Depression and 24-hour urinary cortisol in medical outpatients with coronary heart disease: The Heart and Soul Study

Pathophysiological mechanisms of post-myocardial infarction depression: a narrative review

Myocardial infarction (MI) can have significant physical and mental consequences. Depression is a prevalent psychiatric condition after MI which can reduce the quality of life and increase the mortality rates of patients. However, the connection between MI and depression has remained under-appreciated. This review examines the potential connection between depression and MI by overviewing the possible pathophysiologic mechanisms including dysregulation of the hypothalamic-pituitary-adrenal axis and autonomic nervous system, coagulation system dysfunction, inflammation, environmental factors, as well as, genetic factors. Furthermore, depression can be an adverse event of medications used for MI treatment including beta-blockers, statins, or anti-platelet agents. The need for early detection and management of depression in patients with MI is, therefore, crucial for improving their overall prognosis. Adherence to treatments and regular follow-up visits can ensure the best response to treatment.

Incidence of depression in kidney transplant recipients in South Korea: a long-term population-based study

Depression is associated with impaired quality of life and increased morbidity and mortality in end-stage kidney disease (ESKD) patients and kidney transplantation (KT) recipients. Depression incidence after KT is unclear. We compared depression incidence among KT recipients, ESKD patients, and healthy controls (HCs). We analyzed a nationwide health insurance database in South Korea and identified patients who underwent KT during 2007-2015. Participants were matched for age, sex, and inclusion year. KT and ESKD patients were further matched for hypertension and diabetes mellitus history. The incidence rate (IR, per 1000 patients-years) of depression was compared among KT, ESKD, and HC groups. We analyzed 5,234 patients per group. Depression incidence was markedly lower in KT than ESKD patients (IR, 18.87 vs. 58.03; hazard ratio [HR], 0.33; 95% confidence interval [CI], 0.30‒0.36), but only slightly higher in KT recipients than in HCs (IR, 18.87 vs. 17.49; HR, 1.08; 95% CI, 0.96‒1.22). After adjusting for comorbidities, the depression risk was lower in KT recipients than in HCs (adjusted HR, 0.52; 95% CI, 0.44‒0.62; p < 0.001), whereas it remained higher in ESKD patients than in HCs (adjusted HR, 1.60; 95% CI, 1.36‒1.87; p < 0.001). Among KT recipients, older age, female sex, lower economic status, and more comorbidities were associated with increased depression risk. Incident depression after KT increased mortality, graft failure, and death-censored graft failure risks in KT recipients. Our data suggest a broader role of KT than previously appreciated in terms of improving quality of life by reducing depression risk.

Associations between depressive symptoms and disease progression in older patients with chronic kidney disease: results of the EQUAL study

Background

Depressive symptoms are associated with adverse clinical outcomes in patients with end-stage kidney disease; however, few small studies have examined this association in patients with earlier phases of chronic kidney disease (CKD). We studied associations between baseline depressive symptoms and clinical outcomes in older patients with advanced CKD and examined whether these associations differed depending on sex.

Methods

CKD patients (≥65 years; estimated glomerular filtration rate ≤20 mL/min/1.73 m²) were included from a European multicentre prospective cohort between 2012 and 2019. Depressive symptoms were measured by the five-item Mental Health Inventory (cut-off ≤70; 0–100 scale). Cox proportional hazard analysis was used to study associations between depressive symptoms and time to dialysis initiation, all-cause mortality and these outcomes combined. A joint model was used to study the association between depressive symptoms and kidney function over time. Analyses were adjusted for potential baseline confounders.

Results

Overall kidney function decline in 1326 patients was –0.12 mL/min/1.73 m²/month. A total of 515 patients showed depressive symptoms. No significant association was found between depressive symptoms and kidney function over time (P = 0.08). Unlike women, men with depressive symptoms had an increased mortality rate compared with those without symptoms [adjusted hazard ratio 1.41 (95% confidence interval 1.03–1.93)]. Depressive symptoms were not significantly associated with a higher hazard of dialysis initiation, or with the combined outcome (i.e. dialysis initiation and all-cause mortality).

Conclusions

There was no significant association between depressive symptoms at baseline and decline in kidney function over time in older patients with advanced CKD. Depressive symptoms at baseline were associated with a higher mortality rate in men.

Arterial stiffness in underweight and weight-restored anorexia nervosa

Cardiovascular complications have been demonstrated in patients with anorexia nervosa (AN) in both the state of starvation and during weight restoration, however, the underlying mechanisms remain unclear. The current study aimed to assess arterial stiffness via carotid-femoral pulse wave velocity (cfPWV) in the acute and weight-restored states of AN. The study also aimed to determine the association between psychological distress and cfPWV. The sample included 37 participants; 10 participants with AN, 17 who were weight-restored (AN-WR; minimum body mass index >18.5 for at least 12 months) and 10 healthy controls (HCs). cfPWV via applanation tonometry was conducted to assess arterial stiffness. Psychological distress was assessed using the depression anxiety stress scale (DASS-21) and the state-trait anxiety inventory (STAI). Between-group comparisons were performed to determine differences between groups, a two-stage hierarchical regression model was performed to determine the contribution of physiological and psychological variables on cfPWV and correlation analyses were also performed. Vascular stiffness was significantly increased in the AN and AN-WR groups, relative to HCs. The total DASS score was the only significant predictor of cfPWV across the sample. There were positive associations between cfPWV and depression, anxiety and stress, as assessed by the DASS. Furthermore, cfPWV was positively associated with STAI trait anxiety. Arterial stiffness was increased in individuals in the acute and weight-restored states of AN, demonstrating early signs of the development of arteriosclerotic cardiovascular disease. Increased arterial stiffness was associated with increased psychological distress, which may be a contributing mechanism to the increased cardiovascular risk in AN.

Delirium and depression in cardiac surgery: A comprehensive review of risk factors, pathophysiology, and management

BACKGROUND

Mental health and wellbeing continue to gain more attention as they are inextricably associated with clinical outcomes, particularly quality of life. Many medical ailments and major surgeries affect patients' mental health, including depression and delirium.

AIMS

The objective of this manuscript was to comprehensively review and critically examine the literature pertaining to cardiac surgery, depression, and delirium.

METHODS

This is a narrative review article. We performed our search analysis by using the following key words: "Cardiac Surgery", "Depression", "Delirium", "Clinical outcomes", and "Mental Health". Search analysis was done on MedLine PubMed, accessing indexed peer-reviewed publications.

RESULTS

Cardiac Surgery is a life-altering intervention indicated to improve morbidity and mortality in patients with cardiovascular diseases. Psychiatric conditions before and after cardiac surgery worsen patient prognosis and increase mortality rate. Specifically, preoperative depression increases postoperative depression and is associated with impaired functional status, slow physical recovery, and an increased readmission rate.

DISCUSSION

Although the exact pathophysiology between depression and cardiovascular disease (CVD) is unknown, several pathways have been implicated. Unmanaged depression can also lead to other psychological conditions such as delirium. Like depression, the exact association between delirium and CVD is not well understood, but believed to be multifactorial.

CONCLUSION

Herein, we provide a comprehensive review of the links between depression, delirium, and cardiovascular surgery. We critically examine the current data that pertains to the pathophysiology of these debilitating mental health issues in the context of cardiac surgery. Finally, we summarize the various treatment options available for managing depression and delirium in the cardiac surgery patient population.

