Effects of antidepressants, but not psychopathology, on cardiac sympathetic control: a longitudinal study

Non-suicidal Self-injury History Moderates the Association Between Maternal Emotional Support and Adolescent Affect During Conflict

Onset of non-suicidal self-injury (NSSI) is most frequent during adolescence. Etiological models indicate that abnormal affective reactivity and regulation within interpersonal contexts is related to heightened NSSI risk. The current study examined the effects of maternal emotional support on adolescent sympathetic nervous system (SNS) activity and observed anger during a conflict discussion among 56 mother-daughter dyads consisting of healthy adolescents and adolescents with a history of self-injury. During the conflict discussion task, maternal emotional support and adolescent anger were coded from behavior, and cardiovascular pre-ejection period was used to index SNS responding. Results demonstrated that maternal emotional support was negatively associated with adolescent anger and SNS activity during the conflict. However, these associations were not significant among adolescents with heightened NSSI history. Maternal emotional support may serve as an interpersonal mechanism for adolescent physiological and behavioral regulation, yet may function differently among adolescents with more frequent NSSI.

Novel mutation in N-terminal fragment of ryanodine receptor 2 causing catecholaminergic polymorphic ventricular tachycardia

CPVT is a rare inherited arrhythmogenic disorder characterized by bidirectional, polymorphic ventricular arrhythmias triggered by catecholamines released during exercise, stress, or sudden emotion in individuals with a normal resting electrocardiogram and structurally normal heart. Mutations in the ryanodine receptor 2 gene are the most common known etiology of this disorder. The c.1195A > G(p.Met399Val) variant in Exon 14 of RyR2 is currently classified as a Variant of Uncertain Significance. We present a case of CPVT caused by this novel disease-causing RyR2 variant and discuss its pathophysiology. The role of SSRIs in treating patients with CPVT unresponsive to mainstream therapies is also highlighted.

Unhealthy lifestyle impacts on biological systems involved in stress response: hypothalamic-pituitary-adrenal axis, inflammation and autonomous nervous system

An unhealthy lifestyle has a critical role in the pathogenesis and course of several chronic disorders. It has been hypothesized that lifestyle may also impact biological systems involved in stress response. A global index of unhealthy lifestyle was calculated based on the cumulative presence of five self-reported lifestyle habits (smoking, excessive alcohol use, drug use, low physical activity and short sleep) in 2783 participants (18-65 years) from the Netherlands Study of Depression and Anxiety. The functioning of biological stress systems was based on multiple physiological measures of cortisol, inflammatory cytokines and autonomic cardiac activity. The unhealthy lifestyle index was associated with hyperactivity of hypothalamus-pituitary-adrenal axis and increased inflammation, indicating that with increasing unhealthy habits, the level of biological stress increases. No association with the autonomic nervous system activity was observed; however, the use of drugs increased parasympathetic cardiac activity and significantly impacted on ANS. Results were not impacted by a recent episode of depression or anxiety disorder. An unhealthy lifestyle may unfavorably impact on biological systems involved in stress response, which may underlie progression of several psychiatric as well as somatic chronic disorders.

Impact of antidepressant use on the autonomic nervous system: A meta-analysis and systematic review

Changes in cardiac autonomic nervous system (ANS) regulation observed in psychiatric disorders may be mitigated by antidepressants. We meta-analyzed and systematically reviewed studies examining antidepressants' effects on ANS outcomes, including heart rate variability (HRV). We conducted a PRISMA/MOOSE-compliant search of PubMed and Scopus until March 28th, 2022. We included randomized placebo-controlled trials (RCTs) and pre-post studies, regardless of diagnosis. We pooled results in random-effects meta-analyses, pooling homogeneous study designs and outcomes. We conducted sensitivity analyses and assessed quality of included studies. Thirty studies could be meta-analyzed. Selective serotonin reuptake inhibitors (SSRIs) were significantly associated with a reduction in the square root of the mean-squared difference between successive R-R intervals (RMSSD) (SMD= -0.48) and skin conductance response (SMD= -0.55) in RCTs and with a significant increase in RMSSD in pre-post studies (SMD=0.27). In pre-post studies, tricyclic antidepressants (TCAs) were associated with a significant decrease in several HRV outcomes while agomelatine was associated with a significant increase in high frequency power (SMD= 0.14). In conclusion, SSRIs reduce skin conductance response but have no or inconclusive effects on other ANS outcomes, depending on study design. TCAs reduce markers of parasympathetic function while agomelatine might have the opposite effect. Studies are needed to investigate the impact of SSRIs on the recovery of cardiac ANS regulation after acute myocardial infarction, and the effects of newer antidepressants.

