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Li G, Zhang L, Liu M. Meta-analysis on inflammation and autonomic nervous system of coronary heart disease combined with depression. BMJ Open 2024; 14:e079980. [PMID: 38453204 PMCID: PMC10921480 DOI: 10.1136/bmjopen-2023-079980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 02/19/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVES This meta-analysis aimed to explore the association between inflammatory factors, heart rate variability (HRV) and the coexistence of coronary heart disease (CHD) and depression. DESIGN Systematic review and meta-analysis. Complying with the Meta-analysis Of Observational Studies in Epidemiology statement. DATA SOURCES We searched PubMed, Web of Science and EMBASE for the data from the inception date to 16 March 2023. ELIGIBILITY CRITERIA We included cross-sectional and cohort studies with inclusion criteria: (1) patients with CHD; (2) depression measurement and (3) including inflammatory factors or cardiac biomarkers or HRV. DATA EXTRACTION AND SYNTHESIS Two authors searched the databases independently. The effect estimates and heterogeneity were synthesised by Review Manager V.5.3. Sensitivity analysis and publication bias were analysed by STATA software. The quantitative synthesis outcomes were presented by mean difference (MD) or standard MD (SMD) with 95% CI. RESULTS By searching the databases, we identified a total of 6750 articles. There were 22 articles left after selection, including 6344 participants. This meta-analysis indicated that patients with CHD with depression had higher levels of C reaction protein (CRP) (SMD 0.50, 95% CI (0.19 to 0.81), p=0.001), high-sensitivity C reactive protein (hs-CRP) (SMD 0.28, 95% CI (0.07 to 0.48), p=0.008), IL-6 (SMD 0.49, 95% CI (0.05 to 0.92), p=0.03) and a lower level of the mean RR interval and the SD of all RR intervals (SMD -0.64, 95% CI (-1.11 to -0.17), p=0.008), SD of the 5 min averages of all normal RR intervals (MD -12.77 ms, 95% CI (-21.20 to -4.33), p=0.003), overage of the SD of all normal RR intervals for each 5 min segment (MD -13.83 ms, 95% CI (-15.94 to -11.72), p<0.00001), root mean square of successive differences (MD: -8.02 ms, 95% CI (-13.62 to -2.43), p=0.005), proportion of adjacent cycles differing by >50 ms (pNN50) (SMD -0.86, 95% CI (-1.41 to -0.31), p=0.002), than those without depression. CONCLUSIONS This study underscores the association between elevated CRP, hs-CRP, IL-6 and lower HRV in patients with CHD with depression. It emphasises the importance of clinicians assessing CRP, hs-CRP, IL-6 and HRV in patients with CHD to potentially identify depressive conditions.
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Affiliation(s)
- Guo Li
- Department of Psychocardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lijun Zhang
- Department of Psychocardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Meiyan Liu
- Department of Psychocardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Garrels E, Kainth T, Silva B, Yadav G, Gill G, Salehi M, Gunturu S. Pathophysiological mechanisms of post-myocardial infarction depression: a narrative review. Front Psychiatry 2023; 14:1225794. [PMID: 37599890 PMCID: PMC10436342 DOI: 10.3389/fpsyt.2023.1225794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023] Open
Abstract
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.
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Affiliation(s)
- Eric Garrels
- Department of Psychiatry, BronxCare Health System, New York, NY, United States
| | - Tejasvi Kainth
- Department of Psychiatry, BronxCare Health System, New York, NY, United States
| | - Briana Silva
- BronxCare Health System, New York, NY, United States
| | - Garima Yadav
- Department of Psychiatry, BronxCare Health System, New York, NY, United States
| | - Gurtej Gill
- Department of Psychiatry, BronxCare Health System, New York, NY, United States
| | - Mona Salehi
- BronxCare Health System, New York, NY, United States
| | - Sasidhar Gunturu
- Department of Psychiatry, BronxCare Health System, New York, NY, United States
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Zhao S, Zhu L, Yang J. Association between depression and macrovascular disease: a mini review. Front Psychiatry 2023; 14:1215173. [PMID: 37457763 PMCID: PMC10344456 DOI: 10.3389/fpsyt.2023.1215173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/15/2023] [Indexed: 07/18/2023] Open
Abstract
Depression and macrovascular diseases are globally recognized as significant disorders that pose a substantial socioeconomic burden because of their associated disability and mortality. In addition, comorbidities between depression and macrovascular diseases have been widely reported in clinical settings. Patients afflicted with coronary artery disease, cerebrovascular disease or peripheral artery disease exhibit an elevated propensity for depressive symptoms. These symptoms, in turn, augment the risk of macrovascular diseases, thereby reflecting a bidirectional relationship. This review examines the physiological and pathological mechanisms behind comorbidity while also examining the intricate connection between depression and macrovascular diseases. The present mechanisms are significantly impacted by atypical activity in the hypothalamic-pituitary-adrenal axis. Elevated levels of cortisol and other hormones may disrupt normal endothelial cell function, resulting in vascular narrowing. At the same time, proinflammatory cytokines like interleukin-1 and C-reactive protein have been shown to disrupt the normal function of neurons and microglia by affecting blood-brain barrier permeability in the brain, exacerbating depressive symptoms. In addition, platelet hyperactivation or aggregation, endothelial dysfunction, and autonomic nervous system dysfunction are important comorbidity mechanisms. Collectively, these mechanisms provide a plausible physiological basis for the interplay between these two diseases. Interdisciplinary collaboration is crucial for future research aiming to reveal the pathogenesis of comorbidity and develop customised prevention and treatment strategies.
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Affiliation(s)
- Shuwu Zhao
- Department of Anesthesiology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Liping Zhu
- Department of Rehabilitation Medicine, The 3rd Xiangya Hospital, Central South University, Changsha, China
| | - Jinfeng Yang
- Department of Anesthesiology, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
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Basile C, Parlati ALM, Paolillo S, Marzano F, Nardi E, Chirico A, Buonocore D, Colella A, Fontanarosa S, Cotticelli C, Marchesi A, Rodolico D, Dellegrottaglie S, Gargiulo P, Prastaro M, Perrone-Filardi P, Montisci R. Depression in Heart Failure with Reduced Ejection Fraction, an Undervalued Comorbidity: An Up-To-Date Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:948. [PMID: 37241180 PMCID: PMC10224073 DOI: 10.3390/medicina59050948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023]
Abstract
Introduction: Depression is a common and severe comorbidity among individuals with heart failure (HF). Up to a third of all HF patients are depressed, and an even higher proportion have symptoms of depression. Aim: In this review, we evaluate the relationship between HF and depression, explain the pathophysiology and epidemiology of both diseases and their relationship, and highlight novel diagnostic and therapeutic options for HF patients with depression. Materials and Methods: This narrative review involved keyword searches of PubMed and Web of Science. Review search terms included ["Depression" OR "Depres*" OR "major depr*"] AND ["Heart Failure" OR "HF" OR "HFrEF" OR "HFmrEF" OR "HFpEF" OR "HFimpEF"] in all fields. Studies included in the review met the following criteria: (A) published in a peer-reviewed journal; (B) described the impact of depression on HF and vice versa; and (C) were opinion papers, guidelines, case studies, descriptive studies, randomized control trials, prospective studies, retrospective studies, narrative reviews, and systematic reviews. Results: Depression is an emergent HF risk factor and strongly relates with worse clinical outcomes. HF and depression share multiple pathways, including platelet dis-reactivity, neuroendocrine malfunction, inappropriate inflammation, tachi-arrhythmias, and frailty in the social and community setting. Existing HF guidelines urge evaluation of depression in all HF patients, and numerous screening tools are available. Depression is ultimately diagnosed based on DSM-5 criteria. There are both non-pharmaceutical and pharmaceutical treatments for depression. Regarding depressed symptoms, non-pharmaceutical treatments, such as cognitive-behavioral therapy and physical exercise, have shown therapeutic results, under medical supervision and with an effort level adapted to the patient's physical resources, together with optimal HF treatment. In randomized clinical studies, selective serotonin reuptake inhibitors, the backbone of antidepressant treatment, did not demonstrate advantage over the placebo in patients with HF. New antidepressant medications are currently being studied and could provide a chance to enhance management, treatment, and control of depression in patients with HF. Conclusions: Despite the substantial link between depression and HF, their combination is underdiagnosed and undertreated. Considering the hopeful yet unclear findings of antidepressant trials, further research is required to identify people who may benefit from antidepressant medication. The goal of future research should be a complete approach to the care of these patients, who are anticipated to become a significant medical burden in the future.
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Affiliation(s)
- Christian Basile
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | | | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Federica Marzano
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Ermanno Nardi
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Alfonsina Chirico
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Davide Buonocore
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Angela Colella
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Sara Fontanarosa
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Ciro Cotticelli
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Anna Marchesi
- Department of Psychiatry, University Vita-Salute San Raffaele, 20132 Milan, Italy
| | - Daniele Rodolico
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00128 Rome, Italy
| | | | - Paola Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Maria Prastaro
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Pasquale Perrone-Filardi
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Roberta Montisci
- Clinical Cardiology, AOU Cagliari, Department of Medical Science and Public Health, University of Cagliari, 09124 Cagliari, Italy
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An L, Ma L, Xu N, Yu B. Life satisfaction, depressive symptoms, and blood pressure in the middle-aged and older Chinese population. J Psychosom Res 2023; 170:111367. [PMID: 37196586 DOI: 10.1016/j.jpsychores.2023.111367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 05/09/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE Both life satisfaction and depressive symptoms have been proven to be related to blood pressure (BP) separately. This longitudinal study aimed to examine whether these two distinct but related psychological constructs are independent predictors of BP in the middle-aged and older Chinese population. METHODS This study used two waves of data from the China Health and Retirement Longitudinal Study (CHARLS) and the analysis were restricted to those respondents aged 45 and older without hypertension and other cardiometabolic conditions [n = 4055, mean age (SD) = 56.7 (8.3); male, 50.1%]. Multiple linear regression models were used to evaluate the associations between baseline life satisfaction, depressive symptoms, and systolic (SBP) and diastolic blood pressure (DBP) at follow-up. RESULTS Life satisfaction was positively associated with SBP (β = 0.03, p = .03), while depressive symptoms were negatively associated with both SBP (β = -0.04, p = .003) and DBP (β = -0.04, p = .004) at follow-up. The associations for life satisfaction became insignificant when all the covariates including depressive symptoms were taken into account. In contrast, the associations for depressive symptoms remained even after controlling for all the covariates including life satisfaction (SBP: β = -0.04, p = .02; DBP: β = -0.04, p = .01). CONCLUSION The results implied that depressive symptoms, rather than life satisfaction, independently predicted BP changes in the Chinese population after four years. These findings expand our knowledge about the association patterns of depressive symptoms and life satisfaction with BP.
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Affiliation(s)
- Li An
- School of Education, Tianjin University, Tianjin, China; Institute of Applied Psychology, Tianjin University, Tianjin, China; Laboratory of Suicidology, Tianjin Municipal Education Commission, Tianjin, China
| | - Ling Ma
- School of Education, Tianjin University, Tianjin, China; Institute of Applied Psychology, Tianjin University, Tianjin, China
| | - Nan Xu
- School of Education, Tianjin University, Tianjin, China; Institute of Applied Psychology, Tianjin University, Tianjin, China
| | - Bin Yu
- Institute of Applied Psychology, Tianjin University, Tianjin, China; Laboratory of Suicidology, Tianjin Municipal Education Commission, Tianjin, China; Academy of Medical Engineering and Translational Medicine, Tianjin University, China.