Mechanism and therapeutic strategies of depression after myocardial infarction

Depression resulted as an important factor associated with the myocardial infarction (MI) prognosis. Patients with MI also have a higher risk for developing depression. Although the issue of depression after MI has become a matter of clinical concern, the molecular mechanism underlying depression after MI remains unclear, whereby several strategies suggested have not got ideal effects, such as selective serotonin reuptake inhibitors. In this review, we summarized and discussed the occurrence mechanism of depression after MI, such as 5-hydroxytryptamine (5-HT) dysfunction, altered hypothalamus-pituitary-adrenal (HPA) axis function, gut microbiota imbalance, exosomal signal transduction, and inflammation. In addition, we offered a succinct overview of treatment, as well as some promising molecules especially from natural products for the treatment of depression after MI.

Comorbid depression in medical diseases

Depression is one of the most common comorbidities of many chronic medical diseases including cancer and cardiovascular, metabolic, inflammatory and neurological disorders. Indeed, the prevalence of depression in these patient groups is often substantially higher than in the general population, and depression accounts for a substantial part of the psychosocial burden of these disorders. Many factors can contribute to the occurrence of comorbid depression, such as shared genetic factors, converging biological pathways, social factors, health behaviours and psychological factors. Diagnosis of depression in patients with a medical disorder can be particularly challenging owing to symptomatic overlap. Although pharmacological and psychological treatments can be effective, adjustments may need to be made for patients with a comorbid medical disorder. In addition, symptoms or treatments of medical disorders may interfere with the treatment of depression. Conversely, symptoms of depression may decrease adherence to treatment of both disorders. Thus, comprehensive treatment plans are necessary to optimize care.

Hormonal Function Responses to Moderate Aerobic Exercise in Older Adults with Depression

Background

Poor daily life physical activities among older people were related to depressive mood especially memory loss. In addition to that, the change in physical ability is significantly associated with the score of depression among older age.

Objective

The present study aimed to evaluate the effects of a supervised aerobic training program with moderate intensity for 12 weeks on mood profiles and hormonal levels of the hypothalamus-pituitary-adrenal axis (HPA axis) of older adults.

Methods

A total of 80 individuals of both gender (90 males, 110 females) of ages ranged between 65 and 95 years were recruited for this study. Based upon the profile of mood states (POMS) analysis, the participants were classified into two groups: control group (n=30) and depressive group (n=50). Leisure-time physical activity (LTPA), adrenal hormones such as ACTH, corticosterone (CORT), cortisol, DHEA/S, and cortisol:DHEA/S ratio were measured at baseline and post-intervention of moderate aerobic exercise for 12 weeks.

Results

Older adults with higher depressive scores showed a remarkable change in the level of adrenal hormones compared to control. There was a significant increase in the level of ACTH, CORT, cortisol, and cortisol:DHEA/S ratio, and decrease in DHEA/S. Compared to females, males showed an improvement in depressive mood score along with an increase in LPTA, DHEA/S and decrease in ACTH, CORT, cortisol, cortisol:DHEA/S ratio following 12 weeks of supervised aerobic training, respectively.

Conclusion

The findings of this study showed that 12 weeks of supervised exercise interventions are promising non-drug therapeutic strategies in improving depression among older adults. The potential performance in a psychological state occurs physiologically via optimizing the levels of the hormones of the HPA axis.

Effects of a mental stress challenge on brain function in coronary artery disease patients with and without depression

OBJECTIVE

Coronary artery disease (CAD) patients with comorbid depression show an increase in mortality compared to cardiac patients without depression, but the mechanisms mediating this effect remain obscure. One possible explanation for this finding is that depressed patients with CAD exhibit an increased vulnerability to stress. The purpose of this study was to assess the effects of stress and depression on brain function and to explore its relationship with myocardial ischemia in CAD patients.

METHODS

Patients with CAD and depression (N = 13) and CAD without depression (N = 15) underwent imaging of the brain with positron emission tomography and [O-15] water and imaging of the heart with single photon emission computed tomography (SPECT) and [Tc-99m] sestamibi under mental stress task and control conditions.

RESULTS

CAD patients with depression compared to nondepressed showed decreased function with mental stress in the rostral anterior cingulate, the hippocampus, parts of the dorsolateral temporal and parietal cortex, the cerebellum, and the uncus, with increased blood flow in the parahippocampus, visual association cortex, and posterior cingulate. Depressed CAD patients who became ischemic during a mental stress task had relative decreases in the caudal and posterior cingulate, orbitofrontal cortex, and cerebellum, and increased activation in the parietal cortex and precuneus/visual association cortex compared to nonischemic depressed CAD patients.

CONCLUSIONS

These findings are consistent with dysfunction in a network of brain regions involved in the stress response in patients with comorbid CAD and depression that has direct and indirect links to the heart, suggesting a pathway by which stress and depression could lead to increased risk of heart disease related morbidity and mortality. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Psychological Distress Among Female Cardiac Patients Presenting to a Women's Heart Health Clinic

Female cardiac patients are at greater risk for mental health disorders than their male counterparts, and these mental health disorders have been associated with increased cardiac morbidity and mortality. However, few studies have closely examined the mental health disorders found among the female cardiac population. The primary aim of this study was to examine the prevalence of psychological distress in a sample of female cardiac outpatients at an academic medical center. A secondary aim was to determine whether different demographic variables, cardiac risk factors, or cardiac diagnoses were associated with different levels of emotional distress. A survey, including demographic information, medical status, and standardized symptom measures was completed by 117 female patients scheduled for medical visits at an outpatient women's heart health clinic over a 4-month period. Using standardized self-report questionnaires, 38% scored in the moderate-to-severe range for at least 1 mental disorder and 50% endorsed current insomnia. Symptoms of clinical depression (20%) and anxiety (42)% were endorsed at higher rates than predominantly male or mixed comparison samples. Although there was no apparent relation between the severity of cardiac problems and the degree of psychological distress, women with diagnoses of hyperlipidemia, prediabetes, and diabetes reported greater psychological distress than those without these problems. Women with lower income also reported more psychological distress. In conclusion, our findings suggest an unmet need for integrated mental health services for female cardiac patients.

New Insights Into the Comorbidity of Coronary Heart Disease and Depression

Coronary heart disease (CHD) and depression are common disorders that markedly impair quality of life and impose a great financial burden on society. They are also frequently comorbid, exacerbating patient condition, and worsening prognosis. This comorbidity strongly suggests shared pathologic mechanisms. This review focuses on the incidence of depression in patients with CHD, deleterious effects of depression on CHD symptoms, and the potential mechanisms underlying comorbidity. In addition to the existing frequent mechanisms that are well known for decades, this review summarized interesting and original potential mechanisms to underlie the comorbidity, such as endocrine substances, gut microbiome, and microRNA. Finally, there are several treatment strategies for the comorbidity, involving drugs and psychotherapy, which may provide a theoretical basis for further basic research and clinical investigations on improved therapeutic interventions.

Methylation of the glucocorticoid receptor gene associated with depression in patients with acute coronary syndrome

OBJECTIVE

The present study investigated the longitudinal effects of NR3C1 1 F exon methylation on the risk of depression following ACS and treatment outcomes.

