Cortisol as a predictor of psychological therapy response in depressive disorders: systematic review and meta-analysis

Two-year course of non-suicidal self-injury in an adolescent clinical cohort: The role of childhood adversity in interaction with cortisol secretion

AIM

Non-suicidal self-injury (NSSI) is a highly prevalent phenomenon during adolescence. Nonetheless, research on predictors of the clinical course of NSSI over time is still scarce. The present study aimed at investigating the impact of adverse childhood experiences (ACE) and hypothalamus-pituitary-adrenal (HPA) axis functioning on the longitudinal course of NSSI.

METHODS

In a sample of n = 51 help-seeking adolescents engaging in NSSI, diurnal cortisol secretion (CAR, cortisol awakening response; DSL, diurnal slope), hair cortisol concentrations and ACE were assessed at baseline. Clinical outcome was defined by change in the frequency of NSSI in the past 6 months measured 12 and 24 months after the baseline assessments. Mixed-effects linear regression models were used to test for effects of ACE and HPA axis functioning on the course of NSSI.

RESULTS

ACE and HPA axis functioning did not show main but interaction effects in the prediction of NSSI frequency over time: Adolescents with a low severity of ACE and either an increased CAR or a flattened DSL showed a steep decline of NSSI frequency in the first year followed by a subsequent increase of NSSI frequency in the second year.

CONCLUSIONS

Our findings could be interpreted in the sense of high diurnal cortisol concentrations in the absence of ACE being favorable for clinical improvement on the short-term but bearing a risk of allostatic load and subsequent increase of NSSI frequency. In contrast, adolescents with severe ACE may benefit from elevated cortisol concentrations leading to slower but lasting decreases of NSSI frequency.

Biomarkers in the Diagnosis and Prediction of Medication Response in Depression and the Role of Nutraceuticals

Depression continues to be a significant and growing public health concern. In clinical practice, it involves a clinical diagnosis. There is currently no defined or agreed upon biomarker/s for depression that can be readily tested. A biomarker is defined as a biological indicator of normal physiological processes, pathogenic processes, or pharmacological responses to a therapeutic intervention that can be objectively measured and evaluated. Thus, as there is no such marker for depression, there is no objective measure of depression in clinical practice. The discovery of such a biomarker/s would greatly assist clinical practice and potentially lead to an earlier diagnosis of depression and therefore treatment. A biomarker for depression may also assist in determining response to medication. This is of particular importance as not all patients prescribed with medication will respond, which is referred to as medication resistance. The advent of pharmacogenomics in recent years holds promise to target treatment in depression, particularly in cases of medication resistance. The role of pharmacogenomics in routine depression management within clinical practice remains to be fully established. Equally so, the use of pharmaceutical grade nutrients known as nutraceuticals in the treatment of depression in the clinical practice setting is largely unknown, albeit frequently self-prescribed by patients. Whether nutraceuticals have a role in not only depression treatment but also in potentially modifying the biomarkers of depression has yet to be proven. The aim of this review is to highlight the potential biomarkers for the diagnosis, prediction, and medication response of depression.

Cortisol interdependence during psychotherapy in major depressive disorder

The current study explored cortisol interdependence between patients and therapists during psychotherapy, the possible moderating effect of patient alliance ratings on this interdependence, and the associations between cortisol interdependence and treatment outcome. While cortisol interdependence was explored in other interpersonal contexts, its presence in psychotherapy has remained unexplored. We hypothesized that (a) patients' and therapists' cortisol levels at pre-session will predict their own and their partner's subsequent cortisol levels at post-session, (b) patient ratings of their relationship with their therapists will moderate these partner effects, and (c) cortisol interdependence will be associated with better treatment outcome. Fifty dyads undergoing 16 weeks of psychodynamic treatment for major depressive disorder participated in this study. Patient-therapist salivary cortisol samples were collected at eight time points, alongside a post-session patient-rated alliance questionnaire and a symptom severity interview. For analyses we employed the actor-partner interdependence model. Results revealed that (a) patients' and therapists' cortisol levels before sessions predicted their own post-session cortisol changes. However, significant cortisol interdependence was observed in patients' pre-session cortisol levels predicting therapists' post-session cortisol levels. Furthermore, (b) poorer alliance ratings associated with more pronounced cortisol interdependence, and (c) in dyads where patient pre-session cortisol predicted therapist's post-session cortisol, a better treatment outcome was found. This study found novel evidence of cortisol interdependence in psychotherapy and is partially in line with other studies inspecting cortisol interdependence in adjacent research fields. These findings emphasize the intricate psychophysiological interactions within therapeutic relationships and their associations with treatment outcome.

In Context: Lessons About Adolescent Unipolar Depression From the Improving Mood With Psychoanalytic and Cognitive Therapies Trial

This paper summarizes the results of the Improving Mood with Psychoanalytic and Cognitive Therapies (IMPACT) study and its implications for psychological treatment of adolescents with moderate to severe unipolar major depression. IMPACT was a pragmatic, superiority, randomized controlled trial conducted in the United Kingdom, which compared the clinical and cost-effectiveness of short-term psychoanalytic therapy (STPP), cognitive-behavioral therapy (CBT), and a brief psychosocial intervention (BPI) in reducing depression symptoms in 465 adolescents with unipolar major depression, aged 11 to 17 years. Although this was a clinically heterogeneous group of adolescents, some symptoms (eg, sleep and concentration difficulties, irritability/anger) were common and disabling. The trial reported no significant difference among the 3 treatments in reducing depression symptoms. One year after treatment, 84% of participants showed improvement in depressive symptoms (<50% of baseline symptoms) and improved psychosocial functioning, achieving this through different symptom reduction trajectories. Although participants attended fewer treatment sessions than planned, the 3 treatments were delivered with fidelity to their respective models. Ending treatment without therapist agreement occurred in 37% of cases. This was not associated with outcomes by treatment group. Adolescents emphasized the importance of the therapeutic relationship in all 3 treatments. Results suggest that although most adolescents respond to time-limited, structured psychological therapy, subgroups of depressed adolescents are likely to need additional treatment or support. These include adolescents who live in complex circumstances and/or who believe that their needs are not met in therapy, some who stop treatment early, and the 16% to 18% of adolescents who do not respond to treatment. CLINICAL TRIAL REGISTRATION INFORMATION: Improving Mood and Preventing Relapse With Psychoanalytic Psychotherapy and Cognitive Behaviour Therapy; https://www.isrctn.com; ISRCTN83033550.

To Be Frail or Not to Be Frail: This Is the Question-A Critical Narrative Review of Frailty

Many factors have contributed to rendering frailty an emerging, relevant, and very popular concept. First, many pandemics that have affected humanity in history, including COVID-19, most recently, have had more severe effects on frail people compared to non-frail ones. Second, the increase in human life expectancy observed in many developed countries, including Italy has led to a rise in the percentage of the older population that is more likely to be frail, which is why frailty is much a more common concern among geriatricians compared to other the various health-care professionals. Third, the stratification of people according to the occurrence and the degree of frailty allows healthcare decision makers to adequately plan for the allocation of available human professional and economic resources. Since frailty is considered to be fully preventable, there are relevant consequences in terms of potential benefits both in terms of the clinical outcome and healthcare costs. Frailty is becoming a popular, pervasive, and almost omnipresent concept in many different contexts, including clinical medicine, physical health, lifestyle behavior, mental health, health policy, and socio-economic planning sciences. The emergence of the new "science of frailty" has been recently acknowledged. However, there is still debate on the exact definition of frailty, the pathogenic mechanisms involved, the most appropriate method to assess frailty, and consequently, who should be considered frail. This narrative review aims to analyze frailty from many different aspects and points of view, with a special focus on the proposed pathogenic mechanisms, the various factors that have been considered in the assessment of frailty, and the emerging role of biomarkers in the early recognition of frailty, particularly on the role of mitochondria. According to the extensive literature on this topic, it is clear that frailty is a very complex syndrome, involving many different domains and affecting multiple physiological systems. Therefore, its management should be directed towards a comprehensive and multifaceted holistic approach and a personalized intervention strategy to slow down its progression or even to completely reverse the course of this condition.