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6
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Manolis TA, Manolis AA, Melita H, Manolis AS. Neuropsychiatric disorders in patients with heart failure: not to be ignored. Heart Fail Rev 2022:10.1007/s10741-022-10290-2. [DOI: 10.1007/s10741-022-10290-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
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Shen Q, Song H, Aspelund T, Yu J, Lu D, Jakobsdóttir J, Bergstedt J, Yi L, Sullivan P, Sjölander A, Ye W, Fall K, Fang F, Valdimarsdóttir U. Cardiovascular disease and subsequent risk of psychiatric disorders: a nationwide sibling-controlled study. eLife 2022; 11:e80143. [PMID: 36269046 PMCID: PMC9718522 DOI: 10.7554/elife.80143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 10/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background The association between cardiovascular disease (CVD) and selected psychiatric disorders has frequently been suggested while the potential role of familial factors and comorbidities in such association has rarely been investigated. Methods We identified 869,056 patients newly diagnosed with CVD from 1987 to 2016 in Sweden with no history of psychiatric disorders, and 910,178 full siblings of these patients as well as 10 individually age- and sex-matched unrelated population controls (N = 8,690,560). Adjusting for multiple comorbid conditions, we used flexible parametric models and Cox models to estimate the association of CVD with risk of all subsequent psychiatric disorders, comparing rates of first incident psychiatric disorder among CVD patients with rates among unaffected full siblings and population controls. Results The median age at diagnosis was 60 years for patients with CVD and 59.2% were male. During up to 30 years of follow-up, the crude incidence rates of psychiatric disorder were 7.1, 4.6, and 4.0 per 1000 person-years for patients with CVD, their siblings and population controls. In the sibling comparison, we observed an increased risk of psychiatric disorder during the first year after CVD diagnosis (hazard ratio [HR], 2.74; 95% confidence interval [CI], 2.62-2.87) and thereafter (1.45; 95% CI, 1.42-1.48). Increased risks were observed for all types of psychiatric disorders and among all diagnoses of CVD. We observed similar associations in the population comparison. CVD patients who developed a comorbid psychiatric disorder during the first year after diagnosis were at elevated risk of subsequent CVD death compared to patients without such comorbidity (HR, 1.55; 95% CI, 1.44-1.67). Conclusions Patients diagnosed with CVD are at an elevated risk for subsequent psychiatric disorders independent of shared familial factors and comorbid conditions. Comorbid psychiatric disorders in patients with CVD are associated with higher risk of cardiovascular mortality suggesting that surveillance and treatment of psychiatric comorbidities should be considered as an integral part of clinical management of newly diagnosed CVD patients. Funding This work was supported by the EU Horizon 2020 Research and Innovation Action Grant (CoMorMent, grant no. 847776 to UV, PFS, and FF), Grant of Excellence, Icelandic Research Fund (grant no. 163362-051 to UV), ERC Consolidator Grant (StressGene, grant no. 726413 to UV), Swedish Research Council (grant no. D0886501 to PFS), and US NIMH R01 MH123724 (to PFS).
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Affiliation(s)
- Qing Shen
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska InstitutetStockholmSweden
- Centre of Public Health Sciences, Faculty of Medicine, University of IcelandReykjavíkIceland
| | - Huan Song
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska InstitutetStockholmSweden
- Centre of Public Health Sciences, Faculty of Medicine, University of IcelandReykjavíkIceland
- West China Biomedical Big Data Center, West China Hospital, Sichuan UniversityChengduChina
- Medical Big Data Center, Sichuan UniversityChengduChina
| | - Thor Aspelund
- Centre of Public Health Sciences, Faculty of Medicine, University of IcelandReykjavíkIceland
| | - Jingru Yu
- Department of Medical Epidemiology and Biostatistics, Karolinska InstitutetStockholmSweden
| | - Donghao Lu
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska InstitutetStockholmSweden
- West China Biomedical Big Data Center, West China Hospital, Sichuan UniversityChengduChina
- Department of Epidemiology, Harvard T.H. Chan School of Public HealthBostonUnited States
| | - Jóhanna Jakobsdóttir
- Centre of Public Health Sciences, Faculty of Medicine, University of IcelandReykjavíkIceland
| | - Jacob Bergstedt
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska InstitutetStockholmSweden
| | - Lu Yi
- Department of Medical Epidemiology and Biostatistics, Karolinska InstitutetStockholmSweden
| | - Patrick Sullivan
- Department of Medical Epidemiology and Biostatistics, Karolinska InstitutetStockholmSweden
- Departments of Genetics and Psychiatry, University of North CarolinaChapel HillUnited States
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska InstitutetStockholmSweden
| | - Weimin Ye
- Department of Medical Epidemiology and Biostatistics, Karolinska InstitutetStockholmSweden
| | - Katja Fall
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska InstitutetStockholmSweden
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro UniversityÖrebroSweden
| | - Fang Fang
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska InstitutetStockholmSweden
| | - Unnur Valdimarsdóttir
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska InstitutetStockholmSweden
- Centre of Public Health Sciences, Faculty of Medicine, University of IcelandReykjavíkIceland
- Department of Epidemiology, Harvard T.H. Chan School of Public HealthBostonUnited States
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Brunet J, Wurz A, Hussien J, Pitman A, Conte E, Ennis JK, Herry CL, Seely AJE, Seely D. Exploring the Effects of Yoga Therapy on Heart Rate Variability and Patient-Reported Outcomes After Cancer Treatment: A Study Protocol. Integr Cancer Ther 2022; 21:15347354221075576. [PMID: 35393867 PMCID: PMC9016564 DOI: 10.1177/15347354221075576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Following cancer treatment, adults commonly report worsened patient-reported outcomes (PROs) such as anxiety, stress, depression, persistent and upsetting cognitive complaints, unrelenting fatigue, and reduced quality of life. Poorer PROs are associated with disrupted autonomic nervous system functioning as measured by heart rate variability (HRV), both of which have been associated with greater morbidity and mortality. Interventions to improve HRV and PROs among adults following cancer treatment are needed. Yoga therapy holds promise as an intervention to improve HRV and PROs. Therefore, we conducted a single-subject exploratory experimental study to investigate the effects of yoga therapy on HRV and specific PROs (ie, cancer-related fatigue, anxiety, cognitive function, depression, stress, quality of life) in adults treated for cancer. To reduce publication bias, improve reproducibility, and serve as a reference for forthcoming reporting of study results, we present the study protocol for this study herein. METHODS Participants were adults who completed cancer treatment that were recruited from the Ottawa Integrative Cancer Centre. Consenting and eligible participants received one 1:1 yoga therapy session (ie, 1 participant, 1 Yoga Therapist) and 6 weekly group-based yoga therapy sessions (ie, 2-3 participants, 1 Yoga Therapist). Participants completed assessments 7 times: 3 times prior to the program (ie, -6 weeks, -3 weeks, immediately prior to the 1:1 yoga therapy session), immediately following the 1:1 yoga therapy session, prior to the first group-based yoga therapy session, after the last group-based yoga therapy session, and at a 6-week follow-up. Hierarchical linear modeling will be used to test the average effects of the yoga therapy program across participants. DISCUSSION This study will explore several novel hypotheses, including whether yoga therapy can improve HRV and/or specific PROs among adults treated for cancer acutely (ie, during a 1:1 yoga therapy session) and/or through repeated exposure (ie, after completing 6 weeks of group-based yoga therapy). Although the findings will require confirmation or refutation in future trials, they may provide initial evidence that YT may benefit adults treated for cancer. TRIAL REGISTRATION ISRCTN registry, ISRCTN64763228. Registered on December 12, 2021. This trial was registered retrospectively. URL of trial registry record: https://www.isrctn.com/ISRCTN64763228.
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Affiliation(s)
- Jennifer Brunet
- University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Institut du savoir de l'Hôpital Montfort, Ottawa, ON, Canada
| | - Amanda Wurz
- University of the Fraser Valley, Chilliwack, BC, Canada
| | | | - Anne Pitman
- The Centre for Health Innovation, Ottawa, ON, Canada
| | - Ellen Conte
- The Centre for Health Innovation, Ottawa, ON, Canada.,Canadian College of Naturopathic Medicine, Toronto, ON, Canada
| | - Julie K Ennis
- The Centre for Health Innovation, Ottawa, ON, Canada
| | | | - Andrew J E Seely
- University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada
| | - Dugald Seely
- University of Ottawa, Ottawa, ON, Canada.,The Centre for Health Innovation, Ottawa, ON, Canada.,Canadian College of Naturopathic Medicine, Toronto, ON, Canada
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9
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Qi-Regulating and Blood Circulation-Promoting Therapy Improves Health Status of Stable Angina Pectoris Patients with Depressive Symptoms. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:7319417. [PMID: 34567219 PMCID: PMC8460386 DOI: 10.1155/2021/7319417] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/04/2021] [Accepted: 08/12/2021] [Indexed: 11/17/2022]
Abstract
Depressive symptoms have been found to be highly prevalent among patients with coronary heart disease (CHD) and seriously affect the patients' quality of life. However, most psychotropic drugs have warnings about potential side effects. Accordingly, safer effective alternatives are urgently demanded. Angina pectoris of CHD is considered as “chest stuffiness and heartache syndrome” in traditional Chinese medicine, with the major syndrome type named Qi stagnation and blood stasis. Qi-regulating and blood circulation-promoting therapy has increasingly shown unique advantages in CHD patients. This study investigated the efficacy of Xuefu Zhuyu decoction, a representative prescription of Qi-regulating and blood circulation-promoting therapy, on angina pectoris patients with depressive symptoms. Depressive symptoms were stratified at baseline in 30 patients with stable angina pectoris who participated in both baseline and 12-week follow-up studies. After performing a stratified analysis, the angina pectoris-specific health status and traditional Chinese medicine “chest stuffiness and heartache syndrome” were evaluated by self-reports using the associated questionnaire scales, respectively. We measured serum concentrations of serotonin, brain-derived neurotrophic factor, and ATP, which are associated with the development of depression. We found that the Xuefu Zhuyu granule significantly improved the angina pectoris-specific health status in patients after 12 weeks of treatment; specifically, it had a better curative effect on patients with depressive symptoms. Xuefu Zhuyu granule also significantly improved the chest stuffiness and heartache syndrome in patients with depressive symptoms (efficacy index is 61.24%, P < 0.05 versus baseline). Interestingly, Xuefu Zhuyu granule has been found to be more susceptible to improving ATP levels in patients with depressive symptoms, indicating that the improvement in serum ATP levels might account for the better efficacy of Xuefu Zhuyu granule in patients with depressive symptoms. Our data provide prospective evidence that Xuefu Zhuyu granule improves angina pectoris-specific health status through regulating Qi and promoting blood circulation. This trial is registered with ChiCTR-IOR-15006989.
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10
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Pham T, Lau ZJ, Chen SHA, Makowski D. Heart Rate Variability in Psychology: A Review of HRV Indices and an Analysis Tutorial. SENSORS (BASEL, SWITZERLAND) 2021; 21:3998. [PMID: 34207927 PMCID: PMC8230044 DOI: 10.3390/s21123998] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/04/2021] [Accepted: 06/04/2021] [Indexed: 12/16/2022]
Abstract
The use of heart rate variability (HRV) in research has been greatly popularized over the past decades due to the ease and affordability of HRV collection, coupled with its clinical relevance and significant relationships with psychophysiological constructs and psychopathological disorders. Despite the wide use of electrocardiograms (ECG) in research and advancements in sensor technology, the analytical approach and steps applied to obtain HRV measures can be seen as complex. Thus, this poses a challenge to users who may not have the adequate background knowledge to obtain the HRV indices reliably. To maximize the impact of HRV-related research and its reproducibility, parallel advances in users' understanding of the indices and the standardization of analysis pipelines in its utility will be crucial. This paper addresses this gap and aims to provide an overview of the most up-to-date and commonly used HRV indices, as well as common research areas in which these indices have proven to be very useful, particularly in psychology. In addition, we also provide a step-by-step guide on how to perform HRV analysis using an integrative neurophysiological toolkit, NeuroKit2.
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Affiliation(s)
- Tam Pham
- School of Social Sciences, Nanyang Technological University, Singapore 639818, Singapore; (T.P.); (Z.J.L.); (D.M.)
| | - Zen Juen Lau
- School of Social Sciences, Nanyang Technological University, Singapore 639818, Singapore; (T.P.); (Z.J.L.); (D.M.)
| | - S. H. Annabel Chen
- School of Social Sciences, Nanyang Technological University, Singapore 639818, Singapore; (T.P.); (Z.J.L.); (D.M.)
- Centre for Research and Development in Learning, Nanyang Technological University, Singapore 637460, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 636921, Singapore
- National Institute of Education, Nanyang Technological University, Singapore 637616, Singapore
| | - Dominique Makowski
- School of Social Sciences, Nanyang Technological University, Singapore 639818, Singapore; (T.P.); (Z.J.L.); (D.M.)
