Individual-specific changes in circadian rest-activity rhythm and sleep in symptom-free patients tapering their antidepressant medication

Introduction

Group-level studies showed cross-sectional and prospective between-person associations between circadian rest-activity rhythms (RAR), physical activity (PA), sleep, and depressive symptoms. However, whether these associations replicate at the within-person level remains unclear. Therefore, it is clinically relevant to investigate these associations within persons and study whether changes in depressive symptoms are related to changes in circadian rhythm and sleep variables.

Objectives

To identify changes in circadian rhythm elements in proximity to a transition in depressive symptoms, whether changes are less frequent in individuals without compared to those with transitions, and whether there are individual differences in the direction of change of circadian rhythm variables.

Methods

Data of remitted individuals tapering antidepressants were used: 12 with and 14 without a transition in depressive symptoms. RAR, PA, and sleep variables were calculated as predictors from four months of actigraphy data. Transitions in depressive symptoms were based on weekly SCL-90 scores and evaluation interviews. Kernel Change Point analyses were used to detect change points (CPs) and CP timing in circadian rhythm variables for each individual separately.

Results

In 67% of individuals with depressive symptoms transitions, CPs were identified in proximity to symptom transitions. CPs were detected less frequently in the no-transition group with 7 CPs in 14 individuals, compared to transition groups with 10 CPs in 12 individuals. For several RAR and sleep variables, consistent changes were detected in expected directions.

Conclusions

Circadian rhythm variables provide potentially clinically relevant information although their patterns around transitions are highly person-specific. Future research is needed to disentangle which variables are predictive for which patients.

Disclosure

No significant relationships.

Chronotype, daily affect and social contact: An ecological momentary assessment study

Eveningness is associated with lower daily positive affect (PA). The relationship between negative affect (NA) and chronotype, however, is less consistent in the literature. Eveningness may be further characterized by increased social isolation, which could explain the associations between chronotype and PA/NA. In the present longitudinal study, we used ecological momentary assessment (EMA) to investigate the associations of chronotype with daily PA, NA, and social contact in individuals with current and remitted major depressive disorder (MDD) and healthy controls. As part of the Netherlands Study of Depression and Anxiety (NESDA), 279 participants (n = 49 depressed, n = 172 remitted, n = 58 controls) monitored daily PA, NA, and social contact (i.e., being alone vs. with others) for two weeks, five times per day. Overall, eveningness was associated with less social contact. This effect became nonsignificant, however, after accounting for sociodemographics (gender, age, education, living situation). Chronotype was not related to PA or NA. Less social contact was associated with lower PA and higher NA independent of chronotype. In conclusion, we could not replicate the finding of lower PA among evening types, but found social contact to associate with both daily PA and NA.

Chronotype changes with age; seven-year follow-up from the Netherlands study of depression and anxiety cohort

BACKGROUND

Chronotype reflects an individual's optimal daily timing of sleep, activity, and cognitive performance. Previous, cross-sectional, studies have suggested an age effect on chronotype with later chronotypes in adolescents and earlier chronotypes in children and elderly. Additionally, later chronotypes have been associated with more depressive symptoms. Few studies have been able to study longitudinal associations between chronotype and age, while adjusting for depressive symptoms.

METHODS

Chronotype was assessed twice with the Munich Chronotype Questionnaire 7 years apart in the Netherlands Study of Depression and Anxiety (T1: N = 1842, mean age (SD): 42.63 years (12.66)) and T2: N = 1829, mean age (SD) 50.67 (13.11)). The longitudinal association between change in age and change in chronotype was tested using a generalized estimated equation analysis adjusted for covariates (including level of depressive symptoms). Using age-bins of 5 years (age at T2), change in chronotype between T1 and T2 was analyzed with Linear Mixed Models.

RESULTS

We found a change towards an earlier chronotype with higher age (B (95% CI): -0.011 (-0.014-0.008), p < 0.001). For the age-bins, the difference in chronotype was significant for the 25-29 years age-bin.

LIMITATIONS

The sample did not include individuals younger than 19 years or older than 68 years.