Pituitary gland volumes and stress: Results of a population-based adult sample

Early and chronic stress was reported to alter the hypothalamic-pituitary-adrenal axis functioning which regulates the secretion of cortisol. Nevertheless, few studies mainly focused on specific study populations (e.g. adolescents, pregnant women, and psychiatric patients), and researched interactive associations of pituitary volumes and single stress markers. The present study used pituitary volumes of two adult general-population cohorts of the Study of Health in Pomerania (SHIP-START-2: N = 1026, 54% Men, 30-90 years; SHIP-TREND-0: N = 1868, 53% Men, 21-82 years). In linear regression models, main effects of the pituitary volumes as well as interaction effects with childhood abuse and neglect (Childhood Trauma Questionnaire) were estimated using depressive symptoms (Beck Depression Inventory-II), and serum cortisol concentrations as outcome variables. The results of both cohorts were integrated via meta-analyses. No main effect between pituitary volumes and depressive symptoms was observed (START-2: β = -0.004 [-0.082; 0.075], p = .929; TREND-0: β = 0.020 [-0.033; 0.073], p = .466; Meta-analysis: β = 0.012 [-0.031; 0.056], p = .580). However, larger pituitary volumes were associated with more depressive symptoms in participants with more severe childhood neglect (START-2: β = 0.051 [-0.024; 0.126], p = .183; TREND-0: β = 0.083 [0.006; 0.159], p = .034; Meta-analysis: β = 0.066 [0.013; 0.120], p = .015). Further, larger pituitary volumes were associated with lower serum cortisol concentrations in participants with more severe depressive symptoms (START-2: β = -0.087 [-0.145; -0.030], p = .003; TREND-0: β = -0.053 [-0.091; -0.015], p = .006; Meta-analysis: β = -0.063 [-0.095; -0.032], p = 8.39e-05). Summarizing, larger pituitary volumes were associated with more severe psychopathological symptoms, particularly in participants reporting early life stress. This was supported by stronger associations between pituitary volumes and cortisol concentrations in participants with more severe depressive symptoms. Future studies are needed to transfer these results into developmental stages of high hormonal changes and patient samples.

[Depressive Disorders in Adolescence: Current State of Studies Concerning the Microbiota-Gut-Brain Axis]

Depressive Disorders in Adolescence: Current State of Studies Concerning the Microbiota-Gut-Brain Axis Abstract. Depressive disorders increase during adolescence and often lead to significant impairment in affected individuals - despite treatment. Current research efforts aim to further investigate the pathophysiology of depression, considering the influence of gut microbiota on the gut-brain axis. The present narrative review outlines the current state of studies of the microbiota-gut-brain axis in depressive disorders as well as the direct and indirect interactions in adolescence. Besides providing promising results from animal studies, studies on the microbiota-gut-brain axis in adults suffering from depressive disorders are growing steadily. In depressed adolescents, however, the study situation is still marginal, making a recommendation for the supplementation of probiotics and prebiotics in depressed children and adolescents impossible according to the current state of research. Against the background of a very limited number of studies involving adolescents with depressive disorders, the interactive role of the microbiota-gut-brain axis in adolescent development should receive special attention in future research projects.

The Role of the Adrenal-Gut-Brain Axis on Comorbid Depressive Disorder Development in Diabetes

Diabetic patients are more affected by depression than non-diabetics, and this is related to greater treatment resistance and associated with poorer outcomes. This increase in the prevalence of depression in diabetics is also related to hyperglycemia and hypercortisolism. In diabetics, the hyperactivity of the HPA axis occurs in parallel to gut dysbiosis, weakness of the intestinal permeability barrier, and high bacterial-product translocation into the bloodstream. Diabetes also induces an increase in the permeability of the blood-brain barrier (BBB) and Toll-like receptor 4 (TLR4) expression in the hippocampus. Furthermore, lipopolysaccharide (LPS)-induced depression behaviors and neuroinflammation are exacerbated in diabetic mice. In this context, we propose here that hypercortisolism, in association with gut dysbiosis, leads to an exacerbation of hippocampal neuroinflammation, glutamatergic transmission, and neuronal apoptosis, leading to the development and aggravation of depression and to resistance to treatment of this mood disorder in diabetic patients.

The antidepressant-like effects of Danzhi Xiaoyao San and its active ingredients

BACKGROUND

Depression is a severe mental illness that endangers human health. Depressed individuals are prone to sleep less and to the loss of appetite for food; their thinking and cognition processes, as well as mood, may even be affected. Danzhi Xiaoyao San (DXS), documented in the Internal Medicine Summary, has been used for hundreds of years in China and is widely applied traditionally to treat liver qi stagnation, liver and spleen blood deficiency, menstrual disorders, and spontaneous and night sweating. DXS can also clear heat and drain the liver. Presently, it is used frequently in the treatment of depression based on its ability to clear the liver and alleviate depression.

PURPOSE

To summarize clinical and preclinical studies on the antidepressant-like effects of DXS, understand the material basis and mechanisms of these effects, and offer new suggestions and methods for the clinical treatment of depression.

METHODS

"Danzhi Xiaoyao", "Danzhixiaoyao", "Xiaoyao", "depression" and active ingredients were entered as keywords in PubMed, Google Scholar, CNKI and WANFANG DATA databases in the search for material on DXS and its active ingredients. The PRISMA guidelines were followed in this review process.

RESULTS

Per clinical reports, DXS has a therapeutic effect on patients with depression but few side effects. DXS and its active ingredients allegedly produce their neuroprotective antidepressant-like effects by modulating monoamine neurotransmitter levels, inhibiting the hypothalamic-pituitary-adrenal (HPA) axis hyperfunction, reducing neuroinflammation and increasing neurotrophic factors.

CONCLUSION

Overall, DXS influences multiple potential mechanisms to exert its antidepressant-like effects thanks to its multicomponent character. Because depression is not caused by a single mechanism, probing the antidepressant-like effects of DXS could further help understand the pathogenesis of depression and discover new antidepressant drugs.

Childhood trauma associated with increased post-awakening cortisol in major depressive disorder

BACKGROUND

Enhanced post-awakening cortisol may serve as a biological marker for individuals with major depressive disorder. However, studies comparing post-awakening cortisol between patients with major depressive disorder (MDD) and healthy controls have produced conflicting findings. The aim of this study was to investigate whether this inconsistency could be due to the effects of childhood trauma.

METHODS

A total of N = 112 patients with MDD and healthy controls were divided into four groups according to the presence of childhood trauma. Saliva samples were collected at awakening and 15, 30, 45, and 60 min later. The total cortisol output and the cortisol awakening response (CAR) were calculated.

RESULTS

The total post-awakening cortisol output was significantly higher in patients with MDD as compared to healthy controls, but only in those individuals reporting childhood trauma. The four groups did not differ regarding the CAR.

CONCLUSIONS

Elevated post-awakening cortisol in MDD may be confined to those with a history of early life stress. Tailoring and/or augmenting of currently available treatments may be required to meet the specific needs of this population.

Fingernail Cortisol: A Biological Signal of Lifetime Major Depressive Disorder

INTRODUCTION

Elevated levels of the hypothalamic-pituitary-adrenal axis hormone cortisol are a frequently replicated finding in major depressive disorder (MDD). However, the current state of research is inconclusive as to whether hypercortisolism represents a trait- or state-like biological signal of MDD. The aim of the present study was to investigate, for the first time, whether cortisol in fingernails, a highly accessible tissue, could distinguish currently remitted individuals with MDD from healthy controls. A further aim was to identify potential confounders of nail cortisol.

METHODS

A total of N = 100 individuals from the general population were recruited. A structured clinical interview was administered, which resulted in two groups: n = 48 with lifetime MDD and n = 52 healthy controls. All participants answered questions on sociodemographic, lifestyle, and psychosocial characteristics. They also grew their nails for 14 days and cut them for the subsequent determination of cortisol.

RESULTS

The groups differed in their nail cortisol concentrations, such that the individuals with lifetime MDD had significantly higher concentrations than the healthy controls (p = 0.041). Within the group of individuals with lifetime MDD, the number of experienced episodes was significantly correlated with cortisol (p = 0.011). Income emerged as the only significant confounder of cortisol (p = 0.008).

CONCLUSION

Elevated fingernail cortisol appears to be a biological signal of MDD, even in the absence of a current major depressive episode. Its high accessibility and robustness render it a promising methodology for remote research as well as for the integration of biomarkers into clinical research and practice.

Major depressive disorder: biomarkers and biosensors

Depressive disorders belong to highly heterogeneous psychiatric diseases. Loss of in interest in previously enjoyed activities and a depressed mood are the main characteristics of major depressive disorder (MDD). Moreover, due to significant heterogeneity in clinical presentation and lack of applicable biomarkers, diagnosis and treatment remains challenging. Identification of relevant biomarkers would allow for improved disease classification and more personalized treatment strategies. Herein, we review the current state of these biomarkers and then discuss diagnostic techniques of aimed to specifically target these analytes using state of the art biosensor technology.

The effect of an internet-based intervention for depression on cortisol and alpha-amylase

INTRODUCTION

Psychotherapeutic interventions for major depressive disorder (MDD) have been suggested to be associated with a normalization of biological stress system (i.e., the hypothalamic-pituitary-adrenal axis and the autonomic nervous system) dysregulation. Furthermore, pre-intervention cortisol parameters have been identified as prescriptive biological markers of treatment success. However, evidence of treatment effects on the biological stress systems is still sparse, and results are heterogeneous. The current study examined the effect of an internet-based intervention for MDD on salivary cortisol and alpha-amylase as well as hair cortisol concentrations. Moreover, the prescriptive capacity of pre-intervention cortisol and alpha-amylase concentrations on treatment response was explored.