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Hoemann K, Khan Z, Kamona N, Dy J, Barrett LF, Quigley KS. Investigating the relationship between emotional granularity and cardiorespiratory physiological activity in daily life. Psychophysiology 2021; 58:e13818. [PMID: 33768687 DOI: 10.1111/psyp.13818] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/09/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023]
Abstract
Emotional granularity describes the ability to create emotional experiences that are precise and context-specific. Despite growing evidence of a link between emotional granularity and mental health, the physiological correlates of granularity have been under-investigated. This study explored the relationship between granularity and cardiorespiratory physiological activity in everyday life, with particular reference to the role of respiratory sinus arrhythmia (RSA), an estimate of vagal influence on the heart often associated with positive mental and physical health outcomes. Participants completed a physiologically triggered experience-sampling protocol including ambulatory recording of electrocardiogram, impedance cardiogram, movement, and posture. At each prompt, participants generated emotion labels to describe their current experience. In an end-of-day survey, participants elaborated on each prompt by rating the intensity of their experience on a standard set of emotion adjectives. Consistent with our hypotheses, individuals with higher granularity exhibited a larger number of distinct patterns of physiological activity during seated rest, and more situationally precise patterns of activity during emotional events: granularity was positively correlated with the number of clusters of cardiorespiratory physiological activity discovered in seated rest data, as well as with the performance of classifiers trained on event-related changes in physiological activity. Granularity was also positively associated with RSA during seated rest periods, although this relationship did not reach significance in this sample. These findings are consistent with constructionist accounts of emotion that propose concepts as a key mechanism underlying individual differences in emotional experience, physiological regulation, and physical health.
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Affiliation(s)
- Katie Hoemann
- Department of Psychology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Zulqarnain Khan
- Department of Electrical and Computer Engineering, Northeastern University, Boston, MA, USA
| | - Nada Kamona
- Department of Psychology, Northeastern University, Boston, MA, USA
| | - Jennifer Dy
- Department of Electrical and Computer Engineering, Northeastern University, Boston, MA, USA
| | - Lisa Feldman Barrett
- Department of Psychology, Northeastern University, Boston, MA, USA.,Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Karen S Quigley
- Department of Psychology, Northeastern University, Boston, MA, USA.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
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12
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Dereli S, Kılınçel O, Çerik İB, Kaya A. Impact of sacubitril/valsartan treatment on depression and anxiety in heart failure with reduced ejection fraction. Acta Cardiol 2020; 75:774-782. [PMID: 32186467 DOI: 10.1080/00015385.2020.1730577] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: In patients with heart failure (HF), depression and anxiety disorders are common and associated with adverse outcomes. Sacubitril/valsartan, which is an angiotensin receptor neprilysin inhibitor (ARNI), has been shown to reduce mortality and hospitalisation in patients with heart failure with reduced ejection fraction (HFrEF). However, its effects on depression and anxiety levels remain unclear.Methods: Sacubitril/valsartan was initiated in 115 symptomatic patients with HFrEF receiving an optimal medical treatment with angiotensin inhibition. Patients underwent 6-minute walk test (6-MWT), The Beck Depression Inventory-II (BDI-II) and Beck Anxiety Inventory (BAI) were administered at the switching to ARNI and at the third-month follow-up of the maximum sacubitril/valsartan dose.Results: A significant improvement was observed in BDI-II and BAI scores when compared before and after the sacubitril/valsartan treatment (13.7 ± 9.7 to 7.6 ± 3.8, p < 0.001 and 13.3 ± 8.9 to 8.1 ± 4.1, p < 0.001, respectively). The 6-MWT distance significantly increased from 213 ± 95 to 327 ± 118 mt (p < 0.001). Overall, the patients exhibited a significant functional improvement following the initiation of sacubitril/valsartan: 27% of the patients improved by two New York Heart Association (NYHA) classes, 52% improved by one NYHA functional class, and 31% remained stable.Conclusion: In patients with HFrEF, the switch from angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker therapy to sacubitril/valsartan resulted in a significant improvement in both depression, anxiety symptoms and functional statuses.
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Affiliation(s)
- Seçkin Dereli
- Deparment of Cardiology, Faculty of Medicine, Ordu University, Ordu, Turkey
| | - Oğuzhan Kılınçel
- Department of Psychiatry, Sakarya Yenikent State Hospital, Sakarya, Turkey
| | - İdris Buğra Çerik
- Deparment of Cardiology, Faculty of Medicine, Ordu University, Ordu, Turkey
| | - Ahmet Kaya
- Deparment of Cardiology, Faculty of Medicine, Ordu University, Ordu, Turkey
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13
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Keogh TM, Howard S, O'Riordan A, Gallagher S. Motivational orientation mediates the association between depression and cardiovascular reactivity to acute psychological stress. Psychophysiology 2020; 58:e13732. [PMID: 33252783 DOI: 10.1111/psyp.13732] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 12/29/2022]
Abstract
Recent theoretical developments in cardiovascular reactivity research suggest the association between depression and blunted reactions to stress is linked to motivational factors. Thus, the present study aimed to test whether the association between depressive symptoms and cardiovascular reactivity to acute stress was mediated by motivation; be it intrinsic or extrinsic motivation. One hundred and eighty-two healthy young adults completed measures of motivation (Global Motivation Scale; GMS), and depression (Hospital Anxiety and Depression Scale; HADS) and had their blood pressure and heart rate monitored throughout a standardised stress testing protocol. Results indicated that depression was negatively associated with both systolic blood pressure (SBP) and heart rate (HR) reactions to the stress task (all ps < .05), such that those who reported higher depressive symptomology displayed a blunted response. Furthermore this relationship was mediated by intrinsic, but not extrinsic motivation; the blunted responses were less pronounced through intrinsic motivation. The present findings add extensively to existing research and confirm that motivation is an underlying mechanism linking depression and cardiovascular reactivity.
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Affiliation(s)
- Tracey M Keogh
- Department of Psychology, Centre for Social Issues Research, Study of Anxiety, Stress and Health Laboratory, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
| | - Siobhán Howard
- Department of Psychology, Centre for Social Issues Research, Study of Anxiety, Stress and Health Laboratory, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
| | - Adam O'Riordan
- Department of Psychology, Centre for Social Issues Research, Study of Anxiety, Stress and Health Laboratory, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
| | - Stephen Gallagher
- Department of Psychology, Centre for Social Issues Research, Study of Anxiety, Stress and Health Laboratory, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
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14
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Walter FA, Gathright E, Redle JD, Gunstad J, Hughes JW. Depressive Symptoms are Associated with Heart Rate Variability Independently of Fitness: A Cross-Sectional Study of Patients with Heart Failure. Ann Behav Med 2020; 53:955-963. [PMID: 30958884 DOI: 10.1093/abm/kaz006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Depression is associated with reduced heart rate variability (HRV) in healthy and cardiac samples, which may be accounted for by physical fitness. In a small sample of cardiac patients, activity and fitness levels attenuated the relationship between HRV and depression. In the current study of heart failure (HF) patients, we hypothesized that depressive symptoms and HRV would be inversely related and physical fitness would attenuate this association. PURPOSE To determine if previous associations among depressive symptoms, physical fitness, and HRV would replicate in a sample of HF patients. METHODS The sample consisted of HF patients (N = 125) aged 68.55 ± 8.92 years, 68.8% male, and 83.2% Caucasian. The study was cross-sectional and a secondary analysis of a nonrandomized clinical trial (Trial Identifier: NCT00871897). Depressive symptoms were evaluated using the Beck Depression Inventory (BDI)-II, fitness with the 2 min step test (2MST), and HRV during a 10 min resting laboratory psychophysiology protocol. The dependent variable in hierarchical linear regressions was the root mean square of successive differences. RESULTS Controlling for sex, age, β-blocker use, hypertension, and diabetes, higher BDI-II scores significantly predicted lower HRV, β = -.29, t(92) = -2.79, p < .01. Adding 2MST did not attenuate the relationship in a follow-up regression. CONCLUSION Depressive symptoms were associated with lower HRV in HF patients, independent of physical fitness. Given the prevalence of depression and suppressed HRV common among HF patients, interventions addressing depressive symptoms and other predictors of poor outcomes may be warranted.
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Affiliation(s)
- Fawn A Walter
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
| | - Emily Gathright
- Department of Psychiatry and Human Behavior, The Miriam Hospital and Alpert School of Medicine at Brown University, Providence, RI, USA
| | - Joseph D Redle
- Summa Health Systems, Cardiovascular Institute, Akron City Hospital, Akron, OH, USA
| | - John Gunstad
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
| | - Joel W Hughes
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
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15
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Association of Depression with Subclinical Coronary Atherosclerosis: a Systematic Review. J Cardiovasc Transl Res 2020; 14:685-705. [PMID: 32198701 DOI: 10.1007/s12265-020-09985-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/02/2020] [Indexed: 01/26/2023]
Abstract
To assess causal association of depression with subclinical coronary atherosclerosis, we performed computer-based and manual search of literature for studies which had assessed relationship of depression disorder with coronary atherosclerosis. All studies had diagnosed depression with validated tools in patients without diagnosed coronary artery disease. The Bradford Hill criteria of cause-effect association was consistently fulfilled by those studies which achieved statistical significance and further showed incremental strength of association with one or more of the following attributes: (1) prospective cohort study, met cause-effect criteria of "temporality"; (2) relatively severe and/or longer period of depression, met cause-effect criteria of "dose-response"; (3) depression with predominantly somatic symptoms cluster, met cause-effect criteria of "scientific plausibility"; (4) multiethnic larger sample, met cause-effect criteria of "population equivalence"; and (5) multicenter study, met criteria of "environmental equivalence." Our results show that there is a significant association of depression with coronary atherosclerosis at its subclinical stages.
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16
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Heart rate variability (HRV): From brain death to resonance breathing at 6 breaths per minute. Clin Neurophysiol 2020; 131:676-693. [DOI: 10.1016/j.clinph.2019.11.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 10/14/2019] [Accepted: 11/06/2019] [Indexed: 12/13/2022]
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17
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Iseger TA, van Bueren NE, Kenemans JL, Gevirtz R, Arns M. A frontal-vagal network theory for Major Depressive Disorder: Implications for optimizing neuromodulation techniques. Brain Stimul 2020; 13:1-9. [DOI: 10.1016/j.brs.2019.10.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/30/2019] [Accepted: 10/08/2019] [Indexed: 12/22/2022] Open
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18
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Jung W, Jang KI, Lee SH. Heart and Brain Interaction of Psychiatric Illness: A Review Focused on Heart Rate Variability, Cognitive Function, and Quantitative Electroencephalography. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2019; 17:459-474. [PMID: 31671483 PMCID: PMC6852682 DOI: 10.9758/cpn.2019.17.4.459] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/30/2018] [Accepted: 12/19/2018] [Indexed: 12/26/2022]
Abstract
Heart rate variability (HRV) reflects beat-to-beat variability in the heart rate due to the dynamic interplay of the sympathetic and parasympathetic nervous systems. HRV is considered an index of the functional status of the autonomic nervous system. A decrease in HRV is thus observed in individuals with autonomic dysfunction. Abnormal HRV has been reported in a range of mental disorders. In this review, we give an overview of HRV in patients with major depressive disorder (MDD), schizophrenia, and posttraumatic stress disorder (PTSD), one of whose core symptoms is cognitive dysfunction. The association between HRV and cognitive function is highlighted in this review. This review consists of three main sections. In the first section, we examine how HRV in patients with MDD, schizophrenia, and PTSD is characterized, and how it is different when compared to that in healthy controls. In the second section, beyond the heart itself, we discuss the intimate connection between the heart and the brain, focusing on how HRV interacts with quantitative electroencephalography (qEEG) in the context of physiological changes in the sleep cycle. Lastly, we finish the review with the examination of the association between HRV and cognitive function. The overall findings indicate that the reduction in HRV is one of main manifestations in MDD, schizophrenia, and PTSD, and also more generally HRV is closely linked to the change in qEEG and also to individual differences in cognitive performance.
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Affiliation(s)
- Wookyoung Jung
- Department of Psychology, Keimyung University, Daegu, Korea
| | - Kuk-In Jang
- 2Department of Biomedicine and Health Sciences, College of Medicine, The Catholic University of Korea, Korea.,Institute of Biomedical Industry, The Catholic University of Korea, Seoul, Korea
| | - Seung-Hwan Lee
- Department of Psychiatry,Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea.,Clinical Emotion and Cognition Research Laboratory, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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19
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Landreani F, Faini A, Martin-Yebra A, Morri M, Parati G, Caiani EG. Assessment of Ultra-Short Heart Variability Indices Derived by Smartphone Accelerometers for Stress Detection. SENSORS 2019; 19:s19173729. [PMID: 31466391 PMCID: PMC6749599 DOI: 10.3390/s19173729] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/12/2019] [Accepted: 08/23/2019] [Indexed: 12/18/2022]
Abstract
Body acceleration due to heartbeat-induced reaction forces can be measured as mobile phone accelerometer (m-ACC) signals. Our aim was to test the feasibility of using m-ACC to detect changes induced by stress by ultra-short heart rate variability (USV) indices (standard deviation of normal-to-normal interval—SDNN and root mean square of successive differences—RMSSD). Sixteen healthy volunteers were recruited; m-ACC was recorded while in supine position, during spontaneous breathing at rest conditions (REST) and during one minute of mental stress (MS) induced by arithmetic serial subtraction task, simultaneous with conventional electrocardiogram (ECG). Beat occurrences were extracted from both ECG and m-ACC and used to compute USV indices using 60, 30 and 10 s durations, both for REST and MS. A feasibility of 93.8% in the beat-to-beat m-ACC heart rate series extraction was reached. In both ECG and m-ACC series, compared to REST, in MS the mean beat duration was reduced by 15% and RMSSD decreased by 38%. These results show that short term recordings (up to 10 s) of cardiac activity using smartphone’s accelerometers are able to capture the decrease in parasympathetic tone, in agreement with the induced stimulus.
