Depressive symptom clusters are differentially associated with atherosclerotic disease

Investigating the Added Value of Beck's Depression Inventory in Atherosclerosis Prediction: Lessons from Paracelsus 10,000

Background: Depression is the most common mental illness worldwide and generates an enormous health and economic burden. Furthermore, it is known to be associated with an elevated risk of arteriosclerotic cardiovascular diseases (ASCVD), particularly stroke. However, it is not a factor reflected in many ASCVD risk models, including SCORE2. Thus, we analysed the relationship between depression, ASCVD and SCORE2 in our cohort. Methods: We analysed 9350 subjects from the Paracelsus 10,000 cohort, who underwent both a carotid artery ultrasound and completed a Beck Depression Inventory (BDI) screening. Patients were categorised binomially based on the BDI score. Atherosclerotic carotid plaque or absence was dichotomised for logistic regression modelling. Odds ratios and adjusted relative risks were calculated using Stata. Results: Subjects with an elevated BDI (≥14) had higher odds for carotid plaques compared to subjects with normal BDI, especially after adjusting for classical risk factors included in SCORE2 (1.21; 95%CI 1.03-1.43, p = 0.023). The adjusted relative risk for plaques was also increased (1.09; 95%CI 1.01-1.18, p = 0.021). Subgroup analysis showed an increased odds of plaques with increases in depressive symptoms, particularly in women and patients ≤55 yrs. Conclusions: In our cohort, the BDI score is associated with subclinical atherosclerosis beyond classical risk factors. Thus, depression might be an independent risk factor which may improve risk stratification if considered in ASCVD risk prediction models, such as SCORE2. Furthermore, reminding clinicians to take mental health into consideration to identify individuals at increased atherosclerosis risk may provide added opportunities to address measures which can reduce the risk of ASCVD.

The Age-Dependent Association Between Vascular Risk Factors and Depressed Mood

OBJECTIVES

Cumulative burden of vascular risk factors (VRFs) has been linked to an increased risk of depressed mood. However, the role of age in this association is still unclear. Here, we investigated whether VRF burden is associated with levels and changes in depressed mood and whether these associations become stronger or weaker from mid- to later life.

METHOD

We used longitudinal data from 5,689 participants (52-89 years) of the English Longitudinal Study of Ageing. A composite score incorporated the presence of 5 VRFs: hypertension, diabetes, smoking, obesity, and hypercholesterolemia. Second-order latent growth models were used to test whether levels and changes of depressed mood differed as a function of baseline VRF burden, and whether these associations were moderated by age.

RESULTS

Baseline VRF burden showed a small association with higher levels of depressed mood (estimate = 0.081; 95% CI: 0.024, 0.138, p = .005). This association varied with age, such that it was stronger in midlife compared to later life (estimate = -0.007; 95% CI: -0.013, -0.002, p = .017). There was no evidence that VRF burden was associated with changes in depressed mood.

DISCUSSION

Our findings suggest that VRF burden in midlife, but less so in later life, predicts individual differences in depressed mood. These findings are consistent with reports on the importance of midlife VRFs and support the idea that promotion of vascular health in this age group or earlier in life may be critical to maintain mental health across adulthood.

Bidimensional structure and measurement equivalence of the Patient Health Questionnaire-9: sex-sensitive assessment of depressive symptoms in three representative German cohort studies

BACKGROUND

The Patient Health Questionnaire-9 (PHQ-9) has been proposed as a reliable and valid screening instrument for depressive symptoms with one latent factor. However, studies explicitly testing alternative model structures found support for a two-dimensional structure reflecting a somatic and a cognitive-affective dimension. We investigated the bidimensional structure of the PHQ-9, with a somatic (sleeping problems, fatigability, appetitive problems, and psychomotor retardation) and a cognitive-affective dimension (lack of interest, depressed mood, negative feelings about self, concentration problems, and suicidal ideation), and tested for sex- and regional-differences.