METHODS

Thirty-eight participants suffering from mild to moderate MDD collected saliva and hair samples throughout the intervention. Biological outcome parameters were salivary cortisol and alpha-amylase (awakening response, total diurnal output, diurnal slope) and hair cortisol concentrations. Treatment response was indicated by change in depression severity and perceived chronic stress.

RESULTS

Treatment response on depression scores or chronic stress was not associated with changes in any of the cortisol or alpha-amylase parameters. Exploratory analysis indicated that non-responders showed a steeper alpha-amylase slope pre-intervention.

DISCUSSION

The results indicate that changes in depressive symptoms did not correspond to changes of the biological stress systems, contradicting the suggested normalization of dysregulated hypothalamic-pituitary-adrenal axis or autonomic nervous system activity through a psychotherapeutic intervention. However, the results point to a potential role of pre-intervention alpha-amylase slope as a prescriptive marker of treatment response for depression.

Association between childhood maltreatment and adult cortisol concentrations mediated through subjective health complaints

Background

Lower cortisol concentrations in adulthood were repeatedly associated with more severe childhood maltreatment. Additionally, childhood maltreatment was reported to promote health risk behavior, such as smoking or alcohol consumption, and to increase the risk of mental and somatic diseases during adulthood, such as major depressive disorders or obesity. The present study investigated if health risk behavior and disease symptoms in adults mediate the associations between past childhood maltreatment and present basal serum cortisol concentrations.

Methods

Data from two independent adult cohorts of the general population-based Study of Health in Pomerania (SHIP-TREND-0: N = 3,517; SHIP-START-2: N = 1,640) was used. Childhood maltreatment was assessed via the Childhood Trauma Questionnaire (CTQ). Cortisol concentrations were measured in single-point serum samples. Health risk behavior and mental and physical symptoms were used as mediators. Mediation analyses were calculated separately for both cohorts; results were integrated via meta-analyses.

Results

In mediator-separated analyses, associations between childhood maltreatment and basal serum cortisol concentrations were partly mediated by depressive symptoms (BDI-II: βindirect effect = -.011, pFDR = .017, 21.0% mediated) and subjective somatic health complaints (somatic complaints: βindirect effect = -.010, pFDR = .005, 19.4% mediated). In the second step, both mediators were simultaneously integrated into one mediation model. The model replicated the mediation effects of the subjective somatic health complaints (whole model: βindirect effect = -.014, p = .001, 27.6% mediated; BDI-II: βindirect effect = -.006, p = .163, 11.4% mediated, somatic complaints: βindirect effect = -.020, p = .020, 15.5% mediated).

Conclusion

The results support the hypothesis that the long-lasting effects of childhood maltreatment on the stress response system are partly mediated through self-perceived disease symptoms. However, no mediation was found for health risk behavior or physically measured mediators. Mediation models with multiple simultaneous mediators pointed to a relevant overlap between the potential mediators. This overlap should be focused on in future studies.

The use of biochemical indexes in hair for clinical studies of psychiatric diseases: What can we learn about mental disease from hair?

Analysis of hair samples provides unique advantages, including non-invasive sampling, sample stability, and the possibility of additional optimization of high sensitivity detection methods. Hair sample analysis is often used in psychiatric disease research to evaluate previous periods of stress encountered by patients. Glucocorticoid analysis is the most frequently tested indicator of stress. Furthermore, the hypothalamus-pituitary-gonad axis and endocannabinoid system also are involved in the occurrence and development of mental disorders. The endocannabinoid and sex hormone levels in patients experiencing mental illness are considerably different from levels observed in healthy individuals. Nevertheless, due to the different methods used to assess the degree of disease and the range of analytical methods involved in clinical research, the trends in changes for these biomarkers are not uniform. The correlations between changes in biomarker concentrations and illness severity also are not clear. The observed alterations suggest these biochemical substances in hair have potential as biomarkers for diagnosis or predictive treatment. However, the variable results obtained thus far could hamper further development of hair samples for clinical assessment in psychiatric disorders. This article summarizes the published reports documenting the changes in the content of relevant substances in hair in individuals experiencing mental illness and the degree of correlation. In the discussion section, we proposed several issues that should be considered in future studies of hair samples obtained from patients with mental disorders to promote the use of hair sample assessment as an aid in diagnosis or predictive treatment.

Neurodevelopmental toxicity induced by PM2.5 Exposure and its possible role in Neurodegenerative and mental disorders

Recent extensive evidence suggests that ambient fine particulate matter (PM2.5, with an aerodynamic diameter ≤2.5 μm) may be neurotoxic to the brain and cause central nervous system damage, contributing to neurodevelopmental disorders, such as autism spectrum disorders, neurodegenerative diseases, such as Alzheimer's disease and Parkinson's disease, and mental disorders, such as schizophrenia, depression, and bipolar disorder. PM2.5 can enter the brain via various pathways, including the blood-brain barrier, olfactory system, and gut-brain axis, leading to adverse effects on the CNS. Studies in humans and animals have revealed that PM2.5-mediated mechanisms, including neuroinflammation, oxidative stress, systemic inflammation, and gut flora dysbiosis, play a crucial role in CNS damage. Additionally, PM2.5 exposure can induce epigenetic alterations, such as hypomethylation of DNA, which may contribute to the pathogenesis of some CNS damage. Through literature analysis, we suggest that promising therapeutic targets for alleviating PM2.5-induced neurological damage include inhibiting microglia overactivation, regulating gut microbiota with antibiotics, and targeting signaling pathways, such as PKA/CREB/BDNF and WNT/β-catenin. Additionally, several studies have observed an association between PM2.5 exposure and epigenetic changes in neuropsychiatric disorders. This review summarizes and discusses the association between PM2.5 exposure and CNS damage, including the possible mechanisms by which PM2.5 causes neurotoxicity.

Recent developments on psychological factors in medically unexplained symptoms and somatoform disorders

Somatic symptoms which are not fully explained by a medical condition (medically unexplained symptoms) have a high relevance for the public health. They are very common both in the general population and in patients in health care, and may develop into chronic impairing conditions such as somatoform disorders. In recent years, the relevance of specific negative psychological factors for the diagnosis and the stability of somatoform disorders and for the impairment by medically unexplained symptoms gained more and more attention. This resulted-among others- in core changes in the diagnostic classification criteria of somatoform disorders. Against this background, the present "Perspective" will outline recent developments and findings in the area of medically unexplained somatic symptoms and somatoform disorders. Moreover, it will lay a special focus on evidence on specific negative psychological factors that may influence the course of unexplained somatic symptoms and disorders and the impairment caused by these symptoms.

Post-awakening salivary alpha-amylase as modulator of treatment response in patients with burnout and major depression

Around 50% of patients with major depression do not respond to standard first-line treatments, such as psychotherapy and pharmacotherapy. At the same time, a subgroup exhibits altered functioning of stress-responsive bodily systems, such as the central locus coeruleus/sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis. Given that these systems impact arousal and cognition, it is possible that this subgroup contributes to the high rates of non-responders. Our aim was to investigate whether sympathetic and HPA axis activity modulate treatment outcomes in patients with stress-related major depression. A total of N = 74 inpatients (median age: 50, 62% male) with signs of burnout who fulfilled diagnostic criteria for major depression were recruited. Saliva samples were collected at awakening as well as 30 and 45 min later. Alpha-amylase activity and cortisol concentrations were determined before patients underwent evidence-based multimodal treatment. Non-responders were defined as patients exhibiting a &lt;50% decrease in depression on the Beck Depression Inventory. Non-responders had significantly higher post-awakening alpha-amylase activity than responders (p = .025). In addition, alpha-amylase activity increased significantly over the course of treatment (p = .004), irrespective of responder status. Post-awakening cortisol was neither a predictor nor an indicator of treatment response. If future research confirms alpha-amylase activity as a modulator of treatment response, this may indicate a subgroup of patients with major depression which may benefit from augmentative treatments, such as heart rate variability biofeedback and/or cognitive interventions targeting high arousal.

Why Does Psychotherapy Work and for Whom? Hormonal Answers

The questions of for whom and why psychotherapy is effective have been the focus of five decades of research. Most of this knowledge is based on self-report measures. Following the biopsychosocial model of mental disorders, this article explores the potential of hormones in answering these questions. The literature on cortisol, oxytocin, and oestradiol in psychotherapy was systematically searched, focusing on (a) baseline hormonal predictors of who may benefit from psychotherapy and (b) hormonal changes as indicators of therapeutic change. The search was limited to depression and anxiety disorders. In sum, the findings show that, of all three hormones, the role of cortisol is most established and that both cortisol and oxytocin are implicated in psychotherapy, although a causal role is still waiting to be demonstrated. Moreover, there is a differential role of hormones in the psychotherapy of depression versus anxiety. The directions of research mapped in this article may elucidate how psychotherapy can be selected to match patients’ endocrine states and how hormonal levels can be manipulated to improve outcomes.