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Affiliation(s)
- Federica Landreani
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milan, Italy
| | - Andrea Faini
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular Neural and Metabolic Sciences, S. Luca Hospital, 20149 Milan, Italy
| | - Alba Martin-Yebra
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milan, Italy
- Department of Biomedical Engineering, Lund University, 22100 Lund, Sweden
| | - Mattia Morri
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milan, Italy
| | - Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular Neural and Metabolic Sciences, S. Luca Hospital, 20149 Milan, Italy
- Department of Medicine and Surgery, Università di Milano-Bicocca, 20126 Milan, Italy
| | - Enrico Gianluca Caiani
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milan, Italy.
- Consiglio Nazionale delle Ricerche, Istituto di Elettronica e di Ingegneria dell'Informazione e delle Telecomunicazioni, 20133 Milan, Italy.
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20
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Abstract
LEARNING OBJECTIVES After participating in this activity, learners should be better able to:• Identify the relationships between depression, anxiety, and heart failure (HF).• Assess methods for accurately diagnosing depression and anxiety disorders in patients with HF.• Evaluate current evidence for treatment of anxiety and depression in patients with HF. BACKGROUND In patients with heart failure (HF), depression and anxiety disorders are common and associated with adverse outcomes such as reduced adherence to treatment, poor function, increased hospitalizations, and elevated mortality. Despite the adverse impact of these disorders, anxiety and depression remain underdiagnosed and undertreated in HF patients. METHODS We performed a targeted literature review to (1) identify associations between depression, anxiety, and HF, (2) examine mechanisms mediating relationships between these conditions and medical outcomes, (3) identify methods for accurately diagnosing depression and anxiety disorders in HF, and (4) review current evidence for treatments of these conditions in this population. RESULTS Both depression and anxiety disorders are associated with the development and progression of HF, including increased rates of mortality, likely mediated through both physiologic and behavioral mechanisms. Given the overlap between cardiac and psychiatric symptoms, accurately diagnosing depression or anxiety disorders in HF patients can be challenging. Adherence to formal diagnostic criteria and utilization of a clinical interview are the best courses of action in the evaluation process. There is limited evidence for the efficacy of pharmacologic and psychotherapy in patients with HF. However, cognitive-behavioral therapy has been shown to improve mental health outcomes in patients with HF, and selective serotonin reuptake inhibitors appear safe in this cohort. CONCLUSIONS Depression and anxiety disorders in HF patients are common, underrecognized, and linked to adverse outcomes. Further research to improve detection and develop effective treatments for these disorders in HF patients is badly needed.
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Affiliation(s)
- Christopher M. Celano
- Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Ana C. Villegas
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | | | - Hanna K. Gaggin
- Harvard Medical School, Boston, MA
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Jeff C. Huffman
- Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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21
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Vloet TD, Jans T, Frey A, Häußler M, Vloet A, Geissler J, Susewind M, von Dobschütz B, Frantz S, Romanos M. Mean Heart Rate and Parameters of Heart Rate Variability in Depressive Children and the Effects of Antidepressant Medication. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2019; 47:253-260. [PMID: 30971175 DOI: 10.1024/1422-4917/a000672] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction: Researchers have repeatedly discovered an association between depression and autonomic cardiac dysregulation in adults. However, corresponding data concerning minors are still rare. Method: For this exploratory, cross-sectional study, we included N = 43 minors (age range 9-17 years). The subjects were depressive subjects with or without antidepressant medication (N = 23) or healthy control children (HC) (N = 20). We assessed several indices of cardiac functioning using long-term electrocardiogram data (mean heart rate, HR, and several parameters of heart rate variability, HRV). We hypothesized that increased HR and reduced HRV are associated with depressive disorders. Furthermore, we assessed the impact of age, sex, and antidepressant medication on HR and HRV. Results: When sex and age were controlled for, HR was significantly increased in depressive minors compared to HC. However, our preliminary data suggest that this might not be the case in medicated patients, and there were no differences between groups regarding HRV parameters. There was no significant correlation in the whole sample between severity of depression and both HR and HRV. In the subsample of patients with depression, antidepressant medication was associated with lower HR and higher indices of HRV. Conclusion: The data indicate an association between depression and altered autonomic cardiac regulation, which can already manifests in minors.
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Affiliation(s)
- Timo D Vloet
- 1 Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Würzburg, Würzburg, Germany.,a First authors
| | - Thomas Jans
- 1 Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Würzburg, Würzburg, Germany.,a First authors
| | - Anna Frey
- 2 Department of Internal Medicine I, University Hospital, Würzburg, Germany
| | - Marie Häußler
- 1 Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Würzburg, Würzburg, Germany
| | - Andrea Vloet
- 1 Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Würzburg, Würzburg, Germany
| | - Julia Geissler
- 1 Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Würzburg, Würzburg, Germany
| | - Moritz Susewind
- 1 Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Würzburg, Würzburg, Germany
| | | | - Stefan Frantz
- 2 Department of Internal Medicine I, University Hospital, Würzburg, Germany
| | - Marcel Romanos
- 1 Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital Würzburg, Würzburg, Germany
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22
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Associations between symptoms of depression and heart rate variability: An exploratory study. Psychiatry Res 2018; 262:482-487. [PMID: 28958456 DOI: 10.1016/j.psychres.2017.09.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 06/27/2017] [Accepted: 09/11/2017] [Indexed: 12/11/2022]
Abstract
Major depressive disorder (MDD) is associated with decreased heart rate variability (HRV), a predictor of cardiovascular morbidity by many, but not all studies. This inconsistency could be due to the association of HRV with specific depressive symptoms. Here, we investigated the association of HRV parameters with components of depressive symptoms from 120 MDD patients, at baseline of a published trial comparing the effect of sertraline to transcranial direct current stimulation. We used Principal Component Analysis to extract components of the Hamilton Rating Scale for Depression (HAM-D-17), the Montgomery Asberg Depression Rating Scale (MADRS) and the Beck Inventory for Depressive Symptomatology (BDI). We constructed one equation of multiple linear regression for each HRV parameter as the dependent variable, and the components of depressive symptoms of the three scales as the independent ones, adjusted for age and gender. A component of HAM-D-17 predicted LF/HF (low frequency/high frequency) and a component of MADRS predicted LF (low frequency). "Guilt" and "loss of interest/pleasure in activities" were present in the components of both scales, and the MADRS component also included "psychomotor retardation". These results suggest that melancholic features might be relevant for the association between MDD and HRV. Considering multiple comparisons, these results are preliminary.
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23
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Measuring physiological responses to the arts in people with a dementia. Int J Psychophysiol 2017; 123:64-73. [PMID: 29158118 DOI: 10.1016/j.ijpsycho.2017.11.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/24/2017] [Accepted: 11/10/2017] [Indexed: 01/29/2023]
Abstract
The dementias are a group of progressive symptoms that have multiple causes, usually caused by disease or injury of the brain, affecting higher brain functions such as language, perception, memory, reasoning and mood; they can also be associated with changes in personality. Arts interventions and interaction with the arts can create meaningful, positive experiences for people with a dementia, as well as improve quality of life. Qualitative research in particular, has been able to describe the emotional responses the arts can produce, but quantifiable changes have not been well documented. Physiological measurements such as stress hormone levels and galvanic skin response show promise in being able to quantify such responses. When taken together, these can give a picture of the kinds of physiological outcomes that are associated with positive affect and improvements in mental wellbeing in the context of arts interventions. This review provides a critical overview of the studies which measure some form of physiological outcome in response to the arts or an arts intervention in people with dementia, and indicates how future research in this area can help to broaden our understanding of the effects of the arts in dementia research and care.
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24
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Schwartz JA, Portnoy J. Lower catecholamine activity is associated with greater levels of anger in adults. Int J Psychophysiol 2017; 120:33-41. [DOI: 10.1016/j.ijpsycho.2017.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/16/2017] [Accepted: 07/10/2017] [Indexed: 10/19/2022]
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25
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Stapelberg NJC, Neumann DL, Shum DHK, McConnell H, Hamilton-Craig I. The sensitivity of 38 heart rate variability measures to the addition of artifact in human and artificial 24-hr cardiac recordings. Ann Noninvasive Electrocardiol 2017; 23. [PMID: 28670841 DOI: 10.1111/anec.12483] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 05/27/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Artifact is common in cardiac RR interval data derived from 24-hr recordings and has a significant impact on heart rate variability (HRV) measures. However, the relative impact of progressively added artifact on a large group of commonly used HRV measures has not been assessed. This study compared the relative sensitivity of 38 commonly used HRV measures to artifact to determine which measures show the most change with increasing increments of artifact. A secondary aim was to ascertain whether short-term and long-term HRV measures, as groups, share similarities in their sensitivity to artifact. METHODS Up to 10% of artifact was added to 20 artificial RR (ARR) files and 20 human cardiac recordings, which had been assessed for artifact by a cardiac technician. The added artifact simulated deletion of RR intervals and insertion of individual short RR intervals. Thirty-eight HRV measures were calculated for each file. Regression analysis was used to rank the HRV measures according to their sensitivity to artifact as determined by the magnitude of slope. RESULTS RMSSD, SDANN, SDNN, RR triangular index and TINN, normalized power and relative power linear measures, and most nonlinear methods examined are most robust to artifact. CONCLUSION Short-term time domain HRV measures are more sensitive to added artifact than long-term measures. Absolute power frequency domain measures across all frequency bands are more sensitive than normalized and relative frequency domain measures. Most nonlinear HRV measures assessed were relatively robust to added artifact, with Poincare plot SD1 being most sensitive.
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Affiliation(s)
- Nicolas J C Stapelberg
- Bond University Faculty of Health Sciences and Medicine, Gold Coast, QLD, Australia.,Gold Coast Hospital and Health Service, Gold Coast, QLD, Australia
| | - David L Neumann
- School of Applied Psychology and Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - David H K Shum
- School of Applied Psychology and Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Harry McConnell
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
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Effects of Forest Therapy on Depressive Symptoms among Adults: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14030321. [PMID: 28335541 PMCID: PMC5369157 DOI: 10.3390/ijerph14030321] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 11/16/2022]
Abstract
This study systematically reviewed forest therapy programs designed to decrease the level of depression among adults and assessed the methodological rigor and scientific evidence quality of existing research studies to guide future studies. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The authors independently screened full-text articles from various databases using the following criteria: (1) intervention studies assessing the effects of forest therapy on depressive symptoms in adults aged 18 years and older; (2) studies including at least one control group or condition; (3) peer-reviewed studies; and (4) been published either in English or Korean before July 2016. The Scottish Intercollegiate Guideline Network measurement tool was used to assess the risk of bias in each trial. In the final sample, 28 articles (English: 13, Korean: 15) were included in the systematic review. We concluded that forest therapy is an emerging and effective intervention for decreasing adults’ depression levels. However, the included studies lacked methodological rigor. Future studies assessing the long-term effect of forest therapy on depression using rigorous study designs are needed.
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Brinks J, Fowler A, Franklin BA, Dulai J. Lifestyle Modification in Secondary Prevention: Beyond Pharmacotherapy. Am J Lifestyle Med 2017; 11:137-152. [PMID: 30202327 PMCID: PMC6125029 DOI: 10.1177/1559827616651402] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/19/2016] [Accepted: 05/04/2016] [Indexed: 12/17/2022] Open
Abstract
Despite significant advances in medical technology and pharmacology, cardiovascular disease (CVD) remains a major contributor to health care expenses and the leading cause of death in the United States. Patients with established CVD and their health care providers are challenged with achieving cardiovascular risk reduction to decrease the likelihood of recurrent cardiovascular events. This "secondary prevention" can be achieved, in part, through adherence to prescribed pharmacotherapies that favorably modify major coronary risk factors (ie, hypertension, hypercholesterolemia, diabetes, and obesity). However, lifestyle modification can also be helpful in this regard, providing independent and additive benefits to the associated reductions in cardiovascular morbidity and mortality. Accordingly, physicians and other health care providers should routinely counsel their coronary patients to engage in structured exercise and increased lifestyle physical activity, consume a heart-healthy diet, quit smoking and avoid secondhand smoke, and purposefully address psychosocial stressors that may elevate cardiovascular risk. These lifestyle interventions, either as an adjunct to medication therapy or independently in those patients where medications may be poorly tolerated, cost prohibitive, or ineffective, can significantly decrease cardiovascular mortality and the risk of recurrent cardiac events.