METHODS

In total, 969 patients admitted for recent ACS were recruited within 2 weeks of ACS; 711 of these patients were followed up at 1 year. Depressive disorder was diagnosed according to DSM-IV criteria and included prevalent depressive disorder at baseline and incident or persistent depressive disorder at follow-up based on depression status at the two examinations. Of the 378 baseline participants who were diagnosed with depression, 255 participated in a randomized double-blind placebo-controlled trial of escitalopram, while the remaining 123 were managed with the usual medical treatment for ACS.NR3C1 1 F exon methylation was measured using peripheral blood samples, and various demographic and clinical characteristics were assessed as covariates.

RESULTS

Higher NR3C1 1 F exon methylation levels were independently associated with prevalent depressive disorder at baseline but not with incident or persistent depressive disorder at follow-up based on logistic regression analyses adjusted for covariates. The effects of escitalopram on the remission of depressive symptoms was not influenced by NR3C1 1 F exon methylation status in ACS patients, but a placebo effect on the remission of depressive symptoms was observed, particularly in patients with lower methylation levels.

CONCLUSIONS

ACS patients with higher NR3C1 1 F exon methylation levels were at higher risk of developing depressive disorder within 2 weeks of ACS. Additionally, adequate antidepressant treatment may be effective for the remission of depressive symptoms regardless of NR3C1 1 F exon methylation status.

Efficacy and acceptability of antidepressants in patients with ischemic heart disease: systematic review and meta-analysis

To assess the efficacy and acceptability of antidepressants in adults with ischemic heart disease (IHD). We gathered all available randomized-controlled trials comparing antidepressants versus placebo or other antidepressants in adults with IHD. The primary outcome was depressive symptoms at the study endpoint, as measured by validated rating scales. We pooled data in a meta-analysis using a random-effects model. The confidence in the estimates (or certainty of the evidence) was assessed using the GRADE approach. Antidepressants appeared to be more effective than placebo in reducing depressive symptoms (11 comparisons; 1685 participants; standardized mean difference -0.71, 95% confidence interval: -1.11 to -0.30; GRADE quality: moderate). This result was confirmed in the subgroup of serotonin selective reuptake inhibitors, and for the single drugs sertraline and citalopram, with a greater magnitude of effect and a higher quality of evidence for the former. No differences between antidepressants and placebo emerged in terms of acceptability and tolerability, quality of life, mortality, and cardiovascular events. Only two small head-to-head studies were identified. Sertraline is a reasonable first-line choice in patients with IHD and depression, whereas the role of citalopram as the first-line agent should be reconsidered.

The pretreatment of chronic restraint stress exerts little impact on the progression of heart failure in mice

Stress is a potent risk factor for depression. Chronic stress can exacerbate and induce symptoms of depression. Clinical studies suggested that depressive patients are more likely to develop coronary artery diseases. However, the causal relationship between depression and heart failure progression remains unclear. In this study, we aimed to explore the relevance between stress and heart failure (HF) in a mouse model subjected to chronic restraint stress and left anterior descending coronary artery (LAD) ligation. Mice were restrained for 3 h daily for 21 days and the processes were repeated once 3 months later. After the repeated chronic restraint stress, mice showed dramatically increased immobility time in the forced swim test, indicating a state of despair. Restrained and control mice were further subjected to LAD ligation surgery. Echocardiography was conducted 1 week, 2 weeks, and 1 month afterward. LAD-operated mice showed a significant decrease in the values of left ventricular ejection fraction (LVEF), and there was no difference in the LVEF values between the restrained and control mice. Relevant gene expression, neurotransmitter system, glial activation, and morphology of the heart-brain axis were comprehensively evaluated. We found no overall differences between the restrained and control mice with HF. Our results revealed that the repeated chronic restraint stress may have little effects on the progression of heart failure.

Inflammation as a predictor of disease course in posttraumatic stress disorder and depression: A prospective analysis from the Mind Your Heart Study

BACKGROUND

Prior research has focused largely on the pro-inflammatory states of PTSD and depression, with few studies evaluating the direction of inflammation's association with these disorders. To clarify whether inflammation plays a role in the development of PTSD or depression, we assessed the predictive value of inflammatory biomarkers on the courses of these conditions in a cohort of Veterans.

METHODS

This research was part of the Mind Your Heart Study, a prospective cohort study designed to examine PTSD-related health outcomes. Between 2008 and 2010, 746 San Francisco area Veterans Administration patients were enrolled. At baseline, inflammatory biomarkers were measured from fasting morning venous blood draws, and cortisol and catecholamine levels were measured from 24-hour urine samples. PTSD was diagnosed using the PTSD Checklist at baseline and annual follow-up. Depression was evaluated using the 9-item Patient Health Questionnaire at baseline and follow-up. Ordinal logistic regression models were used to assess the predictive value of baseline biomarker levels on clinically relevant courses of PTSD and depression categorized and ordered as none, resolved, developed, and chronic.

RESULTS

After adjustment for age and sex, elevated levels of white blood cell count (OR = 1.27(1.10-1.47), p = 0.001), C-reactive protein (OR = 1.20(1.04-1.39), p = 0.02), fibrinogen (OR = 1.19(1.03-1.38), p = 0.02), and ESR (OR = 1.17(1.00-1.36, p = 0.05), and decreased levels of urine cortisol (OR = 0.84(0.71-0.99), p = 0.04) were significant predictors of poorer courses of PTSD. Elevated levels of WBC count (OR = 1.31(1.14-1.50), p < 0.001), CRP (OR = 1.24(1.07-1.43), p = 0.003), fibrinogen (OR = 1.26(1.09-1.46), p = 0.002), and catecholamines (OR = 1.17(1.01-1.36), p = 0.04) were significant predictors of poorer courses of depression. After additionally controlling for physical activity, elevated WBC count (p = 0.002) and decreased levels of urine cortisol (p = 0.05) remained significant predictors of PTSD course, and elevated WBC count (p = 0.001), CRP (p = 0.03), and fibrinogen (p = 0.02) remained significant predictors of depression course. After adjusting for all significant variables, elevated WBC count (p = 0.02) was a significant predictor of a poorer course of PTSD, and elevated WBC count (p = 0.04) and platelet count (p = 0.03) were significant predictors of a poorer course of depression.

CONCLUSIONS

Increased levels of several inflammatory biomarkers were associated with significantly increased odds of clinically worse courses of PTSD and depression. Inflammation may be a target for prevention and treatment of these mental health disorders.

Diet Quality for Sodium and Vegetables Mediate Effects of Whole Food Diets on 8-Week Changes in Stress Load

Very little is known about how whole food diets, such as those based on the Dietary Guidelines for Americans (DGA), influence psychological stress and physiological stress load. To better understand the effects of whole food diets on stress, we examined in a randomized control trial the effects of a DGA-based diet on markers of psychological and physiological stress. A randomized, double-blind, controlled 8-week intervention was conducted in overweight and obese women randomly assigned to one of two diet groups: a diet based on the 2010 DGA or a diet based on a Typical American Diet (TAD). The Perceived Stress Scale and allostatic load were used to assess stress load. Eight-week change in perceived stress did not significantly (p = 0.45) differ between the DGA (+0.53 ± 0.99) and TAD (-0.57 ± 0.99) groups. Likewise, 8-week change in allostatic load did not significantly (p = 0.79) differ between the two diet intervention groups (DGA: +0.001 ± 0.26 vs. TAD: +0.105 ± 0.28). However, we did find strong inverse associations between 8-week change in stress and intervention-based improvements in diet quality (lower sodium and higher vegetable consumption). When statistically accounting for these inverse associations, we found that perceived stress and allostatic load were higher (p < 0.04) in the DGA group. These findings suggest that improvements in dietary vegetable and sodium intake mediated effects of the diet intervention on psychological and physiological stress load. That is, adopting and adhering to a diet of higher quality (DGA) for 8 weeks may have been generally more stressful in the absence of improvements in vegetable or sodium consumption. This study provides further evidence for the mental health benefits of maximizing vegetable and minimizing sodium consumption.