CONCLUSIONS

In the whole sample chronotype changed towards becoming more morning-type over a period of 7 years, but this change was only significant for those aged 25-29 years. The study was performed in a large naturalistic cohort study with a wide age-range, including patients with a diagnosis of depressive and anxiety disorder and healthy controls.

Affect fluctuations examined with ecological momentary assessment in patients with current or remitted depression and anxiety disorders

BACKGROUND

There is increasing interest in day-to-day affect fluctuations of patients with depressive and anxiety disorders. Few studies have compared repeated assessments of positive affect (PA) and negative affect (NA) across diagnostic groups, and fluctuation patterns were not uniformly defined. The aim of this study is to compare affect fluctuations in patients with a current episode of depressive or anxiety disorder, in remitted patients and in controls, using affect instability as a core concept but also describing other measures of variability and adjusting for possible confounders.

METHODS

Ecological momentary assessment (EMA) data were obtained from 365 participants of the Netherlands Study of Depression and Anxiety with current (n = 95), remitted (n = 178) or no (n = 92) DSM-IV defined depression/anxiety disorder. For 2 weeks, five times per day, participants filled-out items on PA and NA. Affect instability was calculated as the root mean square of successive differences (RMSSD). Tests on group differences in RMSSD, within-person variance, and autocorrelation were performed, controlling for mean affect levels.

RESULTS

Current depression/anxiety patients had the highest affect instability in both PA and NA, followed by remitters and then controls. Instability differences between groups remained significant when controlling for mean affect levels, but differences between current and remitted were no longer significant.

CONCLUSIONS

Patients with a current disorder have higher instability of NA and PA than remitted patients and controls. Especially with regard to NA, this could be interpreted as patients with a current disorder being more sensitive to internal and external stressors and having suboptimal affect regulation.

Overnight affective dynamics and sleep characteristics as predictors of depression and its development

Introduction

Greater affective inertia during the day (higher carry-over effects of prior affect to the current moment) is associated with depression and its development. However, the role of overnight affective inertia (from evening to morning) in depression, and the role of sleep therein, has been scarcely studied.

Objectives

We examined i) the difference in overnight inertia for positive (PA) and negative affect (NA) between individuals with past depression, current depression, and no depression; ii) how sleep duration and quality influence overnight affective inertia in these groups, and iii) whether overnight affective inertia predicts depression development.

Methods

We used data of 579 women from the East-Flanders Prospective Twin Survey. First, individuals with past (n=82), current (n=26), and no depression (n=471) at baseline were examined, and then individuals who did (n=58) and did not (n=319) develop depression at 12-months follow-up. Affect was assessed 10 times a day for 5 days. Sleep was assessed with sleep diaries. Affective inertia was operationalized as the influence of affectt-1 on affectt. Linear mixed-effect models were used to test the hypotheses.

Results

Overnight affective inertia was not associated with depression, neither was it differently associated with sleep characteristics in the depression groups. However, sleep characteristics were more negatively associated with morning NA in both depression groups compared to the non-depressed group. Overnight affective inertia did not predict the development of depression at follow-up.

Conclusions

Depression and sleep characteristics might be more related to mean affect levels rather than to more complex emotion dynamics measures. Replication of these findings with longer time-series is needed.

Screening for depression: The added value of actigraphy and smartphone-based intensive sampling of depressive affect and behaviors

Introduction

In many countries, depressed individuals often first visit primary care settings for consultation, but a considerable number of clinically depressed patients remains unidentified. Introducing additional screening tools may facilitate the diagnostic process.

Objectives

This study aims to examine whether Experience Sampling Method (ESM)-based measures of depressive affect and behaviors can discriminate depressed from non-depressed individuals. In addition, the added value of actigraphy-based measures was examined.

Methods

We used data from two samples to develop and validate prediction models. The development dataset included 14 days of ESM and continuous actigraphy of currently depressed (n=43) and non-depressed individuals (n=82). The validation dataset included 30 days of ESM and continuous actigraphy of currently depressed (n=27) and non-depressed individuals (n=27). Backward stepwise logistic regression analyses were applied to build the prediction models. The performance of the models was assessed with the goodness of fit indices, calibration curves, and discriminative ability (AUC, the area under the receiver operating characteristic curve).