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Affiliation(s)
- Jenna Brinks
- Jenna Brinks, MS, Manager, Preventive Cardiology and Cardiac Rehabilitation, William Beaumont Hospital, Beaumont Health Center, Cardiac Rehabilitation, 4949 Coolidge Highway, Royal Oak, MI 48073, USA; e-mail:
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Princip M, Scholz M, Meister-Langraf RE, Barth J, Schnyder U, Znoj H, Schmid JP, Thayer JF, von Känel R. Can Illness Perceptions Predict Lower Heart Rate Variability following Acute Myocardial Infarction? Front Psychol 2016; 7:1801. [PMID: 27917140 PMCID: PMC5114266 DOI: 10.3389/fpsyg.2016.01801] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 11/01/2016] [Indexed: 12/19/2022] Open
Abstract
Objective: Decreased heart rate variability (HRV) has been reported to be a predictor of mortality after myocardial infarction (MI). Patients' beliefs and perceptions concerning their illness may play a role in decreased HRV. This study investigated if illness perceptions predict HRV at 3 months following acute MI. Methods: 130 patients referred to a tertiary cardiology center, were examined within 48 h and 3 months following acute MI. At admission, patients' cognitive representations of their MI were assessed using the German version of the self-rated Brief Illness Perception Questionnaire (Brief IPQ). At admission and after 3 months (follow-up), frequency and time domain measures of HRV were obtained from 5-min electrocardiogram (ECG) recordings during stable supine resting. Results: Linear hierarchical regression showed that the Brief IPQ dimensions timeline (β coefficient = 0.29; p = 0.044), personal control (β = 0.47; p = 0.008) and illness understanding (β = 0.43; p = 0.014) were significant predictors of HRV, adjusted for age, gender, baseline HRV, diabetes, beta-blockers, left ventricular ejection fraction (LVEF), attendance of cardiac rehabilitation, and depressive symptoms. Conclusions: As patients' negative perceptions of their illness are associated with lower HRV following acute MI, a brief illness perception questionnaire may help to identify patients who might benefit from a specific illness perceptions intervention.
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Affiliation(s)
- Mary Princip
- Department of Neurology, Inselspital, Bern University Hospital, and University of BernBern, Switzerland; Psychosomatic Research Group, Department of Clinical Research, University of BernBern, Switzerland; Department of Cardiology, Inselspital, Bern University HospitalBern, Switzerland
| | - Marco Scholz
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern Bern, Switzerland
| | - Rebecca E Meister-Langraf
- Department of Neurology, Inselspital, Bern University Hospital, and University of BernBern, Switzerland; Psychosomatic Research Group, Department of Clinical Research, University of BernBern, Switzerland; Clienia Schlössli AG, Private Psychiatric and Psychotherapy ClinicOetwil am See, Switzerland
| | - Jürgen Barth
- Institute for Complementary and Integrative Medicine, University Hospital Zurich Zurich, Switzerland
| | - Ulrich Schnyder
- Department of Psychiatry and Psychotherapy, University Hospital Zurich, University of Zurich Switzerland
| | - Hansjörg Znoj
- Division of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Bern Bern, Switzerland
| | - Jean-Paul Schmid
- Cardiology Clinic, Tiefenauspital, Bern University Hospital Bern, Switzerland
| | - Julian F Thayer
- Department of Psychology, Ohio State University Columbus Columbus, OH, USA
| | - Roland von Känel
- Department of Neurology, Inselspital, Bern University Hospital, and University of BernBern, Switzerland; Psychosomatic Research Group, Department of Clinical Research, University of BernBern, Switzerland; Department of Psychosomatic Medicine, Clinic BarmelweidBarmelweid, Switzerland
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Thome J, Densmore M, Frewen PA, McKinnon MC, Théberge J, Nicholson AA, Koenig J, Thayer JF, Lanius RA. Desynchronization of autonomic response and central autonomic network connectivity in posttraumatic stress disorder. Hum Brain Mapp 2016; 38:27-40. [PMID: 27647521 DOI: 10.1002/hbm.23340] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 05/26/2016] [Accepted: 07/25/2016] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Although dysfunctional emotion regulatory capacities are increasingly recognized as contributing to posttraumatic stress disorder (PTSD), little work has sought to identify biological markers of this vulnerability. Heart rate variability (HRV) is a promising biomarker that, together with neuroimaging, may assist in gaining a deeper understanding of emotion dysregulation in PTSD. The objective of the present study was, therefore, to characterize autonomic response patterns, and their related neuronal patterns in individuals with PTSD at rest. METHODS PTSD patients (N = 57) and healthy controls (N = 41) underwent resting-state fMRI. Connectivity patterns of key regions within the central autonomic network (CAN)-including the ventromedial prefrontal cortex (vmPFC), amygdala, and periaqueductal gray (PAG)-were examined using a seed-based approach. Observed connectivity patterns were then correlated to resting HRV. RESULTS In contrast to controls, individuals with PTSD exhibited lower HRV. In addition, whereas controls engaged a localized connectivity pattern of CAN-related brain regions, in PTSD, key CAN regions were associated with widespread connectivity patterns in regions related to emotional reactivity (vmPFC and amygdala to insular cortex and lentiform nucleus; PAG to insula) and motor readiness (vmPFC and amygdala to precentral gyrus; PAG to precentral gyrus and cerebellum). Critically, whereas CAN connectivity in controls was strongly related to higher HRV (insula, mPFC, superior frontal cortex, thalamus), HRV covariation was absent in PTSD subjects. CONCLUSIONS This study provides the first evidence for a specific psychophysiological-neuronal profile in PTSD individuals characterized by lower resting HRV and a lack of HRV covariation with CAN-related brain connectivity. Hum Brain Mapp 38:27-40, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Janine Thome
- Medical Faculty Mannheim, Institute of Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health, University of Heidelberg, Germany
| | - Maria Densmore
- Department of Psychiatry, University of Western Ontario, London, Ontario, Canada
| | - Paul A Frewen
- Department of Psychiatry, University of Western Ontario, London, Ontario, Canada.,Department of Psychology, University of Western Ontario, London, Ontario, Canada.,Department of Neuroscience, University of Western Ontario, London, Ontario, Canada
| | - Margaret C McKinnon
- Department of Psychiatry and Behavioral Neurosciences, Mc Master University, Hamilton, Ontario, Canada
| | - Jean Théberge
- Department of Psychiatry, University of Western Ontario, London, Ontario, Canada.,Department of Medical Imaging, Lawson Health Research Institute, London, Ontario, Canada
| | - Andrew A Nicholson
- Department of Neuroscience, University of Western Ontario, London, Ontario, Canada
| | - Julian Koenig
- Department of Psychology, Ohio State University, Columbus, Ohio.,Section for Translational Psychobiology in Child and Adolescent Psychiatry, Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany
| | - Julian F Thayer
- Department of Psychology, Ohio State University, Columbus, Ohio
| | - Ruth A Lanius
- Department of Psychiatry, University of Western Ontario, London, Ontario, Canada.,Department of Neuroscience, University of Western Ontario, London, Ontario, Canada
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Catipović-Veselica K, Galić A, Jelić K, Baraban-Glavas V, Sarić S, Prlić N, Catipović B. Relation between Major and Minor Depression and Heart Rate, Heart-Rate Variability, and Clinical Characteristics of Patients with Acute Coronary Syndrome. Psychol Rep 2016; 100:1245-54. [PMID: 17886512 DOI: 10.2466/pr0.100.4.1245-1254] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study examined the prevalence of major and minor depression in patients with acute coronary syndrome and their relation with heart rate and heart-rate variability, and clinical characteristics. The study group included 297 patients, 200 men and 97 women, between ages of 21 and 70 years ( M age = 57.5 ± 9.6), who were admitted to a coronary care unit with acute coronary syndrome and survived to discharge from the hospital. Major and minor depression were diagnosed using DSM-IV. There were 44.1% patients with acute coronary syndrome without depression, 29.3% with minor depression, and 26.6% with major depression. The prevalence of minor and major depression was more elevated in patients with non-ST-segment elevation myocardial infarction and unstable angina than in patients with ST-segment elevation myocardial infarction. Ventricular fibrillation and atrial fibrillation were more common in patients with major and minor depression than in patients without depression. The 24-hr. duration of heart-beat intervals and heart-rate variability were significantly lower in patients with major and minor depression than in patients without depression. This study implies that clinical depression was significantly comorbid with the acute coronary syndrome and was related to hypertension, diabetes mellitus, age, sex, type of acute coronary syndrome, left ventricular failure, higher heart rate, and lower heart-rate variability.
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Affiliation(s)
- Katija Catipović-Veselica
- Department of Medicine, Medical Faculty, University of J J Strossmayer Osijek, University Hospital Osijek, Croatia.
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Autonomic dysfunction: a link between depression and cardiovascular mortality? The FINE Study. ACTA ACUST UNITED AC 2016; 14:796-802. [DOI: 10.1097/hjr.0b013e32829c7d0c] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Great advances have been made in our understanding of Takotsubo syndrome in the past decade, but the aetiology of the condition remains incompletely understood. The most established theory, that catecholamine-mediated myocardial stunning is provoked by emotional or physiological stress, is supported by the presence of supraphysiological levels of plasma catecholamines in patients with Takotsubo syndrome. For this reason, the hyperexcitability of the autonomic nervous system under conditions of physical and emotional stress is often assessed in these patients. Observational studies have indicated that a predisposing influence of chronic or traumatic stress, anxiodepressive disorders, and maladaptive personality traits are linked to the pathogenesis of Takotsubo syndrome. Chronic stress can influence autonomic function through dysregulation of the hypothalamic-pituitary-adrenal axis and contribute to the development of cardiovascular disorders. In this Perspectives article, we discuss the current knowledge of the psychoneuroendocrinological and psychosocial mechanisms underlying the pathophysiology of Takotsubo syndrome.
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Linking Daily Stress Processes and Laboratory-Based Heart Rate Variability in a National Sample of Midlife and Older Adults. Psychosom Med 2016; 78:573-82. [PMID: 26867082 PMCID: PMC4891238 DOI: 10.1097/psy.0000000000000306] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This study evaluates the associations between people's trait-like patterns of stress in daily life (stressor frequency, perceived stressor severity, affective reactivity to stressors, and negative affect) and laboratory-assessed heart rate variability (HRV). METHODS Data were collected from 909 participants aged 35 to 85 years in the Midlife in the United States Study. Participants reported negative affect and minor stressful events during telephone interviews on 8 consecutive evenings. On a separate occasion, HRV was measured from electrocardiograph recordings taken at rest during a laboratory-based psychophysiology protocol. Regression models were used to evaluate the associations between daily stress processes and three log-transformed HRV indices: standard deviation of R-R intervals (SDRR), root mean square of successive differences (RMSSD), and high-frequency power (high-frequency HRV [HF-HRV]). Analyses were adjusted for demographics, body mass index, comorbid conditions, medications, physical activity, and smoking. RESULTS Stressor frequency was unrelated to HRV (r values ranging from -0.04 to -0.01, p values >.20). However, people with greater perceived stressor severity had lower resting SDRR (fully adjusted B [standard error {SE}] = -0.05 [0.02]), RMSSD (-0.08 [0.03]), and HF-HRV (-0.16 [0.07]). Individuals with more pronounced affective reactivity to stressors also had lower levels of all three HRV indices (SDRR: B [SE] = -0.28 [0.14]; RMSSD: -0.44 [0.19]; HF-HRV: -0.96 [0.37]). Furthermore, aggregated daily negative affect was linked to reduced RMSSD (B [SE] = -0.16 [0.08]) and HF-HRV (-0.35 [0.15]). CONCLUSIONS In a national sample, individual differences in daily negative affect and responses to daily stressors were more strongly related to cardiovascular autonomic regulation than the frequency of such stressors.