The association of comorbid depression with mortality and amputation in veterans with peripheral artery disease

OBJECTIVE

Peripheral artery disease (PAD) is an increasing health concern with rising incidence globally. Previous studies have shown an association between PAD incidence and depression. The objective of the study was to determine the association of comorbid depression with PAD outcomes (amputation and all-cause mortality rates) in veterans.

METHODS

An observational retrospective cohort of 155,647 patients with incident PAD (2003-2014) from nationwide U.S. Veterans Health Administration hospitals was conducted using the national Veterans Affairs Corporate Data Warehouse. Depression was measured using concurrent International Classification of Diseases, Ninth Revision diagnosis codes 6 months before or after PAD diagnosis. The main outcomes were incident major amputation and all-cause mortality. Crude associations were assessed with Kaplan-Meier plots. The effects of depression adjusted for covariates were analyzed using Cox proportional hazards models.

RESULTS

Depression was present in 16% of the cohort, with the occurrence of 9517 amputations and 63,287 deaths (median follow-up, 5.9 years). Unadjusted hazard ratios (HRs) of comorbid depression for amputations and all-cause mortality were 1.32 (95% confidence interval [CI], 1.25-1.39) and 1.02 (95% CI, 0.99-1.04), respectively. After adjustment for covariates in Cox regression models, a diagnosis of comorbid depression at the time of PAD diagnosis was associated with a 13% higher amputation (HR, 1.13; 95% CI, 1.07-1.19) and 17% higher mortality (HR, 1.17; 95% CI, 1.14-1.20) risk compared with patients with no depression. On stratification by use of antidepressants, depressed patients not taking antidepressants had a 42% higher risk of amputation (HR, 1.42; 95% CI, 1.27-1.58) compared with those without depression. Patients taking antidepressants for depression still had increased risk of amputation but only 10% higher compared with those without depression (HR, 1.10; 95% CI, 1.03-1.17). Interestingly, patients taking antidepressants for other indications also had a higher risk of amputation compared with those not having depression or not taking antidepressants (HR, 1.08; 95% CI, 1.03-1.14). Having any diagnosis of depression or the need for antidepressants increased the mortality risk by 18% to 25% in the PAD cohort compared with those without depression and not taking antidepressants for any other indication.

CONCLUSIONS

PAD patients with comorbid depression have a significantly higher risk of amputation and mortality than PAD patients without depression. Furthermore, untreated depression was associated with an increased amputation risk in the PAD population, more so than depression or other mental illness being treated by antidepressants. The underlying mechanisms for causality, if any, remain to be determined. The association of antidepressant treatment use with amputation risk should prompt further investigations into possible mechanistic links between untreated depression and vascular dysfunction.

Anxiety and depression predicted quality of life among patients with heart failure

Purpose

Anxiety and depression are prevalent among patients with heart failure. However, their effect on the quality of life (QoL) is not well investigated in developing countries. Therefore, the purpose of this study was to test the effect of anxiety and depression on QoL among Jordanian patients with heart failure.

Patients and methods

Two hundred patients with a confirmed diagnosis of heart failure from 1 governmental and 1 private hospital in Amman, Jordan, were recruited between March and August, 2017. A descriptive, cross-sectional design was used. Anxiety and depression were measured using the Arabic version of the Hospital Anxiety and Depression Scale. QoL was measured using the Arabic version of the Short Form-36.

Results

Patients reported poor QoL in both physical component summary (M ± SD; 35.8±9.6) and mental component summary (M ± SD; 41.5±11.3). Prevalence rates for anxiety and depression were 62% and 65%, respectively. In stepwise regression analysis, anxiety and depression were independent predictors for poor QoL in both summaries, p<0.001.

Conclusion

Patients with heart failure have poor QoL and high anxiety and high depression prevalence rates. Inclusion of routine assessment and management of anxiety and depression in heart failure protocols is highly recommended.

Review of biologic and behavioral risk factors linking depression and peripheral artery disease

The incidence of depression has been rising rapidly, and depression has been recognized as one of the world’s leading causes of disability. More recently, depression has been associated with an increased risk of symptomatic atherosclerotic disease as well as worse perioperative outcomes in patients with cardiovascular disease. Additionally, recent studies have demonstrated an association between depression and peripheral artery disease (PAD), which has been estimated to affect more than 200 million people worldwide. These studies have identified that depression is associated with poor functional and surgical outcomes in patients with PAD. Although the directionality and specific mechanisms underlying this association have yet to be clearly defined, several biologic and behavioral risk factors have been identified to play a role in this relationship. These factors include tobacco use, physical inactivity, medical non-adherence, endothelial and coagulation dysfunction, and dysregulation of the hypothalamic-pituitary-adrenal axis, autonomic system, and immune system. In this article, we review these potential mechanisms and the current evidence linking depression and PAD, as well as future directions for research and interventional strategies. Understanding and elucidating this relationship may assist in preventing the development of PAD and may improve the care that patients with PAD and comorbid depression receive.

Relationship between Chronic Kidney Disease and Depression in Elderly Koreans Using the 2013 Korea National Health and Nutrition Examination Survey Data

BACKGROUND

Depression is prevalent in patients with chronic kidney disease (CKD) and continues to increase in elderly adults. Therefore, the aim of our study was to examine the relationship between CKD and depression in older patients.

METHODS

We conducted a cross-sectional study based on 2013 Korea National Health and Nutrition Examination Survey data. In total, data of 973 subjects aged ≥65 years were analyzed, and the estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation.

RESULTS

The prevalence of depression in older adults was 4.1% in men and 8.8% in women (P=0.004). The prevalence of depression did not differ according to CKD stage in women (normal eGFR and CKD stages 1 and 2 women, 41/474 [8.6%]) vs. CKD stages 3-5 women, 6/63 [9.5%]); however, the prevalence of depression in men with CKD stages 3-5 (8/83 [9.6%]) was significantly higher than in men with normal eGFR and CKD stage 1 and 2 (10/353 [2.8%], P=0.010). Multivariate logistic regression analysis showed that the odds ratio for depression in men with CKD stages 3-5 was 3.822 (95% confidence interval, 1.229 to 11.879) after adjusting for social status and chronic diseases (P=0.021).

CONCLUSION

The prevalence of depression was higher in elderly women than in men, while the prevalence of depression increased in elderly men with CKD stages 3-5 and was almost equal to that of women. Therefore, elderly men with progressive renal function impairment should be counseled and monitored for psychological problems.

