychosocial stress has been shown to be a contributing factor in the development of atherosclerosis. Although the underlying mechanisms have not been elucidated entirely, it has been shown previously that the transcription factor nuclear factor-κB (NF-κB) is an important component of stress-activated signaling pathway. In this study, we aimed to decipher the mechanisms of stress-induced NF-κB-mediated gene expression, using an in vitro and in vivo model of psychosocial stress. Induction of stress led to NF-κB-dependent expression of proinflammatory (tissue factor, intracellular adhesive molecule 1 [ICAM-1]) and protective genes (manganese superoxide dismutase [MnSOD]) via p50, p65 or cRel. Selective inhibition of the different subunits and the respective kinases showed that inhibition of cRel leads to the reduction of atherosclerotic lesions in apolipoprotein(-/-) (ApoE(-/-)) mice via suppression of proinflammatory gene expression. This observation may therefore provide a possible explanation for ineffectiveness of antioxidant therapies and suggests that selective targeting of cRel activation may provide a novel approach for the treatment of stress-related inflammatory vascular disease.

Perceived stress in myocardial infarction: long-term mortality and health status outcomes

OBJECTIVES

This study sought to determine the association of chronic stress with long-term adverse outcomes after acute myocardial infarction (AMI).

BACKGROUND

Chronic stress has been shown to be associated with the development of cardiovascular disease and, in the case of particular types of stress such as job and marital strain, with recurrent adverse events after AMI. Little is known, however, about the association of chronic stress with mortality and adverse health status outcomes in a general AMI population.

METHODS

In a cohort of 4,204 AMI patients from 24 U.S. hospitals completing the Perceived Stress Scale-4 (sum scores ranging from 0 to 16) during hospitalization, moderate/high stress over the previous month was defined as scores in the top 2 quintiles (scores of 6 to 16). Detailed data on sociodemographics, psychosocial status, and clinical characteristics were collected at baseline. Outcomes included patients' 1-year health status, assessed with the Seattle Angina Questionnaire, Short Form-12, and EuroQol Visual Analog Scale, and 2-year mortality.

RESULTS

AMI patients with moderate/high stress had increased 2-year mortality compared with those having low levels of stress (12.9% vs. 8.6%; p < 0.001). This association persisted after adjusting for sociodemographics, clinical factors (including depressive symptoms), revascularization status, and GRACE (Global Registry of Acute Coronary Events) discharge risk scores (hazard ratio: 1.42: 95% confidence interval: 1.15 to 1.76). Furthermore, moderate/high stress was independently associated with poor 1-year health status, including a greater likelihood of angina, worse disease-specific and generic health status, and worse perceived health (p < 0.01 for all).

CONCLUSIONS

Moderate/high perceived stress at the time of an AMI is associated with adverse long-term outcomes, even after adjustment for important confounding factors. Future studies need to examine whether stress mediates observed racial and socioeconomic disparities and whether novel interventions targeting chronic stress and coping skills can improve post-AMI outcomes.

Uplifts and sleep

Recently, there has been a growth of interest in factors that play a protective role in sleep. This study is an exploratory analysis investigating relations between daily hassles and uplifts (events appraised as pleasant) and measures of subjective and polysomnography (PSG)-assessed sleep in a group of healthy adults (N = 135). Hassles and uplifts were assessed with the Combined Hassles and Uplifts Scale (CHUS), subjective sleep was assessed with the Pittsburgh Sleep Quality Index (PSQI), and objective sleep was assessed with standard PSG. After controlling for covariates, uplifts intensity was associated with subjective sleep and PSG-assessed sleep. Specifically, increased uplifts intensity was associated with better subjective sleep, decreased time slept in Stage 2 sleep, and increased time slept in slow wave sleep (SWS). One's perception of the magnitude of positive events may play a role in sleep and should be examined in future investigations.

Relationships among stress measures, risk factors, and inflammatory biomarkers in law enforcement officers

Law enforcement officers suffer higher morbidity and mortality rates from all causes than the general population. Cardiovascular disease (CVD) accounts for a significant portion of the excess illness, with a reported prevalence as high as 1.7 times that of the general population. To determine which occupational hazards cause this increased risk and morbidity, it is imperative to study law enforcement officers before they retire. The long-range goal of our research is to reduce the incidence of CVD-related illness and death among aging law enforcement officers. The purpose of the present study was to measure pro- and anti-atherogenic inflammatory markers in blood samples from law enforcement officers (n = 71) and determine what types of occupation-related stress correlate with differences in these markers. For each outcome variable of interest, we developed separate regression models. Two groups of potential predictors were examined for inclusion in the models. Selected measures of stress were examined for inclusion in the models, in addition to general covariates, such as gender, ethnicity, years in law enforcement, and body mass index. Our results revealed statistically significant relationships between several physiologic variables and measures of stress.