Results

In the development dataset, the discriminative ability was good for the actigraphy model (AUC=0.790) and excellent for the ESM (AUC=0.991) and combined-domains model (AUC=0.993). In the validation dataset, the discriminative ability was reasonable for the actigraphy model (AUC=0.648) and excellent for the ESM (AUC=0.891) and combined-domains model (AUC=0.892).

Conclusions

ESM is a good diagnostic predictor and is easy to calculate, and, therefore, holds promise for implementation in clinical practice. Actigraphy shows no added value to ESM as a diagnostic predictor, but might still be useful when active monitoring with ESM is not feasible.

Disclosure

No significant relationships.

Personalized ESM monitoring and feedback to support psychological treatment for depression: a pragmatic randomized controlled trial (Therap-i)

BACKGROUND

Major depressive disorder (MDD) is a highly prevalent mental disorder with large disease burden, high levels of relapse or persistence, and overall suboptimal outcomes of protocolized pharmacological and psychotherapeutic treatments. There is an urgent need to improve treatment effectiveness, possibly through systematic treatment personalization. In psychotherapeutic treatments this can be achieved by case conceptualization. To support this process, we developed the Therap-i module, which consists of personalized Experienced Sampling Methodology (ESM) and feedback. The Therap-i module is integrated into outpatient psychotherapeutic treatment as usual (TAU) for depression. The study aim is to investigate the efficacy of the Therap-i module in decreasing symptomatology in unresponsive or relapsing patients diagnosed with MDD. We hypothesize that the Therap-i module will contribute to TAU by i) decreasing depressive symptoms, and ii) improving general functioning, therapeutic working alliance, and illness perception. This paper provides details of the study rationale, aims, procedures, and a discussion on potential pitfalls and promises of the module.

METHODS

Patients diagnosed with MDD (n = 100) will enrol in a pragmatic two-armed randomized controlled trial. Randomization is stratified according to the patient's treatment resistance level assessed with the Dutch Method for quantification of Treatment Resistance in Depression (DM-TRD). All fill-out the Inventory of Depressive Symptomatology Self Report (IDS-SR), Outcome Questionnaire (OQ-45), Illness Perception Questionnaire Mental Health (IPQ-MH), and Work Alliance Inventory Self Report (WAI-SR). In the intervention arm, through close collaboration between patient, clinician, and researcher, a personalized ESM diary is developed based on the patient's case conceptualization. During the ESM monitoring period (8 weeks, 5 assessments/day), patients receive feedback three times, which is discussed among the abovementioned three parties. Both patients and clinicians will evaluate the Therap-i module.

RESULTS

Data collection is ongoing.

DISCUSSION

This is the first study in which personalized ESM and feedback is integrated in outpatient psychotherapeutic TAU for depression. The labour intensive procedure and methodological pitfalls are anticipated challenges and were taken into account when designing the study. When hypotheses are confirmed, the Therap-i module may advance treatment for depression by providing insights into personalized patterns driving or perpetuating depressive complaints.

TRIAL REGISTRATION

Trial NL7190 (NTR7381) , registered prospectively 03-08-2018.

Can chronotype function as predictor of a persistent course of depressive and anxiety disorder?

BACKGROUND

The role of chronotype, the individual timing of sleep/activity, has been studied in relation to depressive and anxiety disorders. A cross-sectional association between a depressive episode and evening-type has been identified. However, until now the predicting capacity of chronotype concerning persistence of psychiatric disorders remains unclear. Our aim is to examine whether a later chronotype in patients with a depressive and/or anxiety disorder can serve as a predictor of a persistent course.

METHODS

A subsample of patients with a depressive and/or anxiety disorder diagnosis and chronotype data of the longitudinal Netherlands Study of Depression and Anxiety (NESDA) was used. Diagnosis of depressive and anxiety disorders (1-month DSM-IV based diagnosis) were determined at baseline (n = 505). From this group persistence was determined at 2-year (FU2) (persistent course: n = 248, non-persistent course: n = 208) and 4-year follow-up (FU4) (persistent course: n = 151, non-persistent course: n = 264). Chronotype was assessed at baseline with the Munich Chronotype Questionnaire.