METHODS

We have included data from the GEnder-Sensitive Analyses of mental health trajectories and implications for prevention: A multi-cohort consortium (GESA). Privacy-preserving analyses to provide information on the overall population and cohort-specific information and analyses of variance to compare depressive, somatic and cognitive-affective symptoms between sexes and cohorts were executed in DataSHIELD. In order to determine the dimensionality and measurement invariance of the PHQ-9 we tested three models (1 factor, 2 correlated factors, and bifactor) via confirmatory analyses and performed multi-group confirmatory factor analysis.

RESULTS

Differences between sex and cohorts exist for PHQ-9 and for both of its dimensions. Women reported depressive symptoms in general as well as somatic and cognitive-affective symptoms more frequently. For all tested models an acceptable to excellent fit was found, consistently indicating a better model fit for the two-factor and bifactor model. Scalar measurement invariance was established between women and men, the three cohorts, and their interaction.

CONCLUSIONS

The two facets of depression should be taken into account when using PHQ-9, while data also render support to a general factor. Somatic and cognitive-affective symptoms assessed by the PHQ-9 can be considered equivalent across women and men and between different German populations from different regions.

Chronic physical health problems moderate changes in depression and substance use among dual diagnosed individuals during and after treatment

BACKGROUND

Physical illnesses frequently co-occur with depression and substance use disorders and may impact their improvement. Physical illness symptoms may overlap with or exacerbate somatic symptoms of depression. Individuals may use substances to cope with symptoms of physical illness.

OBJECTIVES

We examined whether chronic physical health problems moderated changes in depression and substance use among dual diagnosed individuals during and in the year following treatment.

METHODS

Participants were recruited from a Veterans Affairs dual diagnosis outpatient program between March 2000 and November 2007 and were randomized to either Integrated Cognitive-Behavioral Therapy or Twelve-Step Facilitation Therapy. A total of 214 veterans with assessment data for the variables of interest were included in analyses. Participants completed quarterly depression, substance use, and health assessments over an 18 month period. We used linear-mixed effects models to analyze patterns of change for depression and substance use.

RESULTS

Individuals with severe chronic health problems and higher intake depression showed slower improvements in both nonsomatic and somatic depression symptoms. Individuals with severe chronic health problems and higher midtreatment substance use showed less improvement in substance use.

CONCLUSIONS

Assessing and addressing physical health issues during depression and substance use disorder treatment may improve outcomes.

Depression in context of low neuroticism is a risk factor for stroke: a 9-year cohort study

OBJECTIVE

Depression predicts stroke; however, meta-analyses show significant heterogeneity. We hypothesize that the risk of depression on incident stroke is conditional upon the relative contribution of vascular disease and of neuroticism in the underlying pathways to depression in a specific patient. We examined whether depression increases stroke in persons with low neuroticism and without preexisting cardiac disease.

METHODS

This was a population-based cohort study with 9-year follow-up (n = 2,050; ≥55 years, 52% female). The incidence of stroke was determined by self-report data as well as data from general practitioners and death certificates. Neuroticism was measured using the Dutch Personality Questionnaire and depression using the Center for Epidemiologic Studies-Depression scale. All data were analysed by Cox proportional hazards regression.

RESULTS

A total of 117 incident cases of stroke occurred during follow-up. Among persons with a history of cardiac disease (n = 401), depression predicted incident stroke independent of neuroticism level with a hazard ratio (HR) of 1.05 (95% confidence interval [CI] 1.01-1.10) (p = 0.02). In persons without cardiac disease (n = 1,649), depression and neuroticism interacted significantly in predicting incident stroke (p = 0.028). Stratified analyses showed that depression predicted incident stroke in those with low neuroticism, HR 1.05 (95% CI 1.00-1.09) (p = 0.033), but not in those with high neuroticism, HR 1.01 (95% CI 0.96-1.05) (p = 0.82).

CONCLUSIONS

In persons without preexistent cardiac disease, depression is only predictive for future stroke in absence of high neuroticism. This might be explained by the hypothesis that late-life depression in context of low neuroticism is a marker of subclinical vascular disease.

History of depression but not current depression is associated with signs of atherosclerosis: data from the Gutenberg Health Study

OBJECTIVES

To test the vascular depression hypothesis in the general population, we analyzed the association between current depression, medical history of depression, cognitive and somatic depressive symptom dimensions and measures of atherosclerosis [intima-media thickness (IMT) and carotid plaques].