The link between cardiac status and depression and anxiety in implantable cardioverter defibrillator patients: Design and first results of the PSYCHE-ICD study

OBJECTIVE

Depression and anxiety in patients with an implantable cardioverter-defibrillator (ICD) are associated with adverse outcomes. This study describes the design of the PSYCHE-ICD study and evaluates the correlation between cardiac status and depression and anxiety in ICD patients.

METHODS

We included 178 patients. Prior to implantation, patients completed validated psychological questionnaires for depression, anxiety and personality traits. Cardiac status was evaluated by means of left ventricular ejection fraction assessment (LVEF), New York Heart Association (NYHA) functional class, 6-minute walk test (6MWT), and 24-h Holter monitoring for heart rate variability (HRV). A cross-sectional analysis was performed. Follow-up with annual study visits, including repeated full cardiac evaluation, will continue 36 months after ICD implantation.

RESULTS

Depressive symptoms were present in 62 (35%) and anxiety in 56 (32%) patients. Values of depression and anxiety significantly increased with higher NYHA class (P < 0.001). Depression symptoms were correlated with a reduced 6MWT (411 ± 128 vs. 488 ± 89, P < 0.001), higher heart rate (74 ± 13 vs. 70 ± 13, P = 0.02), higher thyroid stimulation hormone levels (1.8 [1.3-2.8] vs 1.5 [1.0-2.2], P = 0.03) and multiple HRV parameters. Anxiety symptoms were correlated with higher NYHA class and a reduced 6MWT (433 ± 112 vs 477 ± 102, P = 0.02).

CONCLUSION

A substantial part of patients receiving an ICD have symptoms of depression and anxiety at time of ICD implantation. Depression and anxiety were correlated with multiple cardiac parameters, suggesting a possible biological links between psychological distress and cardiac disease in ICD patients.

The Role of Depressive Disorders in Autonomic Cardiovascular Dysregulation in Fibromyalgia

OBJECTIVE

Previous research revealed aberrances in autonomic cardiovascular regulation in fibromyalgia, which may be relevant to symptoms genesis and the increased risk of cardiovascular disorders in individuals with fibromyalgia. This study investigated the role of comorbid depression in autonomic cardiovascular dysregulations in fibromyalgia.

METHODS

Cardiovascular recordings were obtained in 53 participants with fibromyalgia who also had depression ( n = 27), in participants with fibromyalgia without depression ( n = 26), and in 29 healthy controls, at rest and during a cold pressor test and an arithmetic task. Assessed parameters included interbeat interval, blood pressure, heart rate variability, baroreflex sensitivity, stroke volume, preejection period, left ventricular ejection time, Heather index, and total peripheral resistance.

RESULTS

Participants with both fibromyalgia and depression displayed lower tonic interbeat interval, baroreflex sensitivity, and heart rate variability compared with participants with fibromyalgia without depression and controls ( p values < .012, d values = 0.71-1.06). Participants with fibromyalgia but without depression did not differ from controls in these variables. Moreover, participants with fibromyalgia who also had depression, but not those without depression, exhibited lower Heather index, stroke volume, and left ventricular ejection time compared with controls ( p values < .013, d values = 0.62-0.78). No group differences arose for preejection period or total peripheral resistance. Stress reactivity was reduced in participants with fibromyalgia, independently of depression, for diastolic blood pressure, interbeat interval, left ventricular ejection time, and heart rate variability, than in controls.

CONCLUSIONS

The role of depression in the autonomic dysregulation in fibromyalgia involves chronotropic cardiac control rather than adrenergic influences on contractility and vascular tone. Blunted cardiovascular reactivity may be ascribable to pathological factors inherent to fibromyalgia. These results underline the importance of diagnostics and treatment of comorbid depressive disorders in the management of fibromyalgia.