Buffer against Cumulative Stress

Abstract. Prolonged elevation of cortisol, the primary stress biomarker, is associated with impaired cognitive and physical health. Cortisol tends to increase in later life among most, but not all, older individuals. The current study considered whether this pattern could be explained by more-positive age stereotypes acting as a stress buffer. The 439 participants drawn from the Baltimore Longitudinal Study of Aging provided 1,789 cortisol measurements, from 24-h collections of urine, across 30 years. Among those aged 50 or greater, the cortisol of the more-negative age-stereotype group increased by 44%, whereas the more-positive age-stereotype group showed no increase. Also as expected, there was no association of age stereotypes and cortisol level among the younger participants, for whom the age stereotypes were self-irrelevant. The findings indicate the importance of considering the relationship between both positive and negative stereotypes and stress biomarkers over time.

Depression 12-months after coronary artery bypass graft is predicted by cortisol slope over the day

Alterations in the diurnal profile of cortisol have been associated with depressed mood in patients with coronary heart disease. The relationship between cortisol output and depressed mood has not been investigated prospectively in coronary artery bypass graft (CABG) patients before. We aimed to study the relationship between cortisol measured pre- and post-operatively and depression symptoms measured 12 months after CABG surgery. We analysed data from 171 patients awaiting first-time, elective CABG surgery from the pre-assessment clinic at St. George's Hospital, London. The Beck Depression Inventory (BDI) was used to assess depression symptoms and saliva samples were collected to measure diurnal cortisol. Baseline assessments of depression and cortisol were obtained an average 29days before surgery, short-term follow-up of cortisol occurred 60days after surgery and long-term follow-up of depression was assessed 378days after surgery. Baseline cortisol slope was not associated with depression at 12-month follow-up. However, a steeper cortisol slope measured 60days after surgery predicted reduced odds of depression (BDI≥10) 12 months after surgery (odds ratio 0.661, 95% confidence interval 0.437-0.998, p=0.049) after controlling for covariates. These findings suggest interventions aimed at improving adaptation in the early recovery period may have long-term benefits in this patient group.

Pre-Operative Cognitive Functioning and Inflammatory and Neuroendocrine Responses to Cardiac Surgery

Background

Cognitive functioning is linked to cardiac mortality and morbidity, but the mechanisms underlying this relationship are unclear.

Purpose

To examine the relationship between pre-operative cognitive functioning and post-operative inflammatory and neuroendocrine responses in patients undergoing coronary artery bypass graft (CABG) surgery.

Methods

One-hundred ninety-three outpatients were screened to assess their cognitive function using the Montreal Cognitive Assessment (MoCA) on average 30 days prior to CABG surgery and provided blood samples for the measurement of interleukin (IL)-6 and C-reactive protein (CRP) and saliva samples for the measurement of diurnal cortisol. Participants were followed-up 4–8 days following surgery for the repeat measurement of IL-6 and CRP and 60 days after surgery for the measurement of diurnal salivary cortisol.

Results

Patients with low cognitive function (MoCA < 26) prior to surgery reached higher IL-6 concentrations in the days after surgery (β = −0.212, p = 0.021) and had greater cortisol output across the day 2 months after surgery (β = −0.179, p = 0.044).

Conclusions

Low cognitive functioning is associated with a more negative pattern of biological response to surgery, indicative of poorer physical recovery. These pathways may contribute to the links between cognitive function and cardiovascular pathology.

Association of Type D personality with increased vulnerability to depression: Is there a role for inflammation or endothelial dysfunction? - The Maastricht Study

BACKGROUND

Type D personality - the combination of negative affectivity (NA) and social inhibition (SI) - has been associated with depression but little is known about underlying mechanisms. We examined whether (1) Type D is a vulnerability factor for depression in general, (2) Type D is associated with inflammation or endothelial dysfunction, and (3) these biomarkers alter the possible association between Type D and depression.

METHODS

In the Maastricht Study, 712 subjects underwent assessment of NA, SI and Type D personality (DS14), depressive disorder (Mini-International Neuropsychiatric Interview) and depressive symptoms (Patient Health Questionnaire-9). Plasma biomarkers of inflammation (hsCRP, SAA, sICAM-1, IL-6, IL-8, TNF-α) and endothelial dysfunction (sVCAM-1, sICAM-1, E-selectin, vWF) were measured with sandwich immunoassays or ELISA and combined into standardized sumscores.

RESULTS

Regarding personality, 49% of the study population was low in NA and SI, 22% had SI only, 12% NA only and 17% had Type D. Depressive disorder and depressive symptoms were significantly more prevalent in Type D versus the other three personality subgroups. Multivariable regression analyses showed that Type D was associated with inflammation (β=0.228, p=0.014) and endothelial dysfunction (β=0.216, p=0.022). After adjustment for these biomarkers, Type D remained independently associated with increased vulnerability to depressive disorder (OR=13.20, p<0.001) and depressive symptoms (β=3.87, p<0.001).

LIMITATIONS

The cross-sectional design restrained us to draw any conclusions on causality. The relatively low prevalence of depressive disorder restrained us to adjust for more potential confounders.

CONCLUSIONS

Type D personality may be a vulnerability factor for depression, irrespective of levels of inflammation or endothelial dysfunction. Future research should examine possible underlying mechanisms.

Insufficient glucocorticoid signaling and elevated inflammation in coronary heart disease patients with comorbid depression

Coronary heart disease (CHD) and depression are very common and often co-existing disorders. In addition to psychological and social morbidity, depression exacerbates adverse cardiac outcomes in CHD patients. Inflammation has been proposed as one of the mechanisms involved in the association between these two debilitating diseases. Therefore, the present study aimed to evaluate inflammatory responses as well as to investigate the pathophysiological mechanisms underlying the putative inflammatory activation in CHD patients with and without depression, by assessing the function of two important biological factors regulating inflammation, the hypothalamus-pituitary-adrenal (HPA) axis and the glucocorticoid receptor (GR). Eighty-three CHD patients with (n=28) and without (n=55) comorbid depression were recruited from primary care services in South London. Depression status was assessed by means of Clinical Interview Schedule Revised for diagnosis of depression, and Beck Depression Inventory for the presence of depressive symptoms. Serum C-reactive protein (CRP), plasma vascular endothelial growth factor (VEGF), and plasma and salivary cortisol were measured using commercially available ELISA kits. Gene expression of GR and interleukin-6 (IL-6) were conducted via qPCR. GR sensitivity was evaluated in vitro in isolated peripheral blood mononuclear cells using the dexamethasone inhibition of lipopolysaccharide-stimulated IL-6 levels. Serum levels of kynurenine pathway metabolites were measured using high performance liquid chromatography. Our results show that CHD patients with depression had higher levels of CRP, IL-6 gene expression, and VEGF compared with CHD non-depressed, as well as lower plasma and saliva cortisol levels. The CHD depressed group also exhibited a reduction in GR expression and sensitivity. Finally, tryptophan levels were significantly lower in patients with depression, who also showed an increased kynurenine/tryptophan ratio. In conclusion, CHD patients with depression had elevated levels of inflammation in the context of HPA axis hypoactivity, GR resistance, and increased activation of the kynurenine pathway. Reduced cortisol bioavailability and attenuated glucocorticoid responsiveness due to decreased expression and sensitivity of GR may lead to insufficient glucocorticoid signaling and thus elevation of inflammation in these patients.