METHOD

We included a representative sample of 5000 participants from the Gutenberg Health Study (GHS). Depression was assessed by the nine-item Patient Health Questionnaire (PHQ-9), and IMT and carotid plaques were measured at both common carotid arteries using an edge detection system. Regression analyses were performed separately for participants with and without cardiovascular disease, adjusting for medical history, cardiovascular risk factors and psychotropic medication.

RESULTS

Contrary to hypotheses, we found no increased IMT for somatic symptoms of depression; the same was true for depression and cognitive symptoms in the fully adjusted model. Only a moderate relationship between medical history of depression and the presence of atherosclerotic plaques was maintained after correction.

CONCLUSIONS

The relationship between depression and atherosclerosis may be more complex than previously assumed. Although the vascular depression hypothesis was not supported, our results support the hypothesis that lasting depression leads to arteriosclerosis.

Association between metabolic syndrome and depressive symptom profiles--sex-specific?

BACKGROUND

The association between depression and metabolic syndrome is becoming more obvious. Waist circumference (WC) might be the most important metabolic syndrome (MetS) feature in relation to late-life depression, with a possible mediating role for adiponectin.

METHODS

Cross-sectional population based survey of 1277 participants (50-70 years). We measured all components of MetS, plasma adiponectin levels and depressive symptoms using Beck Depression Inventory (BDI). Principal components analysis on the BDI items revealed two factors, representing a cognitive-affective and a somatic-affective symptom-cluster. Multiple linear regression models with the BDI sum score and both depression symptom-clusters as dependent variables, respectively, were used to examine the association with each component of metabolic syndrome adjusted for confounders. We explored sex-differences as well as a hypothesised mediating effect of adiponectin.

RESULTS

The presence of MetS as well as number of metabolic risk factors were significantly associated with BDI sum score. In men WC, triglycerides and HDL cholesterol explained variance in depressive symptoms, whereas in women this effect was confined to WC. Moreover, irrespective of sex, all associations were primarily driven by the somatic-affective symptom-cluster. Adiponectin neither mediated nor moderated any of the associations found.

LIMITATIONS

Cross-sectional design limits causal interpretation. Being a population-based survey, some selection bias might have occurred toward healthier part of population.

CONCLUSIONS

Although pathophysiological mechanisms underlying the association between metabolic disturbances and depression remains to be elucidated, our study points to sex-differences as well as a specific phenotype of depression that is associated with metabolic disturbances.

Differential associations of depressive symptom dimensions with cardio-vascular disease in the community: results from the Gutenberg health study

A current model suggested that the somatic symptom dimension accounts for the adverse effect of depression in patients with coronary heart disease (CHD). In order to test this model we sought to determine in a large population-based sample how symptom dimensions of depression are associated with CHD, biomarkers and traditional risk factors. The associations of cognitive and somatic symptom dimensions of depression with CHD, risk factors, endothelial function, and biomarkers of inflammation and myocardial stress were analyzed cross-sectionally in a sample of n = 5000 Mid-Europeans aged 35–74 years from the Gutenberg Health Study (GHS). Only the somatic symptom dimension of depression was associated with CHD, biomarkers (inflammation, vascular function) and cardio-vascular risk factors. When multivariable adjustment was applied by demographic and cardiovascular risk factors, the weak associations of the somatic symptom dimension with the biomarkers disappeared. However, the associations of the somatic symptom dimension with CHD, myocardial infarction, obesity, dyslipidemia and family history of myocardial infarction remained. Both dimensions of depression were independently associated with a previous diagnosis of depression and distressed personality (type D). Thus, our results partly confirm current models: Somatic, but not cognitive-affective symptom dimensions are responsible for the association between depression and CHD, inflammation, vascular function and cardiovascular risk factors in the general population. However, our findings challenge the assumptions that somatic depression might be due to inflammation or vascular dysfunction as consequence of progressed atherosclerotic disease. They rather emphasize a close interplay with life-style factors and with a family history of MI.