Depressive rumination and heart rate variability: A pilot study on the effect of biofeedback on rumination and its physiological concomitants

Objective

Recent studies suggest that lower resting heart rate variability (HRV) is associated with elevated vulnerability to depressive rumination. In this study, we tested whether increases in HRV after HRV-biofeedback training are accompanied by reductions in rumination levels.

Materials and methods

Sixteen patients suffering from depression completed a 6-week HRV-biofeedback training and fourteen patients completed a control condition in which there was no intervention (waitlist). The training included five sessions per week at home using a smartphone application and an ECG belt. Depressive symptoms and autonomic function at rest and during induced rumination were assessed before and after each of the two conditions. We used a well-established rumination induction task to provoke a state of pervasive rumination while recording various physiological signals simultaneously. Changes in HRV, respiration rate, skin conductance, and pupil diameter were compared between conditions and time points.

Results

A significant correlation was found between resting HRV and rumination levels, both assessed at the first laboratory session (r = -0.43, p < 0.05). Induction of rumination led to an acceleration of heart rate and skin conductance increases. After biofeedback training, resting vagal HRV was increased (p < 0.01) and self-ratings of state anxiety (p < 0.05), rumination (p < 0.05), perceived stress (p < 0.05), and depressive symptoms (QIDS, BDI; both p < 0.05) were decreased. In the control condition, there were no changes in autonomic indices or depressive symptomatology. A significant interaction effect group x time on HRV was observed.

Conclusion

Our results indicate that a smartphone-based HRV-biofeedback intervention can be applied to improve cardiovagal function and to reduce depressive symptoms including self-rated rumination tendencies.

Associations of three major physiological stress systems with suicidal ideation and suicide attempts in patients with a depressive and/or anxiety disorder

BACKGROUND

People with depressive and/or anxiety disorders are at increased risk of suicidal ideation and suicide attempts, but biological correlates signaling such risk remain unclear. Independent and cumulative dysregulations in physiological stress systems, in particular the hypothalamic-pituitaryadrenal axis (HPA-axis), immune-inflammatory system, and autonomous nervous system (ANS), may contribute to this risk. However, findings have either been heterogeneous or absent thus far.

METHODS

Associations between individual markers and cumulative indices of the HPA-axis (cortisol awakening response and evening cortisol), immune-inflammatory system (C-reactive protein, interleukin-6 (IL-6), and tumor necrosis factor-α), and the ANS (heart rate, respiratory sinus arrhythmia, and pre-ejection period) and the outcomes no suicide ideation with suicide attempt (SI-SA+), suicide ideation without suicide attempt (SI+SA-) and suicide ideation with suicide attempt (SI+SA+) were investigated in 1749 persons with depressive and/or anxiety disorders from the Netherlands Study of Depression and Anxiety (NESDA).

RESULTS

High levels of CRP and IL-6 were associated with SI-SA+ and SI+SA+ respectively when compared to non-suicidal patients after adjusting for confounders and multiple testing. Also, cumulative immune-inflammatory dysregulations were positively associated with SI+SA+, suggesting a dose-response effect. No significant associations were found between HPA-axis or ANS indicators and suicide-outcomes and between immune-inflammatory system markers or cumulative stress system dysregulations and SI+SA-.

CONCLUSION

Although stress system markers could not differentiate between SI+SA- and non-suicidal patients, findings indicate that dysregulations of individual and cumulative immune-inflammatory markers are associated with suicide attempts in depressive and/or anxiety patients. Thus, immune-inflammatory system dysregulation may be involved in the pathophysiology of suicidal behavior, supporting further examination of the effects of anti-inflammatory interventions on suicidality.

Behavioral, cortical and autonomic effects of single-dose escitalopram on the induction and regulation of fear and disgust: Comparison with single-session psychological emotion regulation with reappraisal

INTRODUCTION

Adaptive and successful emotion regulation, the ability to flexibly exert voluntary control over emotional experience and the ensuing behavior, is vital for optimal daily functioning and good mental health. In clinical settings, pharmacological and psychological interventions are widely employed to modify pathological emotion processing and ameliorate its deleterious consequences.