Salivary Cortisol Awakening Response as a Predictor for Depression Severity in Adult Patients with a Major Depressive Episode Performing a Daily Exercise Program

INTRODUCTION

The hypothalamic-pituitary-adrenal axis function in depression has been the subject of considerable interest, and its function has been tested with a variety of methods. We investigated associations between saliva cortisol at awakening and the 24-h urine cortisol output, both measured at study baseline, with endpoint depression scores.

METHODS

Patients were admitted to a psychiatric inpatient ward with a major depressive episode and were started on fixed duloxetine treatment. They delivered saliva samples at awakening and 15, 30, and 60 min post-awakening and sampled urine for 24 h. Subsequently, they started a daily exercise program maintained for a 9-week period. Clinician-rated depression severity was blindly assessed with the Hamilton Depression Rating 6-item subscale (HAM-D6). The cortisol awakening response was quantified by the area under the curve with respect to the ground (AUCG) and with respect to the rise (AUCI) using saliva cortisol levels in the 1-h period after awakening. Analysis of expected associations between depression severity, AUCG, AUCI, exercise, and 24-h cortisol output was performed in a general linear model.

RESULTS

In all, 35 participants delivered saliva or 24-h urine samples. The mean age was 49.0 years (SD = 11.0) with 48.6% females with a mean baseline HAM-D6 score of 12.2 (SD = 2.3). In a statistical model investigating the association between HAM-D6 at week 9 as a dependent variable and AUCI, concurrent HAM-D6, gender, smoking, and exercise volume as covariates, we found a significant effect of AUCI, concurrent HAM-D6, and exercise. The following statistics were found: AUCI (regression coefficient 0.008; F value = 9.1; p = 0.007), concurrent HAM-D6 (regression coefficient 0.70; F value = 8.0; p = 0.01), and exercise (regression coefficient -0.005; F value = 5.7; p = 0.03). The model had an R2 of 0.43. The association between HAM-D6 endpoint scores and the AUCI showed that higher AUCI values predicted higher HAM-D6 endpoint values. The association between HAM-D6 endpoint scores and the exercise level showed that a high exercise level was associated with lower HAM-D6 endpoint values.

CONCLUSION

The results thus showed that high AUCI values predicted less improvement of depression and high exercise levels predicted more improvement of depression. These findings need to be confirmed in larger samples to test if more covariates can improve prediction of depression severity.

Psychobiological Mechanisms in Somatic Symptom Disorder and Depressive Disorders: An Ecological Momentary Assessment Approach

OBJECTIVE

Persistent somatic symptoms cause strong impairment in persons with somatic symptom disorder (SSD) and depressive disorders (DDs). Specific negative psychological factors (NPFs), such as catastrophizing, negative affectivity, and behavioral avoidance, are assumed to contribute to this impairment and may maintain symptoms via dysregulations of biological stress systems. We examined the associations between NPF and somatic symptoms in the daily life of women with SSD or DD and investigated the mediating role of psychobiological stress responses.

METHODS

Twenty-nine women with SSD and 29 women with DD participated in an ecological momentary assessment study. For 14 days, intensity of and impairment by somatic symptoms, NPF, and stress-related biological measures (cortisol, alpha-amylase) were assessed five times per day using an electronic device and saliva samples. Multilevel models were conducted.

RESULTS

The greater the number of NPF, the higher the concurrent and time-lagged intensity of and impairment by somatic symptoms in both groups (12.0%-38.6% of variance explained; χ2(12) p < .001 for all models). NPFs were associated with higher cortisol levels in women with DD and with lower levels in women with SSD (interaction NPF by group: B = -0.04, p = .042 for concurrent; B = -0.06, p = .019 for time-lagged). In women with SSD, lower cortisol levels were associated with higher intensity at the next measurement time point (group by cortisol: B = -1.71, p = .020). No mediation effects were found.

CONCLUSIONS

NPFs may be considered as transdiagnostic factors in the development and treatment of impairing somatic symptoms. Our findings will allow the development of new treatment strategies that use ecological momentary intervention approaches focusing on NPF.

A cluster analytic approach to examining the role of cortisol in the development of post-traumatic stress and dysphoria in adult traumatic injury survivors

Identification of specific risk factors for posttraumatic stress disorder (PTSD) versus depression after trauma has been challenging, in part due to the high comorbidity of these disorders. As exposure to trauma triggers activation of the hypothalamic-pituitary-adrenal (HPA)-axis, examining atypical stress responses via HPA-axis hormones, namely cortisol, may help in the delineation of these disorders. Indeed, extant research demonstrates that, following stress, individuals with chronic PTSD exhibit hypocortisolism (e.g., lower cortisol response than controls), while those with chronic depression exhibit hypercortisolism (e.g., higher response than controls). Less is known about the role of cortisol and these seemingly disparate profiles immediately following traumatic injury as well as whether cortisol can be used as a predictor of future development of PTSD versus depression symptoms. In this study cortisol was measured blood from 172 traumatic injury survivors during hospitalization (on average 2.5 days post-injury). PTSD and depression severity were assessed from Clinician Assessed PTSD Scale (CAPS-5) six-eight months later using a two-factor dimensional approach that measures trauma-specific symptoms of PTSD versus dysphoria (akin to depression). Cluster analysis was used to group individuals based on post-injury cortisol, PTSD, and dysphoria. Results demonstrated that trauma survivors who only developed symptoms of dysphoria at six months (with minimal symptoms of PTSD) were differentiated by high post-injury cortisol compared to other groups. By contrast, individuals who developed symptoms of both PTSD and dysphoria were differentiated by low post-injury cortisol and most severe symptoms of PTSD. Findings provide support for the presence of subgroups of trauma survivors defined, in part, by post-trauma cortisol.

Childhood Trauma, the HPA Axis and Psychiatric Illnesses: A Targeted Literature Synthesis

Studies of early life stress (ELS) demonstrate the long-lasting effects of acute and chronic stress on developmental trajectories. Such experiences can become biologically consolidated, creating individual vulnerability to psychological and psychiatric issues later in life. The hippocampus, amygdala, and the medial prefrontal cortex are all important limbic structures involved in the processes that undermine mental health. Hyperarousal of the sympathetic nervous system with sustained allostatic load along the Hypothalamic Pituitary Adrenal (HPA) axis and its connections has been theorized as the basis for adult psychopathology following early childhood trauma. In this review we synthesize current understandings and hypotheses concerning the neurobiological link between childhood trauma, the HPA axis, and adult psychiatric illness. We examine the mechanisms at play in the brain of the developing child and discuss how adverse environmental stimuli may become biologically incorporated into the structure and function of the adult brain via a discussion of the neurosequential model of development, sensitive periods and plasticity. The HPA connections and brain areas implicated in ELS and psychopathology are also explored. In a targeted review of HPA activation in mood and psychotic disorders, cortisol is generally elevated across mood and psychotic disorders. However, in bipolar disorder and psychosis patients with previous early life stress, blunted cortisol responses are found to awakening, psychological stressors and physiological manipulation compared to patients without previous early life stress. These attenuated responses occur in bipolar and psychosis patients on a background of increased cortisol turnover. Although cortisol measures are generally raised in depression, the evidence for a different HPA activation profile in those with early life stress is inconclusive. Further research is needed to explore the stress responses commonalities between bipolar disorder and psychosis in those patients with early life stress.

Effects of Modified Electroconvulsive Therapy on Serum Cortisol, Nesfatin-1, and Pro-inflammatory Cytokine Levels in Elderly Patients With Treatment-Resistant Depression

AIM

Modified electroconvulsive therapy (MECT) is an effective strategy for treatment-resistant depression (TRD); however, the mechanism underlying effects of MECT remains unclear. Accumulating evidence suggests that TRD is closely associated with dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis, anorexigenic peptides, and pro-inflammatory cytokines. However, MECT effects on the HPA axis, anorexigenic peptides, and pro-inflammatory cytokines in elderly patients with TRD remain unclear. In this study, we investigated whether the HPA axis (cortisol), anorexigenic peptides (nesfatin-1), and pro-inflammatory cytokines (C-reactive protein, tumor necrosis factor-α, and interleukin-6, and interleukin-1β) are involved in the mechanism underlying MECT effects in elderly patients with TRD.

METHODS

Elderly patients with TRD were enrolled in this study between December 2019 and October 2021; all patients underwent MECT after physical examination. Serum cortisol, nesfatin-1, and pro-inflammatory cytokine levels were measured before and after the first, third, and sixth MECT sessions. The Hamilton Depression Rating Scale-24 (HAMD-24) and the Mini-Mental State Examination (MMSE) were used to evaluate depression and cognitive impairment, respectively. We compared pre- and post-MECT serum cortisol, nesfatin-1, and pro-inflammatory cytokine levels to confirm the short-term effects of MECT on these serum indices. We compared these serum indices across three time points (before the first, third, and sixth MECT sessions) to determine the long-term effects of MECT on serum cortisol, nesfatin-1, and pro-inflammatory cytokine levels.