RESULTS

A later chronotype did not predict a persistent course of depressive and/or anxiety disorder at FU2 (OR (95% CI) = 0.99 (0.83-1.19), P = 0.92) or at FU4 (OR (95% CI) = 0.94 (0.77-1.15), P = 0.57).

LIMITATIONS

Persistence was defined as having a diagnosis of depressive and/or anxiety disorder at the two-year and four-year follow-up, patients may have remitted and relapsed between assessments.

CONCLUSION

Chronotype, measured as actual sleep timing, of patients with a depressive or anxiety disorder did not predict a persistent course which suggests it might be unsuitable as predictive tool in clinical settings.

Neuroticism's prospective association with mental disorders halves after adjustment for baseline symptoms and psychiatric history, but the adjusted association hardly decays with time: a meta-analysis on 59 longitudinal/prospective studies with 443 313 participants

BACKGROUND

This meta-analysis seeks to quantify the prospective association between neuroticism and the common mental disorders (CMDs, including anxiety, depression, and substance abuse) as well as thought disorders (psychosis/schizophrenia) and non-specific mental distress. Data on the degree of confounding of the prospective association of neuroticism by baseline symptoms and psychiatric history, and the rate of decay of neuroticism's effect over time, can inform theories about the structure of psychopathology and role of neuroticism, in particular the vulnerability theory.

METHOD

This meta-analysis included 59 longitudinal/prospective studies with 443 313 participants.

RESULTS

The results showed large unadjusted prospective associations between neuroticism and symptoms/diagnosis of anxiety, depression, and non-specific mental distress (d = 0.50-0.70). Adjustment for baseline symptoms and psychiatric history reduced the associations by half (d = 0.10-0.40). Unadjusted prospective associations for substance abuse and thought disorders/symptoms were considerably weaker (d = 0.03-0.20), but were not attenuated by adjustment for baseline problems. Unadjusted prospective associations were four times larger over short (<4 year) than long (⩾4 years) follow-up intervals, suggesting a substantial decay of the association with increasing time intervals. Adjusted effects, however, were only slightly larger over short v. long time intervals. This indicates that confounding by baseline symptoms and psychiatric history masks the long-term stability of the neuroticism vulnerability effect.

CONCLUSION

High neuroticism indexes a risk constellation that exists prior to the development and onset of any CMD. The adjusted prospective neuroticism effect remains robust and hardly decays with time. Our results underscore the need to focus on the mechanisms underlying this prospective association.

Catechol-O-methyltransferase gene methylation and substance use in adolescents: the TRAILS study

Substance use often starts in adolescence and poses a major problem for society and individual health. The dopamine system plays a role in substance use, and catechol-O-methyltransferase (COMT) is an important enzyme that degrades dopamine. The Val(108/158) Met polymorphism modulates COMT activity and thus dopamine levels, and has been linked to substance use. COMT gene methylation, on the other hand, may affect expression and thus indirectly COMT activity. We investigated whether methylation of the COMT gene was associated with adolescents' substance use. Furthermore, we explored whether the COMT Val(108/158) Met polymorphism interacts with COMT gene methylation in association with substance use. In 463 adolescents (mean age=16, 50.8% girls), substance use (cigarette smoking, alcohol and cannabis use) was assessed with self-report questionnaires. From blood samples, COMT Val(108/158) Met genotype and methylation rates of membrane bound (MB) and soluble (S) COMT promoters were assessed. MB-COMT promoter methylation was associated with non-daily smoking [odds ratio (OR)=1.82, P=0.03], but not with daily smoking (OR=1.20, P=0.34), MB-COMT promoter methylation was not associated with alcohol use. Adolescents with the Met/Met genotype and high rates of MB-COMT promoter methylation were less likely to be high-frequent cannabis users than adolescents with the Val/Val or Val/Met genotype. S-COMT promoter methylation was not associated with substance use. These results indicate that there is an association between substance use and COMT gene methylation. Although this association is complex, combining genetic and epigenetic variation of the COMT gene may be helpful in further elucidating the influence of the dopamine system on substance use in adolescence.