METHODS

In this study, we investigated the acute effects of single-dose escitalopram on the induction and regulation of fear and disgust in healthy subjects. Furthermore, we compared these pharmacological effects with psychological emotion regulation that utilized a cognitive strategy with reappraisal. Emotion induction and regulation tasks were performed before and 4 h after ingestion of placebo or 10 mg escitalopram in a randomized, double-blind design. The International Affective Picture System (IAPS) was used as a source of images, with threat-related pictures selected for fear and disease and contamination-related pictures for disgust. Behavioral data, electrodermal activity (EDA), and functional near-infrared spectroscopy (fNIRS) recordings were collected.

RESULTS

Escitalopram significantly reduced emotion intensity for both fear and disgust during emotion induction, albeit with differing electrodermal and hemodynamic activity patterns for the two negative emotions. At rest, i.e., in the absence of emotive stimuli, escitalopram increased sympathetic activity during the fear but not during the disgust experiments. For both fear and disgust, emotion regulation with reappraisal was more effective in reducing emotion intensity compared to pharmacological intervention with escitalopram or placebo.

DISCUSSION

We concluded that emotion regulation with reappraisal and acute administration of escitalopram, but not placebo, reduce emotion intensity for both fear and disgust, with cognitive regulation being significantly more efficient compared to pharmacological regulation under the conditions of this study. Results from the fNIRS and EDA recordings support the concept of differential mechanisms of emotion regulation that could be emotion-specific.

Depressive and anxiety disorders in concert-A synthesis of findings on comorbidity in the NESDA study

BACKGROUND

Comorbidity of depressive and anxiety disorders is common and remains incompletely comprehended. This paper summarizes findings from the Netherlands Study of Depression and Anxiety (NESDA) regarding prevalence, temporal sequence, course and longitudinal patterns; sociodemographic, vulnerability and neurobiological indicators; and functional, somatic and mental health indicators of comorbidity.

METHODS

Narrative synthesis of earlier NESDA based papers on comorbidity (n=76).

RESULTS

Comorbidity was the rule in over three-quarter of subjects with depressive and/or anxiety disorders, most often preceded by an anxiety disorder. Higher severity and chronicity characterized a poorer comorbidity course. Over time, transitions between depressive and anxiety disorders were common. Consistent comorbidity risk indicators in subjects with depressive and anxiety disorders were childhood trauma, neuroticism and early age of onset. Psychological vulnerabilities, such as trait avoidance tendencies, were more pronounced in comorbid than in single disorders. In general, there were few differences in biological markers and neuroimaging findings between persons with comorbid versus single disorders. Most functional, somatic, and other mental health indicators, ranging from disability to cardiovascular and psychiatric multimorbidity, were highest in comorbid disorders.

LIMITATIONS

The observational design of NESDA limits causal inference. Attrition was higher in comorbid relative to single disorders.

CONCLUSIONS

As compared to single disorders, persons with comorbid depressive and anxiety disorders were characterized by more psychosocial risk determinants, more somatic and other psychiatric morbidities, more functional impairments, and poorer outcome. These results justify specific attention for comorbidity of depressive and anxiety disorders, particularly in treatment settings.

An integrated approach to understand biological stress system dysregulation across depressive and anxiety disorders

BACKGROUND

Affective disorders involve dysregulation of major biological stress systems (hypothalamic-pituitary-adrenal (HPA)-axis, immune system, autonomic nervous system (ANS)). Suchdysregulationshave rarely beensimultaneously examined across different stress systems.

METHODS

In the Netherlands Study of Depression and Anxiety (n=2789), we investigated whether current or remitted depressive and/or anxiety disorders (based on the CIDI semi-structured interview), including specific symptom profiles, were associated with separate markers and cumulative indexes of the HPA-axis (cortisol awakening response, evening cortisol, dexamethasone suppression test cortisol), immune system (C-reactive protein, interleukin-6, tumor necrosis factor-α), and ANS (heart rate, respiratory sinus arrhythmia, pre-ejection period).

RESULTS

Depressive andanxiety disorderswere significantlyassociated with changes in three biological stress systemsincluding HPA-axis hyperactivity, increased inflammatory activity, and a higher ANS tone, particularly for integrative and cumulative indexes of these stress systems (pFDR <.05) vs. controls. The strongest associations were seen with current disorders andcumulative indexes of the HPA-axis (β=.124, pFDR=.001), the immune system (β =.057, pFDR=.032), and total cumulative index across stress systems (β=.102, pFDR=.004). Atypical, energy-related depression severity was linked to immune system markers (pFDR<0.001), melancholic depression severity to HPA-axis markers (pFDR=.032), and anxiety arousal severity to both HPA-axis and immune system markers (pFDR<0.05). Findings were partially explained by poorer lifestyle, more chronic diseases,or (especially for ANS-function) antidepressant use.