RESULTS

We observed no statistically significant changes in the pre- and post-MECT serum cortisol, nesfatin-1, or pro-inflammatory cytokine levels. No significant changes in serum cortisol, nesfatin-1, and pro-inflammatory cytokine levels were observed across the aforementioned time points. Moreover, there were no statistically significant sex-based differences in the aforementioned serum indices. Furthermore, the serum cortisol level was negatively correlated with the serum IL-6 level before and after the first MECT session in patients with high cortisol levels (> the 50^th percentile value of all samples). Additionally, the post-MECT HAMD-24 and MMSE scores were significantly lower.

CONCLUSIONS

MECT reduced depressive symptoms despite an adverse effect on cognition and had no significant effect on the serum cortisol, nesfatin-1, and pro-inflammatory cytokine levels in elderly patients with TRD.

In(s) and out(s) of adolescent depression - Trajectories of development and recovery

While the role of biological markers in understanding major depressive disorder (MDD) in adults have been studied extensively, less has been done to identify the biomarkers of MDD development and recovery in adolescence. With the majority of mental health disorders starting in adolescence, identifying biomarkers of transition and recovery from MDD early in life is critical for developing effective prevention strategies. Considering most of the child and adolescent populations come from low-and-middle-income countries (LMICs), it is vital to focus on adolescent populations in these settings. With most studies coming from high-income countries (HICs), evidence suggests that elevated morning cortisol levels including cortisol awakening response (CAR), increased peripheral inflammation and brain abnormalities such as cortico-limbic dysregulation or blunted activity in reward related regions in response to positive information are associated with MDD and being at-risk for MDD development in adolescence. We also find that some of the biological mechanisms of recovery from MDD, mainly normalisation in the cortico-limbic dysregulation, are reported following psychological therapy, suggesting shared pathways leading to MDD vulnerability and recovery. Although, only a few studies include adolescent populations. Understanding molecular mechanisms through which psychological interventions are effective, as well as molecular markers of transition to depression in individuals at-risk, are important to inform effective prevention and intervention strategies.

Sex differences in the association between basal serum cortisol concentrations and cortical thickness

Background

Basal cortisol concentrations vary between men and women. Likewise, previous findings suggest stress-related cortical thickness alterations. Thus, we aimed at elucidating sex differences in the association between serum cortisol concentrations and cortical thickness.

Methods

Data of 2594 participants (55.55% male; mean age = 53.55 years ± 13.17 years) of the general population were used to investigate sex differences in basal serum cortisol concentrations and associations of serum cortisol concentrations with global and regional cortical thickness. The validity of the results was tested by including sex hormone concentrations as a biological and childhood maltreatment and depressive symptoms as a psychological confounder.

Results

Basal serum cortisol concentrations were higher in men than in women (β = -0.158, t₍₂₅₇₅₎ = -6.852, p = 9.056e-12). Sex differences in serum cortisol concentrations were diminished by including serum concentrations of testosterone, estrone, or estradiol in the models. In men but not in women, serum cortisol concentrations were inversely associated with the global cortical thickness (men: β = -0.064, t₍₁₄₁₂₎ = -3.010, p = .003; women: β = -0.016, t₍₁₁₃₁₎ = -0.607, p = .544). Additionally, these effects were observed in eleven cortical regions after adjusting for multiple testing. The associations were independent of childhood maltreatment and depressive symptoms.

Conclusion

Sex differences in serum cortisol concentrations and the association between serum cortisol concentrations and cortical thickness suggest important sex-specific effects of stress on the brain. Future studies should integrate the interaction between the hypothalamic-pituitary-adrenal (HPA) axis and hypothalamic-pituitary-gonadal (HPG) axis in sex-stratified analyses.

Patient and Therapist In-Session Cortisol as Predictor of Post-Session Patient Reported Affect

The importance of the role of affect in psychotherapy for major depressive disorder (MDD) is well established, but the common use of self-reported measures may limit our understanding of its underlying mechanisms. A promising predictor of patient affect is the stress hormone cortisol. To date, no studies have studied in-session changes in cortisol in psychotherapy for MDD. We investigated whether an increase in patient cortisol over the course of a session correlated with higher negative and lower positive affect. Given previous findings on healthy individuals on the contagious nature of stress, an additional aim was to examine whether these relationships are moderated by therapist cortisol. To this end, 40 dyads (including 6 therapists) provided saliva samples before and after four pre-specified sessions (616 samples). After each session, the patients provided retrospective reports of in-session affect. We found no association between patient cortisol and affect. However, increases in patient cortisol predicted negative affect when the therapists exhibited decreases in cortisol, and increases in patient cortisol predicted positive affect when the therapists showed increases. Our study provides initial evidence for the importance of the social context in the cortisol-affect relationship in MDD.

δEPCD: the electrophysiologic coefficient of depressiveness

Despite research advances, recently identified biological markers for depression are either non-specific or impractical in daily clinical practice. Hence, we aim to identify a novel biomarker: δ_EPCD, the electrophysiologic coefficient of depressiveness. δ_EPCD must be sensitive and specific to the vulnerability towards depression. It should also detect the presence of a depressive clinical state and be able to quantify its severity. Moreover, it should be easily accessible and cost-effective. Accordingly, combining high-frequency heart rate variability (HF-HRV), which reflects a reduction in vagal tone, and tryptophan metabolism, which influences serotonin synthesis pathway, may have a good diagnostic and prognostic accuracy in depression. δ_EPCD is the multiplication of the intrinsic difference between state 0 (rest) and state 1 (exposure to stress) of HF-HRV and the plasma concentration ratio between quinolinic acid and kynurenine. δ_EPCD theoretically fluctuates between -1000 and 0 where being closer to 0 signifies no vulnerability to depression. Individuals with a score between -16.7 and -167 have a high vulnerability to depression. Finally, individuals with a δ_EPCD closer to -1000 have the most severe forms of depression. δ_EPCD is theoretically conceived to be easy to assess and monitor which makes it a candidate for further evaluation of reliability and validity.CLINICAL SIGNIFICANCEDepression is currently diagnosed based on emotional and behavioural symptoms; however there is currently a rising interest in the field of neurobiological markers that could improve diagnostic accuracy.Many current biological approaches are primarily based on single neurobiological markers that are either non-specific or impractical in daily clinical practice.Among other neurological effects, depression may modify the parasympathetic nervous system tone and disturb the tryptophan metabolism.The electrophysiological coefficient of depressiveness δ_EPCD combines heart rate variability (HRV) and tryptophan metabolism to reflect the intrinsic individual vulnerability towards depression and the inherent severity of an index depressive disorder.δ_EPCD is the intrinsic difference between state 0 (without stress) and state 1 (exposed to a stressful task) of the high-frequency heart rate variability multiplied by the intrinsic difference between both states, e.g. state 0 and 1, of the plasma concentration ratio of quinolinic acid over kynurenine.

Blood-Brain Barrier Dysfunction in the Pathogenesis of Major Depressive Disorder

Major depression represents a complex and prevalent psychological disease that is characterized by persistent depressed mood, impaired cognitive function and complicated pathophysiological and neuroendocrine alterations. Despite the multifactorial etiology of depression, one of the most recent factors to be identified as playing a critical role in the development of depression is blood-brain barrier (BBB) disruption. The occurrence of BBB integrity disruption contributes to the disturbance of brain homeostasis and leads to complications of neurological diseases, such as stroke, chronic neurodegenerative disorders, neuroinflammatory disorders. Recently, BBB associated tight junction disruption has been shown to implicate in the pathophysiology of depression and contribute to increased susceptibility to depression. However, the underlying mechanisms and importance of BBB damage in depression remains largely unknown. This review highlights how BBB disruption regulates the depression process and the possible molecular mechanisms involved in development of depression-induced BBB dysfunction. Moreover, insight on promising therapeutic targets for treatment of depression with associated BBB dysfunctions are also discussed.