The effects of ethnic discrimination and socioeconomic status on endothelin-1 among blacks and whites

BACKGROUND

Ethnic disparities in cardiovascular disease (CVD) may partially reflect differences in chronic stress burden that vary by social class and exposure to ethnic discrimination. Stress is associated with increased endothelin-1 (ET-1). This study examined the relationship of ET-1 to socioeconomic status (SES) and to perceived ethnic discrimination among black (n = 51) and white (n = 65) adults (mean age 36.5).

METHODS

The Perceived Discrimination subscale of the Scale of Ethnic Experience measured exposure to discrimination and the Hollingshead Two-Factor Index of Social Position assessed SES. Plasma ET-1 was sampled upon awakening after an overnight admission.

RESULTS

SES and ET-1 levels were similar across ethnic groups, but mean discrimination scores were higher among blacks than whites (P < 0.001). Multiple regressions found that the SES x ethnicity interaction was associated with ET-1 (P < 0.05), after adjustment for gender, resting mean arterial pressure (MAP), body mass index (BMI), and exercise frequency. Regressions stratified by ethnicity revealed that lower SES correlated with higher ET-1 in whites (P < 0.001), but not blacks, and accounted for 21% of the variance. Another series of regressions revealed an interaction effect of ethnicity by discrimination on ET-1 (P < 0.05). Increased discrimination correlated with increased ET-1 among blacks (P < 0.05), but not whites, and explained 11% of the variance after adjustment for SES, gender, exercise frequency, and socially desirable response bias.

CONCLUSIONS

Thus, ET-1 levels increased in association with different psychosocial burdens in blacks and whites. Plasma ET-1 was higher among whites with lower SES and among blacks with higher levels of perceived ethnic discrimination, regardless of SES.

Psychological stress and cardiovascular disease

There is an enormous amount of literature on psychological stress and cardiovascular disease. This report reviews conceptual issues in defining stress and then explores the ramifications of stress in terms of the effects of acute versus long-term stressors on cardiac functioning. Examples of acute stressor studies are discussed in terms of disasters (earthquakes) and in the context of experimental stress physiology studies, which offer a more detailed perspective on underlying physiology. Studies of chronic stressors are discussed in terms of job stress, marital unhappiness, and burden of caregiving. From all of these studies there are extensive data concerning stressors' contributions to diverse pathophysiological changes including sudden death, myocardial infarction, myocardial ischemia, and wall motion abnormalities, as well as to alterations in cardiac regulation as indexed by changes in sympathetic nervous system activity and hemostasis. Although stressors trigger events, it is less clear that stress "causes" the events. There is nonetheless overwhelming evidence both for the deleterious effects of stress on the heart and for the fact that vulnerability and resilience factors play a role in amplifying or dampening those effects. Numerous approaches are available for stress management that can decrease patients' suffering and enhance their quality of life.

Escala hassles & uplifts: versão em português

A escala Hassles & Uplifts avalia a intensidade da resposta a pequenos eventos cotidianos, sendo considerada um preditor de sintomas psicológicos. O objetivo deste estudo foi avaliar uma tradução da escala Hassles & Uplifts, aqui intitulada Aborrecimentos e Alegrias; para tal, realizou-se a réplica de um estudo norte-americano que mediu o desempenho, nessa escala, de indivíduos cujo padrão de comportamento fosse do tipo A ou B segundo a escala de Jenkins (Escala Aborrecimentos e Alegrias). As escalas Aborrecimentos e Alegrias e A/B foram aplicadas em 145 universitários brasileiros. Os resultados mostraram que: 1) as pontuações médias de Aborrecimentos e Alegrias foram similares às do estudo norte-americano, exceto pelos Aborrecimentos dos participantes tipo B; 2) a intensidade das Alegrias dos participantes tipo A foi significativamente superior à dos tipo B, como na literatura; 3) a intensidade de Alegrias e Aborrecimentos não diferiu entre os dois tipos, provavelmente devido à especificidade da época do teste. Concluiu-se que o padrão e a consistência dos resultados indicam que a tradução pode ser utilizada como instrumento confiável de pesquisa.