LIMITATIONS

Cross-sectional analyses limit examination of temporal associations.

CONCLUSION

Patients withdepressive and anxiety disorders showed consistent dysregulation across biological stress systems, particularly for current episodes.To understand stress system functionality in affective disorders, an integrated approach capturing cumulative stress indices within and across biological stress systems is important.

Cardiovascular Variability and Reactivity in Major Depressive Disorder

Abstract. This study investigated cardiovascular variability and stress reactivity in major depressive disorder (MDD). While previous research has documented reduced heart rate variability, knowledge about blood pressure variability in MDD remains scarce. Regarding reactivity, a particular focus was placed on the time courses of the cardiovascular responses, which may provide insight into the autonomic mechanisms underlying the hypo-reactivity expected in MDD. In 76 MDD patients and 71 healthy controls, blood pressure was continuously recorded at rest and during mental stress induced by a 3-min serial subtraction task. Compared to controls, patients exhibited lower systolic and diastolic blood pressure, heart rate variability, and systolic and diastolic blood pressure variability. Moreover, smaller stress-related changes in heart rate, systolic and diastolic blood pressure, and sensitivity of the cardiac baroreflex arose in patients. Cardiovascular parameters did not differ between patients using antidepressants and unmedicated patients. According to time-course analysis, reduced hemodynamic modulations in MDD mainly occurred after 50 s of the stress period. Low heart rate variability in MDD reflects deficient top-down integration of the brain mechanisms allowing flexible autonomic and behavioral control; diminished blood pressure variability is indicative of poor homeostatic capacity with respect to the regulation of blood pressure and organ perfusion. Moreover, blunted cardiovascular reactivity implies poor adjustment of energetic resources to internal and environmental demands and may be a correlate of deficient motivational dynamics characterizing MDD. While cardiovascular hypo-reactivity in MDD may be mediated by baroreflex and adrenergic mechanisms, the fast-acting parasympathetic system may play a subordinate role.

[Characteristics of arterial hypertension clinical course in patients with obesity and anxiety-depressive disorders]

This article covers an important subject clinical course of arterial hypertension in patients with metabolic abnormalities with obesity and anxiety-depressive disorders. Relevance of this topic is defined with high incidence of each aforementioned conditions and their influence on quality of life and social functioning of patients. Review of literature covers subjects of comorbidity and multimorbidity. Relevant data are presented which are focusing on complex management of arterial hypertension co-existing with obesity and anxiety-depressive disorders.

Comparison of Autonomic Reactivity to the Stress between Adjustment Disorder and Major Depressive Disorder

OBJECTIVE

Adjustment disorder (AD) remains an ambiguous diagnosis that overlaps with major depressive disorder (MDD). This study compared autonomic reactivity to the stress between AD and MDD to test for biological differences.

METHODS

Physically healthy Korean male soldiers admitted to a psychiatric ward were recruited for participation. Clinical diagnoses indicated that 62 patients with AD and 47 with MDD were selected. Procedures consisted of electrocardiogram measurements according to three consecutive phases lasting five minutes each [i.e., resting, stress (including a mental arithmetic task and Stroop color word test), and recovery].

RESULTS

The reactive trends of all heart rate variability (HRV) parameters related to the stress tasks in participants with AD did not differ from those with MDD. High-frequency HRV (a proxy of parasympathetic activity) increased during times of stress for participants with AD and MDD. Despite similar reactive trends, AD participants had higher HRV values than participants with MDD during whole phases, particularly for variables reflecting overall autonomic activity.

CONCLUSION

AD is associated with higher basal activity in the autonomous nervous system when compared to MDD. However, both are associated with pathophysiology indicating an altered autonomic reactivity to stress.