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Ryu E, Chamberlain AM, Pendegraft RS, Petterson TM, Bobo WV, Pathak J. Quantifying the impact of chronic conditions on a diagnosis of major depressive disorder in adults: a cohort study using linked electronic medical records. BMC Psychiatry 2016; 16:114. [PMID: 27112538 PMCID: PMC4845377 DOI: 10.1186/s12888-016-0821-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 04/18/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Major depressive disorder (MDD) is often comorbid with other chronic mental and physical health conditions. Although the literature widely acknowledges the association of many chronic conditions with the risk of MDD, the relative importance of these conditions on MDD risk in the presence of other conditions is not well investigated. In this study, we aimed to quantify the relative contribution of selected chronic conditions to identify the conditions most influential to MDD risk in adults and identify differences by age. METHODS This study used electronic health record (EHR) data on patients empanelled with primary care at Mayo Clinic in June 2013. A validated EHR-based algorithm was applied to identify newly diagnosed MDD patients between 2000 and 2013. Non-MDD controls were matched 1:1 to MDD cases on birth year (±2 years), sex, and outpatient clinic visits in the same year of MDD case diagnosis. Twenty-four chronic conditions defined by Chronic Conditions Data Warehouse were ascertained in both cases and controls using diagnosis codes within 5 years of index dates (diagnosis dates for cases, and the first clinic visit dates for matched controls). For each age group (45 years or younger, between 46 and 60, and over 60 years), conditional logistic regression models were used to test the association between each condition and subsequent MDD risk, adjusting for educational attainment and obesity. The relative influence of these conditions on the risk of MDD was quantified using gradient boosting machine models. RESULTS A total of 11,375 incident MDD cases were identified between 2000 and 2013. Most chronic conditions (except for eye conditions) were associated with risk of MDD, with different association patterns observed depending on age. Among 24 chronic conditions, the greatest relative contribution was observed for diabetes mellitus for subjects aged ≤ 60 years and rheumatoid arthritis/osteoarthritis for those over 60 years. CONCLUSIONS Our results suggest that specific chronic conditions such as diabetes mellitus and rheumatoid arthritis/osteoarthritis may have greater influence than others on the risk of MDD.
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Affiliation(s)
- Euijung Ryu
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN USA
| | | | | | | | - William V. Bobo
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN USA
| | - Jyotishman Pathak
- Division of Health Informatics, Department of Healthcare Policy & Research, Weill Cornell Medicine, Cornell University, New York, NY, USA.
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Chang SS, Bjørngaard JH, Tsai MK, Bjerkeset O, Wen CP, Yip PSF, Tsao CK, Gunnell D. Heart rate and suicide: findings from two cohorts of 533 000 Taiwanese and 75 000 Norwegian adults. Acta Psychiatr Scand 2016; 133:277-88. [PMID: 26493376 DOI: 10.1111/acps.12513] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To investigate the association of resting heart rate with suicide in two large cohorts. METHOD The MJ cohort (Taiwan) included 532 932 adults from a health check-up programme (1994-2008). The HUNT cohort (Norway) included 74 977 adults in the Nord-Trøndelag County study (1984-1986), followed up to 2004. In both cohorts heart rate was measured at baseline, and suicide was ascertained through linkage to cause-of-death registers. Risk of suicide was estimated using Cox proportional hazards models. RESULTS There were 569 and 188 suicides (average follow-up period of 8.1 and 16.9 years) in the MJ and HUNT cohorts respectively. Sex- and age-adjusted hazard ratio for every 10 beat increase in heart rate per minute was 1.08 (95% Confidence Interval 1.00-1.16) and 1.24 (1.12-1.38) in the MJ and HUNT cohorts, respectively. In the MJ cohort this association was confined to individuals with a history of heart diseases vs. those without such a history (P for interaction = 0.008). In the HUNT cohort the association did not differ by history of heart diseases and was robust to adjustment for health-related life style, medication use, and symptoms of anxiety and depression. CONCLUSION Elevated resting heart rate may be a marker of increased suicide risk.
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Affiliation(s)
- S-S Chang
- Institute of Health Behaviors and Community Sciences, and Department of Public Health, College of Public Health, National Taiwan University, Taipei, Taiwan.,Hong Kong Jockey Club Centre for Suicide Research and Prevention, The University of Hong Kong, Hong Kong SAR, China.,Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong SAR, China
| | - J H Bjørngaard
- Department of Public Health, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Forensic Department and Research Centre, Bröset St. Olav's University Hospital Trondheim, Trondheim, Norway
| | - M K Tsai
- China Medical University Hospital, Taichung, Taiwan.,Institute of Population Health Science, National Health Research Institutes, Miaoli, Taiwan
| | - O Bjerkeset
- Faculty of Health Sciences, Nord-Trøndelag University College (HiNT), Levanger, Norway.,Institute of Neuromedicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - C P Wen
- China Medical University Hospital, Taichung, Taiwan.,Institute of Population Health Science, National Health Research Institutes, Miaoli, Taiwan
| | - P S F Yip
- Hong Kong Jockey Club Centre for Suicide Research and Prevention, The University of Hong Kong, Hong Kong SAR, China.,Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong SAR, China
| | - C K Tsao
- MJ Health Management Institution, Taipei, Taiwan
| | - D Gunnell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Horsley KJ, Rouleau CR, Garland SN, Samuels C, Aggarwal SG, Stone JA, Arena R, Campbell TS. Insomnia symptoms and heart rate recovery among patients in cardiac rehabilitation. J Behav Med 2016; 39:642-51. [PMID: 26944765 DOI: 10.1007/s10865-016-9725-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/04/2016] [Indexed: 01/26/2023]
Abstract
Insomnia symptoms (i.e., difficulty falling asleep, difficulty staying asleep, and early morning awakenings) are common among people with cardiovascular disease, and have been linked to adverse cardiovascular health outcomes. Reduced parasympathetic tone is one pathway through which risk may be conferred. The purpose of this study was to evaluate whether insomnia symptoms are associated with lower parasympathetic tone in cardiac rehabilitation patients with suspected insomnia. Participants (N = 121) completed a self-report measure of insomnia severity. 1-min heart rate recovery (HRR), an index of parasympathetic tone, was obtained during a maximal exercise test. Difficulty falling asleep, but not difficulty staying asleep or early awakenings, was associated with attenuated 1-min HRR. When analyses were restricted to participants with moderate and severe insomnia severity (n = 51), the strength of this association increased. In a sample of cardiac rehabilitation patients with insomnia, only the symptom of difficulty falling asleep was associated with lower parasympathetic tone, suggesting that individual insomnia symptoms may show specificity in their associations with physiological mechanisms.
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Affiliation(s)
| | - Codie R Rouleau
- Department of Psychology, University of Calgary, Calgary, AB, Canada
| | - Sheila N Garland
- Department of Psychology, Memorial University, St. John's, NL, Canada
| | - Charles Samuels
- Department of Family Medicine, University of Calgary, Calgary, AB, Canada
| | - Sandeep G Aggarwal
- TotalCardiology™ Rehabilitation, Calgary, AB, Canada.,Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - James A Stone
- TotalCardiology™ Rehabilitation, Calgary, AB, Canada.,Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Tavis S Campbell
- Department of Psychology, University of Calgary, Calgary, AB, Canada.
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Lee MS, Kim YH, Park WS, Park OK, Kwon SH, Hong KS, Rhim H, Shim I, Morita K, Wong DL, Patel PD, Lyons DM, Schatzberg AF, Her S. Temporal variability of glucocorticoid receptor activity is functionally important for the therapeutic action of fluoxetine in the hippocampus. Mol Psychiatry 2016; 21:252-60. [PMID: 25330740 PMCID: PMC5189925 DOI: 10.1038/mp.2014.137] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/11/2014] [Accepted: 09/04/2014] [Indexed: 12/19/2022]
Abstract
Previous studies have shown inconsistent results regarding the actions of antidepressants on glucocorticoid receptor (GR) signalling. To resolve these inconsistencies, we used a lentiviral-based reporter system to directly monitor rat hippocampal GR activity during stress adaptation. Temporal GR activation was induced significantly by acute stress, as demonstrated by an increase in the intra-individual variability of the acute stress group compared with the variability of the non-stress group. However, the increased intra-individual variability was dampened by exposure to chronic stress, which was partly restored by fluoxetine treatment without affecting glucocorticoid secretion. Immobility in the forced-swim test was negatively correlated with the intra-individual variability, but was not correlated with the quantitative GR activity during fluoxetine therapy; this highlights the temporal variability in the neurobiological links between GR signalling and the therapeutic action of fluoxetine. Furthermore, we demonstrated sequential phosphorylation between GR (S224) and (S232) following fluoxetine treatment, showing a molecular basis for hormone-independent nuclear translocation and transcriptional enhancement. Collectively, these results suggest a neurobiological mechanism by which fluoxetine treatment confers resilience to the chronic stress-mediated attenuation of hypothalamic-pituitary-adrenal axis activity.
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Affiliation(s)
- M-S Lee
- Bio-Imaging Centre, Korea Basic Science Institute, Chuncheon, South Korea
| | - Y-H Kim
- Bio-Imaging Centre, Korea Basic Science Institute, Chuncheon, South Korea
| | - W-S Park
- Bio-Imaging Centre, Korea Basic Science Institute, Chuncheon, South Korea
| | - O-K Park
- Bio-Imaging Centre, Korea Basic Science Institute, Chuncheon, South Korea
| | - S-H Kwon
- Bio-Imaging Centre, Korea Basic Science Institute, Chuncheon, South Korea
| | - K S Hong
- Division of MR Research, Korea Basic Science Institute, Cheongwon, South Korea
| | - H Rhim
- Neuroscience Centre, Korea Institute of Science and Technology, Seoul, South Korea
| | - I Shim
- Acupuncture and Meridian Science Research Centre, Kyung Hee University, Seoul, South Korea
| | - K Morita
- Department of Nursing, Shikoku University, School of Health Sciences, Tokushima, Japan
| | - D L Wong
- Department of Psychiatry, Harvard Medical School and Laboratory of Molecular and Developmental Neurobiology, McLean Hospital, Belmont, MA, USA
| | - P D Patel
- Department of Psychiatry, Molecular and Behavioral Neuroscience Institute, University of Michigan Medical Centre, Ann Arbor, MI, USA
| | - D M Lyons
- Departments of Psychiatry, Stanford University Medical Centre, Stanford, CA, USA
| | - A F Schatzberg
- Departments of Psychiatry, Stanford University Medical Centre, Stanford, CA, USA
| | - S Her
- Bio-Imaging Centre, Korea Basic Science Institute, Chuncheon, South Korea,Bio-Imaging Centre, Korea Basic Science Institute, 192-1 Hyoja 2-Dong, Chuncheon, Gangwon-Do 200-701, South Korea. E-mail:
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Sun G, Shinba T, Kirimoto T, Matsui T. An Objective Screening Method for Major Depressive Disorder Using Logistic Regression Analysis of Heart Rate Variability Data Obtained in a Mental Task Paradigm. Front Psychiatry 2016; 7:180. [PMID: 27867364 PMCID: PMC5095117 DOI: 10.3389/fpsyt.2016.00180] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 10/20/2016] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Heart rate variability (HRV) has been intensively studied as a promising biological marker of major depressive disorder (MDD). Our previous study confirmed that autonomic activity and reactivity in depression revealed by HRV during rest and mental task (MT) conditions can be used as diagnostic measures and in clinical evaluation. In this study, logistic regression analysis (LRA) was utilized for the classification and prediction of MDD based on HRV data obtained in an MT paradigm. METHODS Power spectral analysis of HRV on R-R intervals before, during, and after an MT (random number generation) was performed in 44 drug-naïve patients with MDD and 47 healthy control subjects at Department of Psychiatry in Shizuoka Saiseikai General Hospital. Logit scores of LRA determined by HRV indices and heart rates discriminated patients with MDD from healthy subjects. The high frequency (HF) component of HRV and the ratio of the low frequency (LF) component to the HF component (LF/HF) correspond to parasympathetic and sympathovagal balance, respectively. RESULTS The LRA achieved a sensitivity and specificity of 80.0 and 79.0%, respectively, at an optimum cutoff logit score (0.28). Misclassifications occurred only when the logit score was close to the cutoff score. Logit scores also correlated significantly with subjective self-rating depression scale scores (p < 0.05). CONCLUSION HRV indices recorded during a MT may be an objective tool for screening patients with MDD in psychiatric practice. The proposed method appears promising for not only objective and rapid MDD screening but also evaluation of its severity.