Glucocorticoid receptor gene (NR3C1) methylation following stressful events between birth and adolescence. The TRAILS study

Stress early in life is a known risk factor for the development of affective disorders later in life. Epigenetic mechanisms, such as DNA methylation, may have an important role in mediating that risk. Recent epigenetic research reported on the long-term relationship between traumatic stress in childhood and DNA methylation in adulthood. In this study, we examined the impact of various types of stress (perinatal stress, stressful life events (SLEs) and traumatic youth experiences) on methylation of the glucocorticoid receptor gene (NR3C1) in the blood of a population sample of 468 adolescents (50.4% female, mean age 16.1 years). Second, we determined whether stress at different ages was associated with higher NR3C1 methylation. NR3C1 methylation rates were higher after exposure to SLEs and after exposure to traumatic youth experiences. NR3C1 methylation in adolescence was not higher after exposure to perinatal stress. Experience of SLEs in adolescence was associated with a higher NR3C1 methylation, independently of childhood SLEs. We demonstrate that not only traumatic youth experiences but also (more common) SLEs are associated with higher NR3C1 methylation. In addition, our findings underline the relevance of adolescent stress for epigenetic changes in the NR3C1 gene.

Negative and positive life events are associated with small but lasting change in neuroticism

BACKGROUND

High neuroticism is prospectively associated with psychopathology and physical health. However, within-subject changes in neuroticism due to life experiences (LEs) or state effects of current psychopathology are largely unexplored. In this 2-year follow-up study, four hypotheses were tested: (1) positive LEs (PLEs) decrease and negative LEs (NLEs) increase neuroticism; (2) LE-driven change in neuroticism is partly long-lasting; and (3) partly independent of LE-driven changes in anxiety/depression; and (4) childhood adversity (before age 16 years) moderates the influence of NLEs/PLEs on neuroticism scores in adult life.

METHOD

Data came from the Netherlands Study of Depression and Anxiety [NESDA, n = 2981, mean age 41.99 years (s.d. = 13.08), 66.6% women]. At follow-up (T₂) we assessed PLEs/NLEs with the List of Threatening Experiences (LTE) over the prior 24 months and categorized them over recent and distant PLE/NLE measures (1-3 and 4-24 months prior to T₂ respectively) to distinguish distant NLE/PLE-driven change in trait neuroticism (using the Dutch version of the Neuroticism-Extroversion-Openness Five Factor Inventory, NEO-FFI) from state deviations due to changes in symptoms of depression (self-rated version of the 30-item Inventory of Depressive Symptomatology, IDS-SR30) and anxiety (Beck Anxiety Inventory, BAI).

RESULTS

Distant NLEs were associated with higher and distant PLEs with lower neuroticism scores. The effects of distant LEs were weak but long-lasting, especially for distant PLEs. Distant NLE-driven change in neuroticism was associated with change in symptoms of anxiety/depression whereas the effect of distant PLEs on neuroticism was independent of any such changes. Childhood adversity weakened the impact of distant NLEs but enhanced the impact of distant PLEs on neuroticism.

CONCLUSIONS

Distant PLEs are associated with small but long-lasting decreases in neuroticism regardless of changes in symptom levels of anxiety/depression. Long-lasting increases in neuroticism associated with distant NLEs are mediated by anxiety/depression.

Bivariate genetic modelling of the response to an oral glucose tolerance challenge: a gene x environment interaction approach

AIMS/HYPOTHESIS

Twin and family studies have shown the importance of genetic factors influencing fasting and 2 h glucose and insulin levels. However, the genetics of the physiological response to a glucose load has not been thoroughly investigated.

METHODS

We studied 580 monozygotic and 1,937 dizygotic British female twins from the Twins UK Registry. The effects of genetic and environmental factors on fasting and 2 h glucose and insulin levels were estimated using univariate genetic modelling. Bivariate model fitting was used to investigate the glucose and insulin responses to a glucose load, i.e. an OGTT.

RESULTS

The genetic effect on fasting and 2 h glucose and insulin levels ranged between 40% and 56% after adjustment for age and BMI. Exposure to a glucose load resulted in the emergence of novel genetic effects on 2 h glucose independent of the fasting level, accounting for about 55% of its heritability. For 2 h insulin, the effect of the same genes that already influenced fasting insulin was amplified by about 30%.