Physical activity and environmental influences on adrenal fatigue of Saudi adults: biochemical analysis and questionnaire survey

[Purpose] This research work was performed to examine whether different levels of physical activity and environmental and social factors are associated with changes in adrenal hormones as markers of adrenal fatigue in Saudi adult volunteers. [Subjects and Methods] A total of 160 Saudi adults aged 15-22 years were included in this study. The adrenal fatigue score, sociodemographic attributes, and the level of physical activity were evaluated via pre-validated internet-based questionnaire surveys. Adrenal hormones such as ACTH and cortisol were measured using immunoassay techniques. [Results] Significant increases in the levels of ACTH and cortisol biomarkers were found in the participants with moderate to severe fatigue scores, poor environmental factors, and low physical activity. However, in physically active participants, significant decreases in ACTH and cortisol levels were found with remarkable improvement in adrenal fatigue status. The decrement in adrenal hormonal levels positively correlated (r= 0.976) with the improvement in adrenal fatigue status in the physically active participants. [Conclusion] Our results suggest that the level of physical activity and environmental and social factors differentially influence the adrenal fatigue status via changes in the levels of adrenal hormones. Also, ACTH and cortisol biomarkers may be useful as markers measuring the severity of adrenal fatigue.

Atherogenic index of plasma and atherogenic coefficient are increased in major depression and bipolar disorder, especially when comorbid with tobacco use disorder

BACKGROUND

There is a robust comorbidity between mood disorders and cardiovascular disorder (CVD). The atherogenic index of plasma (AIP) and the atherogenic coefficient (AC) are important atherogenic indexes. The aims of this study were to delineate whether AIP and AC are increased in mood disorders especially when comorbid with tobacco use disorder (TUD).

METHODS

In this case-control study we included 134 patients with mood disorders, bipolar disorder and unipolar depression (cases), and 197 individuals without mood disorder (controls) divided into those with and without TUD (defined as never-smokers). Total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDLc) and low-density lipoprotein cholesterol (LDLc) were measured. AIP and AC were computed as log (TG/HDLc) and non-HDLc/HDLc, respectively.

RESULTS

The AIP and AC indexes were significantly increased in patients with mood disorders versus controls, both in depression and bipolar disorder. Patients with mood disorder without TUD and patients with TUD without mood disorder showed higher AIP and AC values than never-smokers while those with comorbid mood disorders and TUD showed significantly higher AIP and AC levels than all other individuals. A large part of the variance in the AIC (26.4%) and AC (20.4%) was explained by mood disorders, TUD, male gender and body mass index.

CONCLUSIONS

The findings suggest that lipid abnormalities leading to an increased atherogenic potential are involved in the pathophysiology of mood disorders (depression and bipolar disorder) and especially comorbid mood disorder and TUD. The comorbidity between mood disorders and CVD may be partly explained increased through AIP and AC indexes, impacting increments in atherogenic potential.

The bidirectional relation between psychiatric disorders with selected cardiovascular and endocrinal diseases: an Egyptian perspective

Cardiovascular and endocrine diseases may act as burdens for individuals suffering from one of these medical illnesses, and whether through the ensuing psychological distress, or some biological mechanisms, these medical diseases can eventually lead to the development of psychiatric morbidities. Moreover, psychiatric morbidities negatively affect the prognosis of both cardiovascular and endocrine diseases. Despite transcultural differences, Egyptian patients with ischemic heart diseases (ISHD), heart failure (HF), diabetes mellitus (DM), or thyroid diseases (TD) endure the same psychological distress as their Western counterparts. Psychiatric assessment and evaluation should be regularly repeated among patients with cardiovascular and endocrinal diseases, and patients who are at risk should be closely followed up.

Social integration and mortality in patients with coronary heart disease: findings from the Heart and Soul Study

OBJECTIVE

To determine why lower social integration predicts higher mortality in patients with coronary heart disease (CHD).

METHODS

The association between social integration and mortality was examined prospectively in 1019 outpatients with stable CHD from the Heart and Soul Study. Baseline social integration was assessed with the Berkman Social Network Index. Cox proportional hazards models were used to determine the extent to which demographic and disease-relevant confounders and potential biological, behavioral, and psychological mediators explained the association between social integration and mortality.

RESULTS

During a mean (standard deviation) follow-up period of 6.7 (2.3) years, the age-adjusted annual rate of mortality was 6.3% among socially isolated patients and 4.1% among nonisolated patients (age-adjusted hazard ratio [HR] = 1.61, 95% confidence interval [CI] = 1.26-2.05, p < .001). After adjustment for demographic and disease-relevant confounders, socially isolated patients had a 50% greater risk of death than did nonisolated patients (HR = 1.50, 95% CI = 1.07-2.10). Separate adjustment for potential biological (HR = 1.53, CI = 1.05-2.25) and psychological mediators (HR = 1.52, CI = 1.08-2.14) did not significantly attenuate this association, whereas adjustment for potential behavioral mediators did (HR = 1.30, CI = 0.91-1.86). C-reactive protein and hemoglobin A1c were identified as important biological and omega-3 fatty acids, smoking, and medication adherence as important behavioral potential mediators, with smoking making the largest contribution.

CONCLUSIONS

In this sample of outpatients with baseline stable CHD, the association between social integration and mortality was largely explained by health-related behavioral pathways, particularly smoking.

Association of subsyndromal and depressive symptoms with inflammatory markers among different ethnic groups: the multi-ethnic study of atherosclerosis (MESA)

OBJECTIVE

Depressive symptoms are associated with inflammation yet the association between inflammation and different levels of depression remains unclear. Therefore, we studied the association of subsyndromal and depressive symptoms with inflammatory markers in a large multi-ethnic cohort.

METHODS

C-reactive protein (CRP) (n=6269), interleukin-6 (IL-6) (n=6135) and tumor necrosis factor-alpha (TNF-α) (n=1830) were measured in selected participants from the multi-ethnic study of atherosclerosis (MESA). Subsyndromal depressive symptoms were defined as a CES-D value from 8 to 15, depressive symptoms as a CES-D≥16 and normal as a CES-D≤7. Depressive states (subsyndromal and depressed) were entered into multivariable linear regression models incrementally adjusting for demographic, behavioral, biologic and comorbidities.

RESULTS

Among 6289 participants not taking antidepressants and free from CVD, the mean age was 62.2, while 52% were women, 36.4% were Caucasian, 28.9% African-American, 22.3% Hispanics and 12.4% Chinese-American. Of the total, 24.2% had subsyndromal depression and 11.8% had depressive symptoms. Compared to the non-depressed group and after controlling for demographics, there was no association between both subsyndromal and depressive symptoms with logCRP (β=-0.01, p=0.80 and β=-0.05, p=0.25 respectively), logIL-6 (β=0.01, p=0.71 and β=-0.04, p=0.07 respectively) and logTNF-α (β=-0.03, p=0.29 and β=0.06, p=0.18 respectively). Moreover, fully adjusted models showed no significant associations for logIL-6 and logTNF-α and the different depressive categories. However, with full adjustment, we found a significant inverse association between depressive symptoms and lnCRP (β=-0.10, p=0.01) that was not present for subsyndromal depression (β=-0.05, p=0.11).

CONCLUSION

Among participants not taking anti-depressants, subsyndromal depression is not associated with inflammation. However, depressive symptoms measured by CES-D≥16 are associated with a lower inflammation (CRP).

Anxiety as predictor of the cortisol awakening response in patients with coronary heart disease

BACKGROUND

Anxiety is associated with worse outcomes in patients with coronary heart disease (CHD). A dysregulation of the HPA axis is a potential mechanism linking psychological factors and coronary disease. No study has yet investigated the relationship between anxiety and cortisol among patients with established CHD.