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Affiliation(s)
- Guanghao Sun
- Graduate School of Informatics and Engineering, The University of Electro-Communications , Tokyo , Japan
| | - Toshikazu Shinba
- Department of Psychiatry, Shizuoka Saiseikai General Hospital , Shizuoka , Japan
| | - Tetsuo Kirimoto
- Graduate School of Informatics and Engineering, The University of Electro-Communications , Tokyo , Japan
| | - Takemi Matsui
- Graduate School of System Design, Tokyo Metropolitan University , Tokyo , Japan
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Yang AC, Yang CH, Hong CJ, Tsai SJ, Kuo CH, Peng CK, Mietus JE, Goldberger AL, Thomas RJ. Sleep state instabilities in major depressive disorder: Detection and quantification with electrocardiogram-based cardiopulmonary coupling analysis. Psychophysiology 2015; 48:285-91. [PMID: 20624250 DOI: 10.1111/j.1469-8986.2010.01060.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Sleep disruption is an important aspect of major depressive disorder but lacks an objective and inexpensive means of assessment. We evaluated the utility of electrocardiogram (ECG)-based cardiopulmonary coupling analysis to quantify physiologic sleep stability in patients with major depression. Relative to controls, unmedicated depressed patients had a reduction in high-frequency coupling, an index of stable sleep, an increase in low-frequency coupling, an index of unstable sleep, and an increase in very-low-frequency coupling, an index of wakefulness/REM sleep. The medicated depressed group showed a restoration of stable sleep to a level comparable with that of the control group. ECG-based cardiopulmonary coupling analysis may provide a simple, cost-efficient point-of-care method to quantify sleep quality/stability and to objectively evaluate the severity of insomnia in patients with major depression.
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Affiliation(s)
- Albert C Yang
- Department of Psychiatry, Chu-Tung Veterans Hospital, Hsin-Chu County, TaiwanDivision of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, TaiwanInstitute of Clinical Medicine, National Yang-Ming University, Taipei, TaiwanDepartment of Psychiatry, Taipei Veterans General Hospital, Taipei, TaiwanDivision of Interdisciplinary Medicine and Biotechnology and Margret and H. A. Rey Institute for Nonlinear Dynamics in Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA and Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MADivision of Pulmonary, Critical Care and Sleep, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Cheng-Hung Yang
- Department of Psychiatry, Chu-Tung Veterans Hospital, Hsin-Chu County, TaiwanDivision of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, TaiwanInstitute of Clinical Medicine, National Yang-Ming University, Taipei, TaiwanDepartment of Psychiatry, Taipei Veterans General Hospital, Taipei, TaiwanDivision of Interdisciplinary Medicine and Biotechnology and Margret and H. A. Rey Institute for Nonlinear Dynamics in Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA and Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MADivision of Pulmonary, Critical Care and Sleep, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Chen-Jee Hong
- Department of Psychiatry, Chu-Tung Veterans Hospital, Hsin-Chu County, TaiwanDivision of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, TaiwanInstitute of Clinical Medicine, National Yang-Ming University, Taipei, TaiwanDepartment of Psychiatry, Taipei Veterans General Hospital, Taipei, TaiwanDivision of Interdisciplinary Medicine and Biotechnology and Margret and H. A. Rey Institute for Nonlinear Dynamics in Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA and Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MADivision of Pulmonary, Critical Care and Sleep, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Shih-Jen Tsai
- Department of Psychiatry, Chu-Tung Veterans Hospital, Hsin-Chu County, TaiwanDivision of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, TaiwanInstitute of Clinical Medicine, National Yang-Ming University, Taipei, TaiwanDepartment of Psychiatry, Taipei Veterans General Hospital, Taipei, TaiwanDivision of Interdisciplinary Medicine and Biotechnology and Margret and H. A. Rey Institute for Nonlinear Dynamics in Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA and Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MADivision of Pulmonary, Critical Care and Sleep, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Chung-Hsun Kuo
- Department of Psychiatry, Chu-Tung Veterans Hospital, Hsin-Chu County, TaiwanDivision of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, TaiwanInstitute of Clinical Medicine, National Yang-Ming University, Taipei, TaiwanDepartment of Psychiatry, Taipei Veterans General Hospital, Taipei, TaiwanDivision of Interdisciplinary Medicine and Biotechnology and Margret and H. A. Rey Institute for Nonlinear Dynamics in Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA and Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MADivision of Pulmonary, Critical Care and Sleep, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Chung-Kang Peng
- Department of Psychiatry, Chu-Tung Veterans Hospital, Hsin-Chu County, TaiwanDivision of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, TaiwanInstitute of Clinical Medicine, National Yang-Ming University, Taipei, TaiwanDepartment of Psychiatry, Taipei Veterans General Hospital, Taipei, TaiwanDivision of Interdisciplinary Medicine and Biotechnology and Margret and H. A. Rey Institute for Nonlinear Dynamics in Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA and Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MADivision of Pulmonary, Critical Care and Sleep, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Joseph E Mietus
- Department of Psychiatry, Chu-Tung Veterans Hospital, Hsin-Chu County, TaiwanDivision of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, TaiwanInstitute of Clinical Medicine, National Yang-Ming University, Taipei, TaiwanDepartment of Psychiatry, Taipei Veterans General Hospital, Taipei, TaiwanDivision of Interdisciplinary Medicine and Biotechnology and Margret and H. A. Rey Institute for Nonlinear Dynamics in Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA and Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MADivision of Pulmonary, Critical Care and Sleep, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Ary L Goldberger
- Department of Psychiatry, Chu-Tung Veterans Hospital, Hsin-Chu County, TaiwanDivision of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, TaiwanInstitute of Clinical Medicine, National Yang-Ming University, Taipei, TaiwanDepartment of Psychiatry, Taipei Veterans General Hospital, Taipei, TaiwanDivision of Interdisciplinary Medicine and Biotechnology and Margret and H. A. Rey Institute for Nonlinear Dynamics in Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA and Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MADivision of Pulmonary, Critical Care and Sleep, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Robert J Thomas
- Department of Psychiatry, Chu-Tung Veterans Hospital, Hsin-Chu County, TaiwanDivision of Psychiatry, School of Medicine, National Yang-Ming University, Taipei, TaiwanInstitute of Clinical Medicine, National Yang-Ming University, Taipei, TaiwanDepartment of Psychiatry, Taipei Veterans General Hospital, Taipei, TaiwanDivision of Interdisciplinary Medicine and Biotechnology and Margret and H. A. Rey Institute for Nonlinear Dynamics in Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA and Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MADivision of Pulmonary, Critical Care and Sleep, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
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Granville Smith I, Parker G, Rourke P, Cvejic E, Vollmer-Conna U. Acute coronary syndrome and depression: A review of shared pathophysiological pathways. Aust N Z J Psychiatry 2015. [PMID: 26219293 DOI: 10.1177/0004867415597304] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To examine the evidence for shared pathophysiological pathways in acute coronary syndrome and major depression and to conceptualise the dynamic interplay of biological systems and signalling pathways that link acute coronary syndrome and depression within a framework of neuro-visceral integration. METHODS Relevant articles were sourced via a search of published literature from MEDLINE, EMBASE and PubMed using a variety of search terms relating to biological connections between acute coronary syndrome and depression. Additional articles from bibliographies of retrieved papers were assessed and included where relevant. RESULTS Despite considerable research efforts, a clear understanding of the biological processes connecting acute coronary syndrome and depression has not been achieved. Shared abnormalities are evident across the immune, platelet/endothelial and autonomic/stress-response systems. From the available evidence, it seems unlikely that a single explanatory model could account for the complex interactions of biological pathways driving the pathophysiology of these disorders and their comorbidity. CONCLUSION A broader conceptual framework of mind-body or neuro-visceral integration that can incorporate the existence of several causative scenarios may be more useful in directing future research and treatment approaches for acute coronary syndrome-associated depression.
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Affiliation(s)
- Isabelle Granville Smith
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Gordon Parker
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Poppy Rourke
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Erin Cvejic
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Uté Vollmer-Conna
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
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Mann SL, Selby EA, Bates ME, Contrada RJ. Integrating affective and cognitive correlates of heart rate variability: A structural equation modeling approach. Int J Psychophysiol 2015; 98:76-86. [PMID: 26168884 PMCID: PMC4980075 DOI: 10.1016/j.ijpsycho.2015.07.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 06/09/2015] [Accepted: 07/03/2015] [Indexed: 12/19/2022]
Abstract
High frequency heart rate variability (HRV) is a measure of neurocardiac communication thought to reflect predominantly parasympathetic cardiac regulation. Low HRV has been associated empirically with clinical and subclinical levels of anxiety and depression and, more recently, high levels of HRV have been associated with better performance on some measures of executive functioning (EF). These findings have offered support for theories proposing HRV as an index measure of a broad, self-regulatory capacity underlying aspects of emotion regulation and executive control. This study sought to test that proposition by using a structural equation modeling approach to examine the relationships of HRV to negative affect (NA) and EF in a large sample of U.S. adults ages 30s-80s. HRV was modeled as a predictor of an NA factor (self-reported trait anxiety and depression symptoms) and an EF factor (performance on three neuropsychological tests tapping facets of executive abilities). Alternative models also were tested to determine the utility of HRV for predicting NA and EF, with and without statistical control of demographic and health-related covariates. In the initial structural model, HRV showed a significant positive relationship to EF and a nonsignificant relationship to NA. In a covariate-adjusted model, HRV's associations with both constructs were nonsignificant. Age emerged as the only significant predictor of NA and EF in the final model, showing inverse relationships to both. Findings may reflect population and methodological differences from prior research; they also suggest refinements to the interpretations of earlier findings and theoretical claims regarding HRV.
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Affiliation(s)
- Sarah L Mann
- Department of Psychology, Rutgers, The State University of New Jersey, Tillett Hall, Livingston Campus, 53 Avenue E, Piscataway, NJ 08854-8040, USA.
| | - Edward A Selby
- Department of Psychology, Rutgers, The State University of New Jersey, Tillett Hall, Livingston Campus, 53 Avenue E, Piscataway, NJ 08854-8040, USA.
| | - Marsha E Bates
- Center of Alcohol Studies, Smithers Hall, Busch Campus, 607 Allison Road, Piscataway, NJ 08854-8001, USA; Department of Psychology, Rutgers, The State University of New Jersey, Tillett Hall, Livingston Campus, 53 Avenue E, Piscataway, NJ 08854-8040, USA.
| | - Richard J Contrada
- Department of Psychology, Rutgers, The State University of New Jersey, Tillett Hall, Livingston Campus, 53 Avenue E, Piscataway, NJ 08854-8040, USA.
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Abstract
OBJECTIVES Major depression is associated with reduced cardiac vagal control, most commonly indexed by heart rate variability. To examine the dynamics of this abnormality, we examined within-participant covariation over time between brain activity, cardiac vagal control, and depressive symptoms in depressed patients treated with sertraline and in healthy volunteers. METHODS Patients with depression and nondepressed control participants were enrolled in a 12-week protocol. After Week 0 assessment, patients began treatment with sertraline. Neural activity and vagal control were measured for all participants at Weeks 0, 2, 6, and 12 using functional magnetic resonance imaging and synchronized electrocardiographic recordings. At each of the four assessments, a moving window analysis was used to estimate vagal control as assessed by respiratory sinus arrhythmia (RSA) from the electrocardiographic data, which was then regressed onto functional magnetic resonance imaging activity. RESULTS At baseline, patients showed reduced blood oxygen level-dependent RSA covariation compared with controls within multiple a priori brain regions associated with vagal control, collectively described as the medial visceromotor network (MVN). Sertraline treatment led to a significant increase in brain-RSA covariation for patients compared with controls, despite a lack of improvement in mean RSA. CONCLUSIONS These data suggest a partial normalization of MVN dysfunction in depression during sertraline treatment. Specifically, results indicate a partial recovery of MVN function. However, this recovery was insufficient to cause a significant change in RSA levels. These results may help to explain both improvements with and limitations of sertraline treatment of depression.
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44
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Messerotti Benvenuti S, Buodo G, Mennella R, Palomba D. Somatic, but not cognitive-affective, symptoms are associated with reduced heart rate variability in individuals with dysphoria. Front Psychol 2015; 6:599. [PMID: 25999905 PMCID: PMC4423301 DOI: 10.3389/fpsyg.2015.00599] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/22/2015] [Indexed: 01/01/2023] Open
Abstract
Background: Somatic, but not cognitive–affective, symptoms of depression have been associated with reduced heart rate variability (HRV), and with poor prognosis in cardiovascular patients. However, factors concomitant with cardiovascular diseases may confound the relationship between somatic symptoms of depression and reduced HRV. Therefore, this study examined whether reduced HRV was differentially associated with cognitive–affective and somatic symptoms of depression in medically healthy individuals with and without dysphoria. Methods: Self-reported cognitive–affective and somatic symptoms as measured with the Beck Depression Inventory-II questionnaire and time and frequency domain parameters of HRV were collected in 62 medically healthy individuals, of whom 25 with and 37 without dysphoria. Results: Somatic, but not cognitive–affective, symptoms of depression were inversely associated with SD of NN intervals (β = -0.476, p < 0.05), number of interval differences of successive NN intervals greater than 50 ms (NN50; β = -0.498, p < 0.03), and HRV total power (β = -0.494, p < 0.04) in the group with dysphoria, after controlling for sex, anxiety, and lifestyle factors. Cognitive–affective and somatic symptoms were not related to any of the HRV parameters in the group without dysphoria (all ps > 0.24). Conclusion: By showing that the relationship between somatic depressive symptoms and reduced HRV extends to medically healthy individuals with dysphoria, the present findings suggest that this association is independent of factors concomitant with cardiovascular diseases. The present study also suggests that individuals with somatic rather than cognitive–affective subsets of depressive symptoms may be at greater risk for developing cardiovascular diseases.