Effect of adverse childhood experiences on hypothalamic-pituitary-adrenal (HPA) axis function and antidepressant efficacy in untreated first episode patients with major depressive disorder

Adverse childhood experiences (ACEs) has been associated not only with an increased vulnerability for stress-related psychiatric disorders but also with distinct alterations of the hypothalamic-pituitary-adrenal (HPA) axis function and the immune system. The aim of this study is to examine differences in the HPA axis between major depressive disorder (MDD) patients with and without ACEs, and to explore differences in efficacy and HPA changes after long term antidepressant treatment between these two groups. A cohort of 803 patients with MDD were recruited. After the determination of cortisol (COR) and adrenocorticotropic hormone (ACTH), Hamilton Rating Scale for Depression (HAMD), Hamilton Rating Scale for Anxiety (HAMA), the Childhood Trauma Questionnaire (CTQ), 403 subjects were recruited for the following treatment study. Finally 330 MDD patients finished the monotherapy treatments of four antidepressants (Fluoxetine, Sertraline, Venlafaxine-extended release (XR), Duloxetine hydrochloride) for 12 weeks. Of 403 patients, 226 (56%) patients reported ACEs. Total score of HAMD in MDD with ACEs were higher than those in MDD without ACEs. There were significant differences for both ACTH and COR between MDD patients with and without ACEs that MDD patients with any types of maltreatment had higher level. Both COR and ACTH was positively and significantly correlated with the total scores of CTQ, HAMD, HAMA. After 12 weeks treatment of antidepressants monotherapy, the mean (SD) changes in HAMD and HAMA total scores was greater in MDD without ACEs than those in MDD with ACEs. At the 12-week end point, response was achieved by 37.2% in the MDD with ACEs group, 59.0% in the MDD without ACEs group respectively, with significant difference. Remission was achieved by 15.2% in the MDD with ACEs group and 32.2% in the MDD without ACEs group, with significant difference. The change in ACTH level in MDD without ACEs was also greater than that in MDD with ACEs, which was positively and significantly correlated with the HAMD total score only in MDD patient without ACEs. Logistic regression analysis showed that the total scores of CTQ, level of COR and ACTH at baseline were significantly associated with the response and remission. These findings indicated that exposure to ACEs for MDD could influence the HPA function and severity of symptoms. ACEs, ACTH and COR could be used as predictors of long term antidepressant treatment, suggested that are poor prognostic signs for antidepressants monotherapy in MDD with ACEs.

The effects of rational emotive behavior therapy for depressive symptoms in adults with congenital heart disease

BACKGROUND

Over 30% of adults with congenital heart disease (CHD) experience depression.

OBJECTIVES

To evaluate the effectiveness of Rational Emotive Behavior Therapy (REBT) in reducing depressive symptoms in adults with CHD.

METHODS

Forty-two adults with CHD were recruited from an outpatient clinic and randomized to a study group (n = 21), which comprised 8-weekly group-based counseling sessions, or a control group (n = 21), which received usual care. REBT effectiveness was examined using the Hamilton Depression Rating Scale, Beck Depression Inventory, Shorten General Attitude and Belief Scale, and salivary cortisol levels before therapy, after the last session, and at follow-up 4 weeks later.

RESULTS

Average participant ages were 30.1 ± 7.58 and 33.3 ± 7.1 years in study and control groups, respectively; 52.4% of participants in each group were female. After REBT, depression (p < 0.001), irrational beliefs (p < 0.001), and salivary cortisol levels (p = 0.006) were significantly lower in the study group than in the control group. Effects of REBT in the study group remained consistent at the 4-week follow-up.

CONCLUSION

REBT may be effective in reducing depression in adults with CHD.

Investigation of the relationship between hot flashes, sweating and sleep quality in perimenopausal and postmenopausal women: the mediating effect of anxiety and depression

Background

To investigate the relationship between sweating from hot flashes, anxiety, depression, and sleep quality in peri- and postmenopausal women. And also the role of anxiety and depression in mediating sweating from hot flashes and sleep quality.

Methods

467 women aged 40–60 years with menopausal problems were enrolled. The sleep quality; hot flashes; sweating; anxiety and depression symptoms were quantitatively evaluated by Pittsburgh Sleep Quality Scale (PSQI), Kupperman Menopause Index, Self-rating Anxiety Scale and Self-rating Depression Scale. Spearman correlation analysis and mediating effect model were used to analyze the relationship between the three.

Results

262 patients’ PSQI score were higher than 6 (58.2%). Total scores of sleep quality were positively correlated with hot flashes, sweating and anxiety and depression symptoms. Anxiety and depression played a mediating role between hot flashes, sweating and sleep quality where the mediating effect of anxiety symptoms accounted for 17.86% (P < 0.01) and depression symptoms accounted for 5.36% (P < 0.01).

Conclusions

The hot flashes, sweating, anxiety and depression of peri/postmenopausal women are risk factors affecting sleep quality. By alleviating these risk factors, the sleep quality of peri- and postmenopausal women could be improved, which prevents the physical and mental diseases due to long-term severe insomnia.

Comorbidity in idiopathic pulmonary fibrosis - what can biomarkers tell us?

Idiopathic pulmonary fibrosis (IPF) is characterized by progressive parenchymal scarring, leading to dyspnoea, respiratory failure and premature death. Although IPF is confined to the lungs, the importance of IPF comorbidities such as pulmonary hypertension and ischaemic heart disease, lung cancer, emphysema/chronic obstructive pulmonary disease, gastroesophageal reflux, sleep apnoea and depression has been increasingly recognized. These comorbidities may be associated with increased mortality and significant loss of quality of life, so their identification and management are vital. The development of good-quality biomarkers could lead to numerous gains in the management of these patients. Biomarkers can be used for the identification of predisposed individuals, early diagnosis, assessment of prognosis, selection of best treatment and assessment of response to treatment. However, the role of biomarkers for IPF comorbidities is still quite limited, and mostly based on evidence coming from populations without IPF. The future development of new biomarker studies could be informed by those that have been studied independently for each of these conditions. For now, clinicians should be mostly attentive to clinical manifestations of IPF comorbidities, and use validated diagnostic methods for diagnosis. As research on biomarkers of most common diseases continues, it is expected that useful biomarkers are developed for these diseases and then validated for IPF populations. The reviews of this paper are available via the supplemental material section.

Associations between baseline cortisol and trajectory of symptom improvement in depressed adolescents receiving psychological therapy

BACKGROUND

Cortisol hypersecretion in depressed adolescents and adults is associated with more persistent illness and may signal a lower response to psychological therapies. A meta-analysis of small and heterogenous studies demonstrated that higher pre-treatment basal cortisol levels were associated with poorer response specifically to psychological therapy for depression. The objective of this study was to investigate the relationship between both morning and evening salivary cortisol levels and response to psychological therapy in depressed adolescents participating in one large randomised controlled trial.

METHODS

We tested the association between morning and evening salivary cortisol levels at baseline and improvement in depressive symptoms in response to psychological therapies in depressed adolescents at 6 time points: baseline, 6, 12, 36, 52- and 86-weeks post-randomisation, using the self-reported Mood and Feelings Questionnaire (MFQ).

RESULTS

High evening cortisol was associated with a slower initial decline in depressive symptoms (cortisol x quadratic time p = .022); however it was not associated with total change in depressive symtoms over the whole course of the study. Morning cortisol was not associated with change in depressive symptoms. These effects were not significantly different across the three psychological therapies.

LIMITATIONS

Results may not generalize to adolescents receiving other treatments (medication) or no treatment, and may not generalize to adults. Only a minority of eligible participants collected valid cortisol samples.

CONCLUSIONS

Higher pretreatment evening cortisol may impair a depressed adolescent's ability to use psychological therapy.

Comparison of hypothalamo-pituitary-adrenal function in treatment resistant unipolar and bipolar depression

Altered functioning of the hypothalamic-pituitary-adrenal (HPA) axis has been demonstrated in patients with treatment-resistant depression, although studies have often conflated patients with unipolar and bipolar depression. This is problematic given that the two groups often present with opposed neurovegetative symptom patterns. The aim of this study was to test, for the first time, whether post-awakening cortisol, a highly reliable, naturalistic measure of HPA functioning, could distinguish patients with clearly defined treatment-resistant unipolar (TRUD) and bipolar depression (TRBD). A total of 37 patients with TRUD, 17 patients with TRBD, and 47 healthy controls were recruited. Areas under the curve (AUC) with respect to the ground (g) and increase (i) of post-awakening cortisol concentrations (awakening, +15, +30, +45, +60, +90 min) were measured over two days. Patients with TRUD had higher total cortisol production in the morning hours compared to controls (AUCg, p = 0.01), while they did not differ in terms of the awakening response (AUCi, p = 0.28). By contrast, subjects with TRBD had lower total cortisol when compared to controls by trend (AUCg, p = 0.07), while they did not differ in the awakening response (AUCi, p = 0.15). A direct comparison of TRUD and TRBD revealed differences in the AUCg (p = 0.003) and AUCi (p = 0.03). This finding of comparatively elevated HPA axis activity in the morning in TRUD and attenuated HPA axis activity in TRBD attests to a fundamental biological distinction between unipolar and bipolar depression. It has implications for the understanding and treatment of bipolar depression and in differentiating the two types of depression.