Depression as a non-causal variable risk marker in coronary heart disease

BACKGROUND

After decades of investigations, explanations for the prospective association between depression and coronary heart disease (CHD) are still incomplete.

DISCUSSION

Depression is often suggested to be causally related to CHD. Based on the available literature, we would rather argue that depression can best be regarded as a variable risk marker, that is, a variable that fluctuates together with mechanisms leading to poor cardiovascular fitness. Despite numerous efforts, no evidence is found that manipulation of depression alters cardiovascular outcomes--a key premise for determining causality. To explain the concept of a variable risk marker, we discuss several studies on the heterogeneity of depression suggesting that depression is particularly harmful for the course of cardiovascular disease when it appears to be a physiological consequence of the cardiovascular disease itself.

SUMMARY

We conclude that instead of depression being a causal risk factor for CHD, the association between depression and CHD is likely confounded, at least by the cardiac disease itself.

Comparing cognitive and somatic symptoms of depression in myocardial infarction patients and depressed patients in primary and mental health care

Depression in myocardial infarction patients is often a first episode with a late age of onset. Two studies that compared depressed myocardial infarction patients to psychiatric patients found similar levels of somatic symptoms, and one study reported lower levels of cognitive/affective symptoms in myocardial infarction patients. We hypothesized that myocardial infarction patients with first depression onset at a late age would experience fewer cognitive/affective symptoms than depressed patients without cardiovascular disease. Combined data from two large multicenter depression studies resulted in a sample of 734 depressed individuals (194 myocardial infarction, 214 primary care, and 326 mental health care patients). A structured clinical interview provided information about depression diagnosis. Summed cognitive/affective and somatic symptom levels were compared between groups using analysis of covariance, with and without adjusting for the effects of recurrence and age of onset. Depressed myocardial infarction and primary care patients reported significantly lower cognitive/affective symptom levels than mental health care patients (F (2,682) = 6.043, p = 0.003). Additional analyses showed that the difference between myocardial infarction and mental health care patients disappeared after adjusting for age of onset but not recurrence of depression. These group differences were also supported by data-driven latent class analyses. There were no significant group differences in somatic symptom levels. Depression after myocardial infarction appears to have a different phenomenology than depression observed in mental health care. Future studies should investigate the etiological factors predictive of symptom dimensions in myocardial infarction and late-onset depression patients.

Cardiovascular fitness in males at age 18 and risk of serious depression in adulthood: Swedish prospective population-based study

BACKGROUND

Studies suggest a role for cardiovascular fitness in the prevention of affective disorders.

AIMS

To determine whether cardiovascular fitness at age 18 is associated with future risk of serious affective illness.

METHOD

Population-based Swedish cohort study of male conscripts (n = 1 117 292) born in 1950-1987 with no history of mental illness who were followed for 3-40 years. Data on cardiovascular fitness at conscription were linked with national hospital registers to calculate future risk of depression (requiring in-patient care) and bipolar disorder.

RESULTS

In fully adjusted models low cardiovascular fitness was associated with increased risk for serious depression (hazard ratios (HR) = 1.96, 95%, CI 1.71-2.23). No such association could be shown for bipolar disorder (HR = 1.11, 95% CI 0.84-1.47).

CONCLUSIONS

Lower cardiovascular fitness at age 18 was associated with increased risk of serious depression in adulthood. These results strengthen the theory of a cardiovascular contribution to the aetiology of depression.

Gait and equilibrium in subcortical vascular dementia

Subcortical vascular dementia is a clinical entity, widespread, even challenging to diagnose and correctly treat. Patients with this diagnosis are old, frail, often with concomitant pathologies, and therefore, with many drugs in therapy. We tried to diagnose and follow up for three years more than 600 patients. Study subjects were men and women, not bedridden, aged 68-94 years, outpatients, recruited from June, 1st 2007 to June, 1st 2010. We examined them clinically, neurologically, with specific consideration on drug therapies. Our aim has been to define gait and imbalance problem, if eventually coexistent with the pathology of white matter and/or with the worsening of the deterioration. Drug intake interference has been detected and considered.