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Affiliation(s)
| | - Giulia Buodo
- Department of General Psychology, University of Padova Padova, Italy ; Center for Cognitive Neuroscience, University of Padova Padova, Italy
| | - Rocco Mennella
- Department of General Psychology, University of Padova Padova, Italy
| | - Daniela Palomba
- Department of General Psychology, University of Padova Padova, Italy ; Center for Cognitive Neuroscience, University of Padova Padova, Italy
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45
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Abstract
Depression occurs in people of all ages across all world regions; it is the second leading cause of disability and its global burden increased by 37.5% between 1990 and 2010. Autonomic changes are often found in altered mood states and appear to be a central biological substrate linking depression to a number of physical dysfunctions. Alterations of autonomic nervous system functioning that promotes vagal withdrawal are reflected in reductions of heart rate variability (HRV) indexes. Reduced HRV characterizes emotional dysregulation, decreased psychological flexibility and defective social engagement, which in turn are linked to prefrontal cortex hypoactivity. Altogether, these pieces of evidence support the idea that HRV might represent a useful endophenotype for psychological/physical comorbidities, and its routine application should be advised to assess the efficacy of prevention/intervention therapies in a number of psychosomatic and psychiatric dysfunctions. Further research, also making use of appropriate animal models, could provide a significant support to this point of view and possibly help to identify appropriate antidepressant therapies that do not interefere with physical health.
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Affiliation(s)
- Andrea Sgoifo
- a Stress Physiology Laboratory, Department of Neuroscience , University of Parma , Parma , Italy and
| | - Luca Carnevali
- a Stress Physiology Laboratory, Department of Neuroscience , University of Parma , Parma , Italy and
| | | | - Mario Amore
- b Department of Neuroscience , Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genova , Genova , Italy
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46
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Reeves GC, Alhurani AS, Frazier SK, Watkins JF, Lennie TA, Moser DK. The association of comorbid diabetes mellitus and symptoms of depression with all-cause mortality and cardiac rehospitalization in patients with heart failure. BMJ Open Diabetes Res Care 2015; 3:e000077. [PMID: 26056566 PMCID: PMC4452727 DOI: 10.1136/bmjdrc-2014-000077] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/23/2015] [Accepted: 04/28/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND More than 22% of individuals with diabetes mellitus have concomitant heart failure (HF), and the prevalence of diabetes in those with HF is nearly triple that of individuals without HF. Comorbid depressive symptoms are common in diabetes and HF. Depressive symptoms are an independent predictor of mortality in individuals with diabetes alone, as well as those with HF alone and are a predictor of rehospitalization in those with HF. However, the association of comorbid HF, diabetes and depressive symptoms with all-cause mortality and rehospitalization for cardiac causes has not been determined. OBJECTIVE The purpose of this study was to evaluate the association of comorbid HF, diabetes and depression with all-cause mortality and rehospitalization for cardiac cause. METHOD Patients provided data at baseline about demographic and clinical variables and depressive symptoms; patients were followed for at least 2 years. Participants were divided into four groups based on the presence and absence of diabetes and depressive symptoms. Cox regression analysis was used to determine whether comorbid diabetes and depressive symptoms independently predicted all-cause mortality and cardiac rehospitalization in these patients with HF. RESULTS Patients (n=663) were primarily male (69%), white (76%), and aged 61±13 years. All-cause mortality was independently predicted by the presence of concomitant diabetes and depressive symptoms (HR 3.71; 95% CI 1.49 to 9.25; p=0.005), and depressive symptoms alone (HR 2.29; 95% CI 0.94 to 5.40; p=0.05). The presence of comorbid diabetes and depressive symptoms was also an independent predictor of cardiac rehospitalization (HR 2.36; 95% CI 1.27 to 4.39; p=0.007). CONCLUSIONS Comorbid diabetes and depressive symptoms are associated with poorer survival and rehospitalization in patients with HF; effective strategies to regularly evaluate and effectively manage these comorbid conditions are necessary to improve survival and reduce rehospitalization rates.
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Affiliation(s)
| | - Abdullah S Alhurani
- University of Kentucky, Lexington, USA
- The University of Jordan, Amman, Jordan
| | | | | | | | - Debra K Moser
- University of Kentucky, Lexington, USA
- The University of Ulster, Newtownabbey, UK
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47
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McGinley JJ, Friedman BH. Autonomic responses to lateralized cold pressor and facial cooling tasks. Psychophysiology 2014; 52:416-24. [PMID: 25250478 DOI: 10.1111/psyp.12332] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 08/05/2014] [Indexed: 12/25/2022]
Abstract
Asymmetry in central nervous system (CNS) control of autonomic nervous system (ANS) activity, a widely debated topic, was investigated via lateralized presentation of two ANS challenges: cold pressor, which elicits primarily sympathetic activation, and facial cooling, a predominantly vagal task. Seventy-three university students (37 female) engaged in these tasks while cardiovascular and electrodermal measures were acquired. Compared to right-side cold pressor, left cold pressor elicited generally larger cardiac, blood pressure, and skin conductance responses, but did not evoke asymmetric changes in heart rate variability. Facial cooling elicited significant increases in vagally mediated heart rate variability, but they were also not lateralized. These findings are consistent with reports of right hemisphere dominance in sympathetic regulation, but indicate that CNS vagal control is relatively symmetric. These results are framed in terms of polyvagal theory and neurovisceral integration two influential models of CNS-ANS integration in the service of adaptive environmental engagement.
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Affiliation(s)
- Jared J McGinley
- Department of Psychology, Virginia Tech, Blacksburg, Virginia, USA
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48
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Carney RM, Steinmeyer B, Freedland KE, Stein PK, Hayano J, Blumenthal JA, Jaffe AS. Nocturnal patterns of heart rate and the risk of mortality after acute myocardial infarction. Am Heart J 2014; 168:117-25. [PMID: 24952868 DOI: 10.1016/j.ahj.2014.04.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 04/22/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND The purposes of this study were to identify nocturnal patterns of heart rate (HR) in depressed and nondepressed patients after an acute myocardial infarction (MI) and to determine which patterns, if any, are associated with all-cause mortality or recurrent infarction. METHODS Functional data analysis and model-based clustering methods were used to identify nocturnal HR patterns in 245 depressed and 247 nondepressed patients with a recent MI. All-cause mortality and recurrent infarctions were ascertained over a median follow-up of 24 months. RESULTS Three HR activity patterns were identified. In the first, HR gradually declined during the nighttime and increased the next morning. The second pattern was similar, but with a higher overall HR during the recording interval. The third showed almost no decrease in HR at night (ie, "nondipping"). All-cause mortality was higher among patients with pattern 3 than pattern 1 (P = .007), and the combined end point of recurrent MI or all-cause mortality was higher in pattern 3 than pattern 2 (P = .05). Patterns 2 and 3 were more common in the depressed than in the nondepressed patients. CONCLUSIONS The nondipping nocturnal HR independently predicts all-cause mortality and recurrent MI. Future studies should examine the underlying causes of nondipping nocturnal HR and its association with depression and investigate the effects of treatment on survival.
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Schramm PJ, Poland RE, Rao U. Bupropion response on sleep quality in patients with depression: implications for increased cardiovascular disease risk. Eur Neuropsychopharmacol 2014; 24:207-14. [PMID: 24239431 PMCID: PMC3948318 DOI: 10.1016/j.euroneuro.2013.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Revised: 08/26/2013] [Accepted: 09/20/2013] [Indexed: 01/27/2023]
Abstract
Depression could be an independent risk factor for cardiovascular disease. We assessed bupropion response in depressed patients by polysomnography (PSG) and cardiopulmonary coupling (CPC) variables. Nineteen subjects participated in a two-session, two consecutive night PSG protocol. Participants received either placebo or bupropion-SR 150 mg, orally, in a randomized, double-blind cross-over fashion on night two. Outcome variables were: sleep stages, REM latency, stable, unstable sleep and very low frequency coupling (VLFC). CPC analysis uses heart rate variability and the electrocardiogram's R-wave amplitude fluctuations associated with respiration to generate frequency maps. Bupropion increased REM latency (p=0.043) but did not impact PSG sleep continuity, architecture and CPC variables. A trend (p=0.092) was observed towards increasing VLFC duration. Bupropion increased the number of stable-unstable sleep transitions (p=0.036). Moderate to strong correlations between PSG and CPC variables were found on placebo and bupropion nights. Limitations include a small sample size, limited power to detect CPC changes and lack of normal controls for comparison. Increased stable-unstable sleep transitions and VLFC duration may indicate vulnerability to cardiovascular disease due to their association with low heart rate variability that has been associated with increased mortality raising the question whether the beneficial effects of the antidepressant medication outweighs the impact on cardiopulmonary dynamics.
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Affiliation(s)
- Preetam J Schramm
- Arbeitsgemeinschaft Wissenschaftliche Psychotherapie-Freiburg, Immental Str. 11, 79104 Freiburg, Germany.
| | - Russell E Poland
- Department of Psychiatry and Behavioral Sciences, Meharry Medical College, Nashville, TN, USA.
| | - Uma Rao
- Department of Psychiatry and Behavioral Sciences, Meharry Medical College, Nashville, TN, USA; Center for Molecular and Behavioral Neuroscience, Meharry Medical College, Nashville, TN, USA; Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN, USA; Vanderbilt Kennedy Center, Vanderbilt University, Nashville, TN, USA.
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50
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Harris PR, Sommargren CE, Stein PK, Fung GL, Drew BJ. Heart rate variability measurement and clinical depression in acute coronary syndrome patients: narrative review of recent literature. Neuropsychiatr Dis Treat 2014; 10:1335-47. [PMID: 25071372 PMCID: PMC4111661 DOI: 10.2147/ndt.s57523] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIM We aimed to explore links between heart rate variability (HRV) and clinical depression in patients with acute coronary syndrome (ACS), through a review of recent clinical research literature. BACKGROUND Patients with ACS are at risk for both cardiac autonomic dysfunction and clinical depression. Both conditions can negatively impact the ability to recover from an acute physiological insult, such as unstable angina or myocardial infarction, increasing the risk for adverse cardiovascular outcomes. HRV is recognized as a reflection of autonomic function. METHODS A narrative review was undertaken to evaluate state-of-the-art clinical research, using the PubMed database, January 2013. The search terms "heart rate variability" and "depression" were used in conjunction with "acute coronary syndrome", "unstable angina", or "myocardial infarction" to find clinical studies published within the past 10 years related to HRV and clinical depression, in patients with an ACS episode. Studies were included if HRV measurement and depression screening were undertaken during an ACS hospitalization or within 2 months of hospital discharge. RESULTS Nine clinical studies met the inclusion criteria. The studies' results indicate that there may be a relationship between abnormal HRV and clinical depression when assessed early after an ACS event, offering the possibility that these risk factors play a modest role in patient outcomes. CONCLUSION While a definitive conclusion about the relevance of HRV and clinical depression measurement in ACS patients would be premature, the literature suggests that these measures may provide additional information in risk assessment. Potential avenues for further research are proposed.
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Affiliation(s)
- Patricia Re Harris
- ECG Monitoring Research Lab, University of California, San Francisco, CA, USA
| | - Claire E Sommargren
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, CA, USA
| | - Phyllis K Stein
- Heart Rate Variability Laboratory, School of Medicine, Washington University, St Louis, MO, USA
| | - Gordon L Fung
- Asian Heart & Vascular Center at Mount Zion, Division of Cardiology, University of California, San Francisco, CA, USA ; Cardiology Consultation Service, Cardiac Noninvasive Laboratory, and The Enhanced External Counterpulsation Unit, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, CA, USA
| | - Barbara J Drew
- Division of Cardiology, University of California, San Francisco, CA, USA ; Department of Physiological Nursing, School of Nursing, University of California, San Francisco, CA, USA
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