Childhood trauma and dysregulation of multiple biological stress systems in adulthood: Results from the Netherlands Study of Depression and Anxiety (NESDA)

BACKGROUND

Childhood trauma (CT) is a risk factor for depressive and anxiety disorders. Although dysregulated biological stress systems may underlie the enduring effect of CT, the relation between CT and separate and cumulative activity of the major stress systems, namely, the hypothalamic-pituitary-adrenal (HPA)-axis, the immune-inflammatory system, and the autonomic nervous system (ANS), remains inconclusive.

METHODS

In the Netherlands Study of Depression and Anxiety (NESDA, n = 2778), we determined whether self-reported CT (as assessed by the Childhood Trauma Interview) was associated with separate and cumulative markers of the HPA-axis (cortisol awakening response, evening cortisol, dexamethasone suppression test cortisol), the immune-inflammatory system (C-reactive protein, interleukin-6, tumor necrosis factor-α), and the ANS (heart rate, respiratory sinus arrhythmia, pre-ejection period) in adulthood.

RESULTS

Almost all individuals with CT (n = 1330) had either current or remitted depressive and/or anxiety disorder (88.6%). Total-sample analyses showed little evidence for CT being significantly associated with the separate or cumulative stress systems' activity in adulthood. These findings were true for individuals with and without depressive and/or anxiety disorders. To maximize contrast, individuals with severe CT were compared to healthy controls without CT. This yielded slight, but significantly higher levels of cortisol awakening response (AUCg, β = .088, p =  .007; AUCi, β = .084, p =  .010), cumulative HPA-axis markers (β = .115, p =  .001), C-reactive protein (β = .055, p = .032), interleukin-6 (β = .053, p =  .038), cumulative inflammation (β = .060, p =  .020), and cumulative markers across all systems (β = .125, p =  .0003) for those with severe CT, partially explained by higher rates of smoking, body mass index, and chronic diseases.

CONCLUSION

While our findings do not provide conclusive evidence on CT directly dysregulating stress systems, individuals with severe CT showed slight indications of dysregulations, partially explained by an unhealthy lifestyle and poorer health.

Getting under the skin: Does biology help predict chronicity of depression?

BACKGROUND

Depressed patients are at risk of an unfavourable course including chronic episodes. Various psychiatric characteristics have shown to be predictive of depression's course trajectory, but whether indicators of somatic health further contribute to course prediction remains unclear. This study aimed to identify somatic health indicators (i.e. biomarkers, health status and lifestyle) that predict 2-year chronicity above and beyond an extensive list of sociodemographic and psychiatric characteristics.

METHODS

Data are from patients with current depression at baseline (n = 903) and available 2-year follow-up participating in a longitudinal cohort study. Baseline demographic, psychiatric and somatic health indicators were associated with 2-year course trajectories, classified as non-chronic versus chronic RESULTS: At 2-year follow up, 40% of the patients showed a chronic course. Of the twenty tested somatic health indicators, short sleep and high interleukin-6 improved the regression model predicting chronicity with a significant, but modest, effect (ROC = 0.78; p = 0.03).

LIMITATIONS

Due to the observational design we did not have the ability to reliably consider the impact of psychiatric treatment. More elaborate information on somatic health such as dietary patterns would strengthen the study.

CONCLUSIONS

This study showed that short sleep duration and high interleukin-6 contributed significantly to the regression model as independent predictors, suggestive of clinical implications for patients with sleep disturbances and elevated inflammation levels. Other somatic health indicators did not add to the model. Overall, somatic health indicators showed modest additive value for predicting chronic course above and beyond sociodemographic and psychiatric indicators.

Cross system autonomic balance and regulation: Associations with depression and anxiety symptoms