PURPOSE

The aim of this study was to assess the association between anxiety and the cortisol awakening response in patients with CHD.

METHOD

Four salivary cortisol samples were used to assess two measures of the cortisol awakening response (CAR) in 47 patients with established CHD. Anxiety was measured using the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Higher anxiety values were associated with a higher total output of cortisol in the first hour after awakening (AUCg, area under the curve with respect to ground) (p = 0.04) and a nonsignificant trend towards a more pronounced increase (AUCi, area under the curve with respect to increase) (p = 0.08). In patients who had a history of myocardial infarction (MI), the cortisol output was lower compared to patients who had no previous MI (p = 0.02). In linear regression analyses, anxiety emerged as significant predictor of AUCg and AUCi after controlling for MI, ejection fraction (LVEF, left ventricular ejection fraction), and depression.

CONCLUSIONS

Our results provide further indications for an association between anxiety and a dysregulation of the HPA axis. History of MI emerged as second predictor of cortisol output in the morning.

HPA axis and aging in depression: systematic review and meta-analysis

One of the most consistent findings in the biology of depression is an altered activity of the hypothalamic-pituitary-adrenal (HPA) axis. However, data concerning this issue have never been examined with a focus on the older population. Here we present a systematic review and meta-analysis, based on studies investigating levels of cortisol, adrenocorticotropic hormone (ACTH) and corticotropin-releasing hormone (CRH) in depressed participants older than 60 and compared with healthy controls. We found 20 studies, for a total of 43 comparisons on different indices of HPA axis functioning. Depression had a significant effect (Hedges' g) on basal cortisol levels measured in the morning (0.89), afternoon (0.83) and night (1.39), but a smaller effect on cortisol measured continuously (0.51). The effect of depression was even higher on post-dexamethasone cortisol levels (3.22), whereas it was non-significant on morning ACTH and CRH levels. Subgroup analyses indicated that various methodological and clinical factors can influence the study results. Overall, older participants suffering from depression show a high degree of dysregulation of HPA axis activity, with differences compared with younger adults. This might depend on several mechanisms, including physical illnesses, alterations in the CNS and immune-endocrinological alterations. Further studies are needed to clarify the implications of altered HPA axis activity in older patients suffering from depression. Novel pharmacological approaches might be effective in targeting this pathophysiological feature, thus improving the clinical outcomes.

Associations of socioeconomic and psychosocial factors with urinary measures of cortisol and catecholamines in the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

Stress hormones have been hypothesized to contribute to the social patterning of cardiovascular disease but evidence of differences in hormone levels across social groups is scant.

PURPOSE

To examine the associations of socioeconomic and psychosocial factors with urinary levels of cortisol and catecholamines and determine whether these associations are modified by race/ethnicity.

METHODS

Measures of cortisol, epinephrine, norepinephrine and dopamine were obtained on 12-h overnight urine specimens from 942 White, African American and Hispanic participants in the Multi-Ethnic Study of Atherosclerosis (MESA). Linear regression was used to examine associations of income-wealth index, education, depression, anger, anxiety and chronic stress with the four hormones after adjustment for covariates.

RESULTS

Higher income-wealth index was associated with lower levels of urinary cortisol, epinephrine, norepinephrine and dopamine, after adjustment for age, sex, race/ethnicity, medication use, body mass index, smoking, and alcohol use. Education and psychosocial factors were not associated with urinary stress hormone levels in the full sample. However, there was some evidence of effect modification by race: SES factors were more strongly inversely associated with cortisol in African Americans than in other groups and anger was inversely associated with catecholamines in African Americans but not in the other groups.

CONCLUSIONS

Lower SES as measured by income-wealth index in a multi-ethnic sample is associated with higher levels of urinary cortisol and catecholamines. Heterogeneity in these associations by race/ethnicity warrants further exploration.

Depression and cardiovascular disease in women: is there a common immunological basis? A theoretical synthesis

Clinical studies have established an inherent comorbidity between depression and the development of cardiovascular disease (CVD). Furthermore, this comorbidity seems to be more amplified in women than in men. To further investigate this comorbidity, a thorough literature review was conducted on studies from 1992 to date. The PubMed database was accessed using the keywords: cardiovascular disease, inflammation, depression, and sex differences. Both human and animal studies were considered. This review takes the standpoint that depression and CVD are both inflammatory disorders, and that their co-occurrence may be related to how the hypothalamic–pituitary–adrenal axis, serotonergic transmission and circulation, and the renin–angiotensin–aldosterone system via angiotensin II are affected by the excess secretion of proinflammatory cytokines. More recently, preliminary research attributes this systemic inflammation to a global deficiency in CD4+CD25+FOXP3 regulatory T cells. 17-β estradiol and progesterone mediated modulation of cytokine secretion may partially explain the sex differences observed. These hormones and reproductive events associated with hormonal fluctuations are discussed in depth, including the analysis of perinatal models of depression and CVD, including preeclampsia. However, as evidenced by this review, there is a need for mechanistic research in humans to truly understand the nature and directionality of the relationship between depression and CVD.

Effects of Buddhism walking meditation on depression, functional fitness, and endothelium-dependent vasodilation in depressed elderly

OBJECTIVES

The objectives of this study were to determine the effects of the novel Buddhism-based walking meditation (BWM) and the traditional walking exercise (TWE) on depression, functional fitness, and vascular reactivity.

DESIGN

This was a randomized exercise intervention study.

SETTINGS/LOCATION

The study was conducted in a university hospital setting.

SUBJECTS

Forty-five elderly participants aged 60-90 years with mild-to-moderate depressive symptoms were randomly allocated to the sedentary control, TWE, and BWM groups.

INTERVENTIONS

The BWM program was based on aerobic walking exercise incorporating the Buddhist meditations performed 3 times/week for 12 weeks.

OUTCOME MEASURES

Depression score, functional fitness, and endothelium-dependent vasodilation as measured by the flow-mediated dilation (FMD) were the outcome measures used.

RESULTS

Muscle strength, flexibility, agility, dynamic balance, and cardiorespiratory endurance increased in both exercise groups (p<0.05). Depression score decreased (p<0.05) only in the BWM group. FMD improved (p<0.05) in both exercise groups. Significant reduction in plasma cholesterol, triglyceride, high-density lipoprotein cholesterol, and C-reactive protein were found in both exercise groups, whereas low-density lipoprotein cholesterol, cortisol, and interleukin-6 concentrations decreased only in the BWM group.

CONCLUSIONS

Buddhist walking meditation was effective in reducing depression, improving functional fitness and vascular reactivity, and appears to confer greater overall improvements than the traditional walking program.

Depressive syndromes in neurological disorders

Depressive syndromes represent a common and often characteristic feature in a number of neurological disorders. One prominent example is the development of post-stroke depression, which can be observed in more than one-third of stroke survivors in the aftermath of an ischemic stroke. Thus, post-stroke depression represents one of the most prevalent, disabling, and potentially devastating psychiatric post-stroke complications. On the other hand, depressive syndromes may also be considered as a risk factor for certain neurological disorders, as recently revealed by a meta-analysis of prospective cohort studies, which demonstrated an increased risk for ischemic events in depressed patients. Moreover, depressive syndromes represent common comorbidities in a number of other neurological disorders such as Parkinson's disease, multiple sclerosis, or epilepsy, in which depression has a strong impact on both quality of life and outcome of the primary neurological disorder.