Biomarkers of Major Depressive Disorder: Knowing is Half the Battle

Major depressive disorder (MDD) is a heterogeneous disease which is why there are currently no specific methods to accurately test the severity, endophenotype or therapy response. This lack of progress is partly attributed to the com-plexity and variability of depression, in association with analytical variability of clinical literature and the wide number of theoretically complex biomarkers. The literature accessible, indicates that markers involved in inflammatory, neuro-trophic and metabolic processes and components of neurotransmitters and neuroendocrine systems are rather strong indicators to be considered clinically and can be measured through genetic and epigenetic, transcriptomic and proteomic, metabolomics and neuroimaging assessments. Promising biologic systems/markers found were i.e., growth biomarkers, endocrine markers, oxidant stress markers, proteomic and chronic inflammatory markers, are discussed in this review. Several lines of evidence suggest that a portion of MDD is a dopamine agonist-responsive subtype. This review analyzes concise reports on the pathophysiological biomarkers of MDD and therapeutic reactions via peripheral developmental factors, inflammative cytokines, endocrine factors and metabolic markers. Various literatures also support that endocrine and metabolism changes are associated with MDD. Accumulating evidence suggests that at least a portion of MDD patients show characteristics pathological changes regarding different clinical pathological biomarkers. By this review we sum up all the different biomarkers playing an important role in the detection or treatment of the different patients suffering from MDD. The review also gives an overview of different biomarker's playing a potential role in modulating effect of MDD.

Treatment-Resistant Depression Revisited: A Glimmer of Hope

Major Depressive Disorder (MDD) is a highly prevalent psychiatric disorder worldwide. It causes individual suffering, loss of productivity, increased health care costs and high suicide risk. Current pharmacologic interventions fail to produce at least partial response to approximately one third of these patients, and remission is obtained in approximately 30% of patients. This is known as Treatment-Resistant Depression (TRD). The burden of TRD exponentially increases the longer it persists, with a higher risk of impaired functional and social functioning, vast losses in quality of life and significant risk of somatic morbidity and suicidality. Different approaches have been suggested and utilized, but the results have not been encouraging. In this review article, we present new approaches to identify and correct potential causes of TRD, thereby reducing its prevalence and with it the overall burden of this disease entity. We will address potential contributory factors to TRD, most of which can be investigated in many laboratories as routine tests. We discuss endocrinological aberrations, notably, hypothalamic-pituitary-adrenal (HPA) axis dysregulation and thyroid and gonadal dysfunction. We address the role of Vitamin D in contributing to depression. Pharmacogenomic testing is being increasingly used to determine Single Nucleotide Polymorphisms in Cytochrome P450, Serotonin Transporter, COMT, folic acid conversion (MTHFR). As the role of immune system dysregulation is being recognized as potentially a major contributory factor to TRD, the measurement of C-reactive protein (CRP) and select immune biomarkers, where testing is available, can guide combination treatments with anti-inflammatory agents (e.g., selective COX-2 inhibitors) reversing treatment resistance. We focus on established and emerging test procedures, potential biomarkers and non-biologic assessments and interventions to apply personalized medicine to effectively manage treatment resistance in general and TRD specifically.

The Role of Inflammatory Proteins in Anti-Glucocorticoid Therapy for Treatment-Resistant Depression

BACKGROUND

Optimising treatments for patients with treatment-resistant depression (TRD) is key to reducing the burden of this severe illness. The anti-glucocorticoid medication metyrapone has mixed evidence supporting a role as a possible augmentation treatment in TRD. The degree of treatment resistance in depression has been associated prospectively and retrospectively with elevated inflammation, and inflammatory activity may influence responses to antidepressant treatments.

AIMS

To investigate whether levels of pro-inflammatory cytokines are associated with clinical outcomes to metyrapone or placebo.

METHODS

A double-blind RCT randomised patients with TRD to 3 weeks of placebo or metyrapone augmentation to ongoing serotonergic antidepressants. No benefit of metyrapone was reported in the primary analysis. The current study assessed levels of pro-inflammatory proteins interleukin-6 (IL-6), tumour necrosis factor (TNFα), c-reactive protein (CRP) and interleukin-10 (IL-10) before randomisation and after treatment as potential moderators and/or mediators of clinical outcomes.

RESULTS

The three pro-inflammatory proteins (but not IL-10) were elevated in this sample of patients with TRD compared to a non-affected control group. High pre-treatment IL-6 levels predicted a poorer response in the trial overall but did not moderate response to metyrapone versus placebo. Changes in IL-6 indirectly mediated depression outcome, with metyrapone increasing IL-6 levels and IL-6 increase associated with a poorer outcome on depression. Other inflammatory proteins did not mediate or moderate treatment outcomes.

INTERPRETATION

Metyrapone is hypothesised to have a therapeutic effect in depression on the basis of inhibiting the synthesis of cortisol. In this study, metyrapone did not reduce cortisol, possibly due to glucocorticoid system overcompensation). The mediation effect of IL-6 may support this and perhaps help to indicate why the treatment was not effective.

Interaction Mechanisms Between Major Depressive Disorder and Non-alcoholic Fatty Liver Disease

Major depressive disorder (MDD), which is highly associated with non-alcoholic fatty liver disease (NAFLD), has complex pathogenic mechanisms. However, a limited number of studies have evaluated the mutual pathomechanisms involved in MDD and NAFLD development. Chronic stress-mediated elevations in glucocorticoid (GC) levels play an important role in the development of MDD-related NAFLD. Elevated GC levels can induce the release of inflammatory factors and changes in gut permeability. Elevated levels of inflammatory factors activate the hypothalamic-pituitary-adrenal (HPA) axis, which further increases the release of GC. At the same time, changes in gut permeability promote the release of inflammatory factors, which results in a vicious circle among the three, causing disease outbreaks. Even though the specific role of the thyroid hormone (TH) in this pathogenesis has not been fully established, it is highly correlated with MDD and NAFLD. Therefore, changing lifestyles and reducing psychological stress levels are necessary measures for preventing MDD-related NAFLD. Among them, GC inhibitors and receptor antagonists may be key in the alleviation of early and mid-term disease progression. However, combination medications may be important in late-stage diseases, but they are associated with various side effects. Traditional Chinese medicines have been shown to be potential therapeutic alternatives for such complex diseases.

Low hair cortisol concentrations in obsessive compulsive disorder: A cross-sectional study

Recent findings have highlighted the association between changes in the activity of the HPA axis, primarily its end-hormone, cortisol and OCD. However, to date, cortisol levels of OCD patients have been assessed mainly in body fluids, such as serum, saliva or urine, frequently leading to ambiguous results because of their inherent lack of stability. The aim of this study was to investigate time-integrated levels of stress exposure in 32 OCD patients and 32 sex and age-matched healthy controls by measuring endogenous cortisol in hair segments reflecting the last 3 months preceding hair collection. Psychometric parameters, including BDI, FQ, STAI, PSS and ECQ-R, were obtained in all participants; Y-BOCS was performed in the OCD patients. The OCD patients exhibited significantly higher scores in all psychometric instruments administered and lower hair cortisol concentrations than the healthy controls (p = 0.001, r = 0.41). No significant correlations were found between the HCC and the Y-BOCS total scores. After having sorted OCD patients into subtypes, according to the nature of their symptomatology, the "washers/cleaners" category showed the lowest HCC (compared to the "checking/harming", "ordering/symmetry" and "sexual/religious obsessions" categories). The novel finding of chronic low cortisol secretion in OCD patients could be attributed to a possible down-regulation of the HPA axis, as an adaptive response to chronic stress exposure. Given that the OCD subtypes reflect the great heterogeneity in the OCD spectrum, studies with larger samples should extend the investigation of HCC in patients with distinctive symptomatology, so as to develop a basis for better neuroendocrine profiling and understanding of the pathophysiology of OCD. Further work is needed in exploring HPA axis' activity over the natural course and treatments of the disorder.

[Gut microbiota and depression : Pathophysiology of depression: hypothalamic-pituitary-adrenal axis and microbiota-gut-brain axis]

Depression is a chronic disease with a complex multifactorial and still not fully clarified etiology. Due to new insights after recent investigations of the microbiota-gut-brain (MGB) axis, a relationship between a disrupted gut microbiota composition and the probability to develop a depression can be assumed. This hypothesis is supported by evidence that there is a strong communication between gut microbiota and the central nervous system (CNS) and that this communication is mediated through the MGB axis. Apparently, this bidirectional axis can be modulated by environmental factors, such as stress, pharmaceuticals (in particular antibiotics) and dietary habits. Moreover, modulation of this axis can also result in mood alterations. As the hypothalamic-pituitary-adrenal (HPA) axis is a key element regulating the MGB axis and is also related to the pathophysiology of depression, it is important to understand the relationship between both biological systems. An English language literature search was conducted using the biomedical database PubMed. We used combined terms, such as "gut microbiota", "depression", "hypothalamic-pituitary-adrenal axis" or "microbiota-gut-brain axis". The current literature supports the idea that the MGB axis has an impact on the risk to develop depression and that stress modulation through the HPA axis plays a key role in this context.