CONCLUSIONS/INTERPRETATION

Exposure to a glucose challenge uncovers new genetic variance for glucose and amplifies the effects of genes that already influence the fasting insulin level. Finding the genes acting on 2 h glucose independently of fasting glucose may offer new aetiological insight into the risk of cardiovascular events and death from all causes.

Neuroticism, recall bias and attention bias for valenced probes: a twin study

BACKGROUND

Prior research on the nature of the vulnerability of neuroticism to psychopathology suggests biases in information processing towards emotional rather than neutral information. It is unclear to what extent this relationship can be explained by genetic or environmental factors.

METHOD

The genetic relationship between a neuroticism composite score and free recall of pleasant and unpleasant words and the reaction time on negative probes (dot-probe task) was investigated in 125 female twin pairs. Interaction effects were modelled to test whether the correlation between neuroticism and cognitive measures depended on the level of the neuroticism score.

RESULTS

The only significant correlation was between neuroticism and the proportion of recalled unpleasant words (heritability is 30%), and was only detectable at the higher end of the neuroticism distribution. This interaction effect seems to be due to environmental effects that make people in the same family more similar (e.g. parental discipline style), rather than genetic factors. An interesting sub-finding was that faster reaction times for left versus right visual field probes in the dot-probe task suggest that cognitive processing in the right hemisphere is more sensitive to subliminal (biologically relevant) cues and that this characteristic is under substantial genetic control (49%). Individual differences in reaction times on right visual field probes were due to environmental effects only.

CONCLUSIONS

There is no evidence that the predisposition of individuals to focus on negative (emotional) stimuli is a possible underlying genetic mechanism of neuroticism.

Job strain and risk indicators for cardiovascular disease in young female nurses

This study examined the possible effects of job demands, decision latitude, and job-related social support on risk indicators for cardiovascular disease (CVD) in 165 female nurses. Job strain was measured with the Job Content Questionnaire; CVD risk was measured with insulin, total cholesterol, triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), fibrinogen, tissue-type plasminogen activator (tPA) antigen, tPA activity, plasminogen activator inhibitor-1 antigen, and blood pressure. Multivariate analysis of covariance and regression analyses revealed no effects of either job strain or social support on these risk indicators. All risk indicators deteriorated with age and body mass index. Oral contraceptive use improved fibrinolytic potential and increased HDL-C but had adverse effects on TG levels. Results suggest that in healthy young women job strain is not associated with an unfavorable metabolic or fibrinolytic risk profile.

Job strain and risk indicators for cardiovascular disease in young female nurses

This study examined the possible effects of job demands, decision latitude, and job-related social support on risk indicators for cardiovascular disease (CVD) in 165 female nurses. Job strain was measured with the Job Content Questionnaire; CVD risk was measured with insulin, total cholesterol, triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), fibrinogen, tissue-type plasminogen activator (tPA) antigen, tPA activity, plasminogen activator inhibitor-1 antigen, and blood pressure. Multivariate analysis of covariance and regression analyses revealed no effects of either job strain or social support on these risk indicators. All risk indicators deteriorated with age and body mass index. Oral contraceptive use improved fibrinolytic potential and increased HDL-C but had adverse effects on TG levels. Results suggest that in healthy young women job strain is not associated with an unfavorable metabolic or fibrinolytic risk profile.

Waist circumference and VO2max are associated with metabolic and hemostatic risk in premenopausal nurses

In 21 nurses (34.4+/-3.9 yr), VO2max physical activity, body composition and lifestyle parameters were measured to determine which of these characteristics are related to metabolic and hemostatic risk for cardiovascular disease. Physical activity was assessed with the 7-day recall interview. VO2max was measured in a progressive and continuous treadmill test to volitional fatigue. Fasting insulin, total cholesterol, HDL-C, triglycerides, fibrinogen, tPA-act, tPA-ag, and PAI-1-ag were determined from fasting blood samples. Contrary to our expectation, there was no association of physical activity with any of these risk indicators. High VO2max was associated with lower levels of insulin and fibrinogen. Regression analyses indicated that metabolic and hemostatic risk indicators, as measured in healthy premenopausal nurses, were mainly predicted by waist circumference and oral contraceptive use.