Depression and cardiovascular disorders

During the past two decades, research in the field of depression and cardiovascular disorders has exploded. Multiple studies have demonstrated that depression is more prevalent in populations with cardiovascular disease, is a robust risk factor for the development of cardiovascular disease in healthy populations, and is predictive of adverse outcomes (such as myocardial infarction and death) among populations with preexisting cardiovascular disease. Mechanistic studies have shown that poor health behaviors, such as physical inactivity, medication nonadherence, and smoking, strongly contribute to this association. Small randomized trials have found that antidepressant therapies may improve cardiac outcomes. Based on this accumulating evidence, the American Heart Association has recommended routine screening for depression in all patients with coronary heart disease. This review examines the key epidemiological literature on depression and cardiovascular disorders and discusses our current understanding of the mechanisms responsible for this association. We also examine current recommendations for screening, diagnosis, and management of depression. We conclude by highlighting new research areas and discussing therapeutic management of depression in patients with cardiovascular disorders.

Depressive symptoms in older adults with chronic kidney disease: mortality, quality of life outcomes, and correlates

OBJECTIVE

Among patients with chronic kidney disease (CKD), we investigated the prevalence of depressive symptoms, their impact on mortality and quality of life, and correlates of depressive symptoms.

DESIGN

Prospective cohort study, followed up to 4 years.

SETTING

General community.

PARTICIPANTS

A total of 362 older adults with CKD (Stages 3 and 4 assessed from estimated glomerular filtration rate [eGFR]) drawn from the Singapore Longitudinal Aging Study cohort.

MEASUREMENTS

Scores on the Geriatric Depression Scale (GDS) and the prevalence of depressive symptoms (GDS ≥5) and other variables were assessed at baseline, and SF-12 quality of life (QOL) (at 2 years) and mortality determined from 4 years of follow-up.

RESULTS

Depressive symptoms were present in 13% of the participants at baseline, and were associated with poorer SF-12 QOL scores (up to 30 percentage point differences). There was a significant association between depressive symptoms and increased mortality risk (odds ratio: 3.17; 95% confidence interval: 1.17-8.61; χ(2) = 5.11; df = 1; p = 0.023), which was statistically significant in unadjusted analysis, but not in multivariate analysis that accounted for covariates (odds ratio: 2.62; 95% confidence interval: 0.77-8.89; χ(2) = 2.37; df = 1; p = 0.13). Baseline cognitive impairment, functional disability, and other chronic illness were significantly associated with both increasing GDS scores and depressive symptoms. No relationship between eGFR and depressive symptoms was observed.

CONCLUSION

Depression among individuals with CKD was significantly associated with poorer quality of life, but not with increased mortality in predialysis CKD patients. More prospective studies are needed to establish the effects of depression on adverse CKD outcomes in predialysis CKD patients.

[Depression and neurological diseases]

In many neurological diseases a depressive syndrome is a characteristic sign of the primary disease or is an important comorbidity. Post-stroke depression, for example, is a common and relevant complication following ischemic brain infarction. Approximately 4 out of every 10 stroke patients develop depressive disorders in the course of the disease which have a disadvantageous effect on the course and the prognosis. On the other hand depression is also a risk factor for certain neurological diseases as was recently demonstrated in a meta-analysis of prospective cohort studies which revealed a much higher stroke risk for depressive patients. Furthermore, depression plays an important role in other neurological diseases with respect to the course and quality of life, such as Parkinson's disease, multiple sclerosis and epilepsy. This article gives a review of the most important epidemiological, pathophysiological and therapeutic aspects of depressive disorders as a comorbidity of neurological diseases and as a risk factor for neurological diseases.

Depression and cardiovascular disease

Approximately one out of every five patients with cardiovascular disease (CVD) suffers from major depressive disorder (MDD). Both MDD and depressive symptoms are risk factors for CVD incidence, severity and outcomes. Great progress has been made in understanding potential mediators between MDD and CVD, particularly focusing on health behaviors. Investigators have also made considerable strides in the diagnosis and treatment of depression among patients with CVD. At the same time, many research questions remain. In what settings is depression screening most effective for patients with CVD? What is the optimal screening frequency? Which therapies are safe and effective? How can we better integrate the care of mental health conditions with that of CVD? How do we motivate depressed patients to change health behaviors? What technological tools can we use to improve care for depression? Gaining a more thorough understanding of the links between MDD and heart disease, and how best to diagnose and treat depression among these patients, has the potential to substantially reduce morbidity and mortality from CVD.

Cortisol and depression: three questions for psychiatry

BACKGROUND

Cortisol plays a multifaceted role in major depression disorder (MDD). Diurnal rhythms are disturbed, there is increased resistance to the feedback action of glucocorticoids, excess cortisol may induce MDD, basal levels may be higher and the post-awakening cortisol surge accentuated in those at risk for MDD. Does this suggest new avenues for studying MDD or its clinical management?

METHOD

The relevant literature was reviewed.

RESULTS

Cortisol contributes to genetic variants for the risk for MDD and the way that environmental events amplify risk. The corticoids' influence begins prenatally, but continues into adulthood. The impact of cortisol at each phase depends not only on its interaction with other factors, such as psychological traits and genetic variants, but also on events that have, or have not, occurred previously.

CONCLUSIONS

This review suggests that the time is now right for serious consideration of the role of cortisol in a clinical context. Estimates of cortisol levels and the shape of the diurnal rhythm might well guide the understanding of subtypes of MDD and yield additional indicators for optimal treatment. Patients with disturbed cortisol rhythms might benefit from restitution of those rhythms; they may be distinct from those with more generally elevated levels, who might benefit from cortisol blockade. Higher levels of cortisol are a risk for subsequent depression. Should manipulation of cortisol or its receptors be considered as a preventive measure for some of those at very high risk of future MDD, or to reduce other cortisol-related consequences such as long-term cognitive decline?

Cortisol response to experimental pain in patients with chronic low back pain and patients with major depression

OBJECTIVE

Chronic pain and major depression have been associated with alterations of the hypothalamus-pituitary-adrenal axis (HPA) activity. Previous studies suggested that HPA activity is diminished in chronic pain but increased in depression. However, little is known about the effects of experimentally induced acute pain on cortisol secretion in patients with chronic pain and depression.

METHODS

On three different occasions (day 1, day 8, day 90), we repeatedly examined 20 patients with chronic low back pain without depression, 22 patients with major depression without pain, and 33 healthy subjects using heat stimuli. Pain intensity was rated by participants using a visual analog scale. Salivary cortisol was assessed prior to 10 blocks of repeated painful heat stimuli, and 45 and 60 minutes afterwards.

RESULTS

In repeated measures analyses of covariance adjusting for age, sex, and time of examination, we found a significant effect of group (P < 0.01) and post-hoc tests confirmed that patients with chronic pain had lower cortisol area-under-the-curve values compared with healthy controls and depressed patients at all time points (all P values <0.01). However, cortisol secretion in depressed patients did not differ from controls.

CONCLUSIONS

Across groups, experimental heat pain stimuli did not elicit a significant cortisol response. Chronic pain appears to be associated with low cortisol secretion. The mechanisms linking chronic pain with low cortisol deserve further study.