The effects of childhood trauma on the onset, severity and improvement of depression: The role of dysfunctional attitudes and cortisol levels

BACKGROUND

Childhood trauma is an important early social risk factor for the development of the major depressive disorder (MDD). Both childhood trauma and depression are associated with dysfunctional attitudes and dysregulation in stress hormones. We aimed to clarify the path from childhood trauma to depression and identify potential predictors of antidepressant treatment outcomes.

OBJECTIVES

One hundred and thirty-nine MDD patients and 112 healthy controls were included at baseline. Depressive symptoms were assessed with both self-reported and expert-rated scales. Childhood trauma and dysfunctional attitudes were evaluated and blood cortisol levels were assayed. Patients received an open-label antidepressant trial with paroxetine and their depressive symptoms were monitored by the Hamilton Depression Rating Scale (HAMD) during 6 months of treatment. After 6 months, 94 patients received the same assessments as the baseline.

RESULTS

At baseline, the influence of childhood trauma on depression diagnosis was mediated by dysfunctional attitudes. In patients with MDD, the influence of childhood trauma on depression severity was mediated by both dysfunctional attitudes and cortisol levels. Baseline childhood trauma predicted the antidepressant treatment outcome during early treatment phase and baseline cortisol levels predicted the antidepressant treatment outcome at later treatment phase. After 6-month antidepressant treatment, a significant remission by time effect was found on dysfunctional attitudes and depression severity but not on cortisol levels.

CONCLUSION

Effect of childhood trauma on depression onset was mediated by dysfunctional attitudes. The relationship between childhood trauma and depressive symptoms was mediated by dysfunctional attitudes and cortisol levels in MDD patients. Baseline childhood trauma and cortisol levels may be moderators for antidepressant treatment response at different treatment phase.

Hair cortisol in patients with a depressive episode treated with electroconvulsive therapy

BACKGROUND

There is substantial evidence showing changes in hypothalamic pituitary adrenal (HPA)-axis activity in patients with major depressive disorder (MDD). Also, there seem to be differences in HPA-axis functioning between MDD subgroups. It is however unclear whether hair cortisol concentrations (HCC), which are a stable marker of long-term cortisol levels, are suitable as a biomarker for identifying subgroups in MDD.

METHODS

We were able to attain valid HCC from a scalp hair sample of sixty-two patients with a major depressive episode right before electroconvulsive therapy (ECT). HCC were our main biological outcome measure. We created subgroups using depression severity as defined by the Hamilton Depression Rating Scale, the presence/absence of psychotic symptoms, the presence of melancholia as defined by the CORE and catatonia as defined by the Bush-Francis Catatonia Rating Scale.

RESULTS

Our analyses of the total group showed a median HCC of 4.4 pg/mg. We found patients with catatonia (N = 10) to have substantially higher median HCC (8.3 pg/mg) than patients without catatonia (3.8 pg/mg). Although presence of melancholia and depression severity were not significantly associated with HCC, more severe psychomotor agitation was associated with higher HCC. Pre-treatment HCC was not associated with ECT outcome.

STRENGTHS AND LIMITATIONS

A complicating factor in interpretation of our results was the large variability in HCC. This could be related to potential confounders such as cardiometabolic and other comorbidities, that were however addressed to the extent possible.

CONCLUSIONS

HCC is a potential biomarker for MDD patients with severe agitation and/or catatonia. CLINICALTRIALS.GOV: Identifier: NCT02562846.

Early life adversity and depressive symptoms predict cortisol in pregnancy

Evidence suggests that exposure to early life adversity (ELA) programs the hypothalamic-pituitary-adrenal (HPA) axis to influence responses to later adversity and predisposes women to depression. However, few studies have examined whether ELA moderates the HPA cortisol response to adulthood adversity and depressive symptoms in pregnant women. The aims of this study were to determine (a) whether ELA, adulthood adversity, and depressive symptoms differentially predict patterns of cortisol and (b) whether ELA moderates the relationship of adulthood adversity or depressive symptoms to cortisol. This was a descriptive, cross-sectional study of pregnant women (N = 58, mean = 26.5 weeks gestation). Participants completed the Stress and Adversity Inventory and Edinburgh Depression Scale and collected salivary cortisol five times per day for 3 days to assess cortisol awakening response (CAR), diurnal cortisol slope, and cortisol area under the curve (AUC). ELA predicted a larger CAR, while depressive symptoms predicted a blunted CAR and higher cortisol AUC. Adulthood adversity predicted a blunted CAR and steeper diurnal slope, but only in women with high ELA. ELA also moderated the effect of depressive symptoms on diurnal slope. Early adversity and depressive symptoms appear to have significant effects on the HPA axis during pregnancy, with early adversity also moderating effects of depressive symptoms and adulthood adversity on cortisol regulation. Early adversity may be an important factor in identifying unique HPA phenotypes and risk for HPA axis dysregulation in pregnancy.

Stress-induced cortisol reactivity as a predictor of success in treatment for affective dimensions

BACKGROUND

Response rates to first-line treatments for depression and anxiety remain unsatisfactory. Identification of predictors or moderators that can optimize treatment matching is of scientific and clinical interest. This study examined the role of prolonged laboratory-induced stress cortisol reactivity as a predictor of outcome for a treatment of affective dimensions (TAD). Patients received 15-sessions of a treatment targeting reductions in negative affect or increases in positive affect (Craske et al., 2019). A second aim was to examine whether treatment type would moderate the association between cortisol reactivity and treatment outcome.

METHODS

Thirty-five participants underwent a 36-minute intermittent stress induction task composed of a mental arithmetic task and a fear-potentiated startle task one week before treatment initiation. Cortisol was collected at five-time points with reactivity being quantified as peak during the task minus basal level of cortisol the evening before the assessment. Using multilevel modeling, we examined the associations between cortisol reactivity and slopes of symptom improvement.

RESULTS

Cortisol reactivity was related to treatment outcome, with average and higher levels of stress-induced cortisol response predicting greater decreases in symptoms throughout treatment and 6-month follow-up. Treatment condition differences (moderation) were not observed in the effect of cortisol reactivity on symptoms.

CONCLUSION

Our findings demonstrate the impact of greater cortisol stress reactivity on treatment outcome. Future studies should investigate how to enhance this therapeutic benefit through capitalizing on endogenous diurnal fluctuations or exogenous cortisol manipulation.

Investigation on the influence of isolated environment on human psychological and physiological health

Crewmembers are working and living in isolated environment lacking natural light and perception. Although their health problems have been documented, the mechanism has not been thoroughly investigated. The aim of the present study is to investigate the psychological and physiological influences of isolated environment on crewmember's health. On account of complexity of the isolated environment, it is necessary to have a manually controllable system to simulate research platform-Bioregenerative Life Support System (BLSS). Symptom checklist 90 (SCL-90) was used to complete emotional status test. Urine samples were collected for metabonomics and hormone secretion analysis. Fecal samples were collected for intestinal microorganisms analysis. Crewmembers (n = 4) followed strict daily schedule during the experimental period. Five emotional factors were significantly (P < 0.05) increased, differential metabolites were enriched in tryptophan metabolism pathway, the relative abundance of Prevotella decreased significantly (P < 0.0001) when crewmembers in isolated environment without natural light. Hormone (melatonin, cortisol) secretion rhythm also changed. Significant positive correlation (r = 0.805, P < 0.05) between cortisol secretion and anxiety was observed. In conclusion, natural light simulation in an isolated environment may have a positive effect on the physiological and psychological health of the crewmember.

Predicting treatment effects in unipolar depression: A meta-review

There is increasing interest in clinical prediction models in psychiatry, which focus on developing multivariate algorithms to guide personalized diagnostic or management decisions. The main target of these models is the prediction of treatment response to different antidepressant therapies. This is because the ability to predict response based on patients' personal data may allow clinicians to make improved treatment decisions, and to provide more efficacious or more tolerable medications to the right patient. We searched the literature for systematic reviews about treatment prediction in the context of existing treatment modalities for adult unipolar depression, until July 2019. Treatment effect is defined broadly to include efficacy, safety, tolerability and acceptability outcomes. We first focused on the identification of individual predictor variables that might predict treatment response, and second, we considered multivariate clinical prediction models. Our meta-review included a total of 10 systematic reviews; seven (from 2014 to 2018) focusing on individual predictor variables and three focusing on clinical prediction models. These identified a number of sociodemographic, phenomenological, clinical, neuroimaging, remote monitoring, genetic and serum marker variables as possible predictor variables for treatment response, alongside statistical and machine-learning approaches to clinical prediction model development. Effect sizes for individual predictor variables were generally small and clinical prediction models had generally not been validated in external populations. There is a need for rigorous model validation in large external data-sets to prove the clinical utility of models. We also discuss potential future avenues in the field of personalized psychiatry, particularly the combination of multiple sources of data and the emerging field of artificial intelligence and digital mental health to identify new individual predictor variables.