The autonomic nervous system (ANS) has demonstrated utility for identifying alterations in emotion processing associated with common psychopathology, including depression and anxiety. To date though the majority of this ANS research has several limitations. Most studies have examined parasympathetic and sympathetic branches separately, requiring activity in the other branch be inferred. This is problematic as each branch may function independently. Composite indices such as cardiac autonomic balance (CAB) and cardiac autonomic regulation (CAR) which examine the relative input between respiratory sinus arrhythmia (RSA) and pre-ejection period (PEP) should provide more comprehensive measures of autonomic functioning and thus stronger predictors of psychopathology. However, the sympathetic branch is driven by multiple neurotransmitter systems, thus PEP does not necessarily reflect overall SNS arousal. We propose two new metrics for assessing ANS functioning associated with psychopathology: parasympathetic effects on cardiac control (RSA) relative to sympathetic effects on the eccrine system (electrodermal activity, EDA), which we term cross-system autonomic balance (CSAB) and regulation (CSAR). Eighty-five women (18-37) completed a baseline physiological assessment with parasympathetic (RSA) and sympathetic indices (PEP, EDA), along with self-reported depressive and anxiety symptoms. Lower CSAB, indicating sympathetic dominance driven by cholinergic neurotransmission, was associated with higher depressive and anxiety symptoms. Lower CAB indicating sympathetic dominance driven by beta-adrenergic neurotransmission was associated specifically with depressive symptoms. CSAB was a more robust index than RSA. Results support the utility of assessing multiple composite ANS indices for identifying physiological substrates of alterations in emotion regulation associated with internalizing disorders.

Internalizing Problems and Attentional Control

Abstract. Individuals with internalizing problems differ in levels of attentional control (AC), and this heterogeneity could be associated with differences in autonomic arousal. The present study investigated whether AC moderated the effect of internalizing problems on self-reported experience and autonomic nervous system (ANS) responses after the induction of negative affect. Children aged 9–13 years were recruited into a patient group (29) and a healthy control group (25). AC was measured by the Early Adolescent Temperament Questionnaire. Heart rate, heart rate variability (HRV) and pre-ejection period (PEP) were recorded during baseline, a sad film clip and recovery, and analyzed using a marginal linear model. Children reported their experienced emotion, valence, and arousal in response to the film. A significant interaction effect showed increased HRV and longer PEP from baseline to recovery for patients with higher AC. Patients with lower AC showed increased HRV followed by a return to baseline values after the film clip and no significant changes in PEP. Healthy controls showed no significant changes in HRV or PEP independent of level of AC. There were no differences between groups in self-reported experience. The results indicate that AC moderated the effect of internalizing problems on ANS regulation. Increased HRV and longer PEP from baseline to recovery were uniquely associated with higher AC and internalizing problems. This physiological response might indicate a cognitive avoidance strategy. AC could be an important factor explaining heterogeneity in ANS activity among individuals with internalizing problems. Clinical implications of the present findings are discussed.

The association of depression and anxiety with cardiac autonomic activity: The role of confounding effects of antidepressants

BACKGROUND

Depression and anxiety may unfavorably impact on cardiac autonomic dysregulation. However, it is unclear whether this relationship results from a causal effect or may be attributable to confounding factors. We tested the relationship between depression and anxiety with heart rate (HR) and heart rate variability (HRV) across a 9-year follow-up (FU) period and investigated possible confounding by antidepressant use and genetic pleiotropy.

METHODS

Data (no. of observations = 6,994, 65% female) were obtained from the longitudinal Netherlands Study of Depression and Anxiety, with repeated waves of data collection of HR, HRV, depression, anxiety, and antidepressant use. Summary statistics from meta-analyses of genome-wide association studies were used to derive polygenic risk scores of depression, HR, and HRV.

RESULTS

Across the 9-year FU, generalized estimating equations analyses showed that the relationship between cardiac autonomic dysregulation and depression/anxiety rendered nonsignificant after adjusting for antidepressant use. A robust association was found between antidepressant use (especially tricyclic antidepressants, selective serotonin, and noradrenalin reuptake inhibitors) and unfavorable cardiac autonomic activity across all waves. However, no evidence was found for a genetic correlation of depression with HR and HRV, indicating that confounding by genetic pleiotropy is minimal.

CONCLUSIONS

Our results indicate that the association between depression/anxiety and cardiac autonomic dysregulation does not result from a causal pathway or genetic pleiotropy, and these traits might therefore not be inevitably linked. Previously reported associations were likely confounded by the use of certain classes of antidepressants.

Gut permeability and depressive symptom severity in unmedicated adolescents

OBJECTIVE

This study examined gut permeability in unmedicated adolescents with and without major depressive disorder.

METHOD

Medically healthy, non-medicated, 12-17 year-old females in a major depressive episode (MDE) or healthy controls, without any psychiatric condition, were enrolled. They completed the Children's Depression Rating Scale-Revised (CDRS-R) and underwent a clinical interview. Preejection period (PEP) and respiratory sinus arrhythmia (RSA) data were collected to measure autonomic nervous system activity. Following an overnight fast, participants ingested lactulose and mannitol and collected urine for 4 hours while still fasting, to examine gut permeability. Plasma cytokines (interleukin 1β, interleukin 6, and tumor necrosis factor α) were measured. Correlational analyses were used to examine the associations between relevant variables.

RESULTS

41 female participants (age: 14.8 ± 1.6 years, n = 25 with MDE) were enrolled. PEP, but not RSA, was inversely associated with neurovegetative symptom severity on the CDRS-R (r = -0.31, p < 0.06). In the 30 participants with gut permeability data, the lactulose to mannitol ratio (LMR) was significantly positively associated with depression severity, particularly neurovegetative symptom severity (r = 0.37, p < 0.05). Notably, the association between neurovegetative symptom severity and PEP was substantially reduced after adjusting for LMR. Additionally, depression severity was significantly associated with circulating cytokines.

CONCLUSIONS

This is the first study to examine gut permeability in unmedicated adolescents, offering preliminary support for a mechanistic pathway linking sympathetic nervous system activation to increased gut permeability and activation of the innate immune system, likely contributing to the emergence of neurovegetative symptoms of depression.

Cardio-Respiratory Fitness and Autonomic Function in Patients with Major Depressive Disorder

Patients with major depressive disorder (MDD) have an augmented risk of cardiovascular morbidity and mortality. Although a link between depression and autonomic dysfunction as well as reduced cardio-respiratory fitness (CRF) is well documented, the underlying cause is a matter of debate. Therefore, we studied the interplay between autonomic function, body composition and severity of the disease to disentangle possible physiological factors influencing the assumed lack of CRF in MDD patients. We investigated seventeen patients suffering from MDD and seventeen control subjects matched with respect to age, sex, body-mass-index, and smoking habits. A resting baseline assessment and a cardiopulmonary exercise test including a prolonged recovery period were performed to study autonomic function (i.e., heart rate responses and heart rate variability) during rest, exercise and recovery as well as CRF. Most investigated autonomic indices were significantly different at rest, during exercise as well as during recovery indicating altered autonomic modulation. Nevertheless, none of our participants was classified as chronotropically incompetent. As expected, a reduced CRF (i.e., peak oxygen uptake and peak power output, p < 0.01) was observed in patients compared to controls. In addition, a correlation of baseline heart rate and of heart rate during recovery with the ventilatory threshold 1 (p < 0.05) was found in patients only, indicating a relation to the lack of CRF. Furthermore, we observed a positive correlation of the severity of the disease with the weekly sitting time (p < 0.01) as well as a negative correlation with the activity time in the intensity domain walking (p < 0.001) and with the total score of the International Physical Activity Questionnaire (p < 0.01) for patients. This study shows that patients with MDD have altered autonomic function not only during resting conditions but also during exercise as well as recovery from exercise. Intervention studies are needed to evaluate how the described autonomic alterations can be influenced by increasing CRF due to appropriate exercise training programs.

Psychopathology, everyday behaviors, and autonomic activity in daily life: An ambulatory impedance cardiography study of depression, anxiety, and hypomanic traits

Discrepancies regarding the link between autonomic nervous system (ANS) activity and psychopathology may be due in part to inconsistent measurement of non-psychological factors, including eating, drinking, activity, posture, and interacting with others. Rather than sources of noise, behaviors like being active and being with others may be the behavioral pathways that connect psychopathology symptoms to autonomic activity. The present study examined whether behaviors mediate the association of depression, anxiety, and hypomanic traits with ANS by using experience sampling methodology and ambulatory impedance cardiography. Participants (n = 49) completed measures of affect and one day of experience sampling and ambulatory impedance cardiography. The association of hypomanic traits with heart rate variability and heart rate was mediated by physical activity, and social activity mediated the association of depressive symptoms and respiration. These results highlight the importance of considering the pathways between psychopathology and ANS and the mediating role that everyday behaviors play.

Association Between Depression, Anxiety, and Antidepressant Use With T-Wave Amplitude and QT-Interval

Objectives: Cardiac repolarization may be affected by psychiatric disorders and/or antidepressant use, but evidence for this is inconclusive. This study examined the relationship between depressive and anxiety disorder and use of antidepressants with T-wave amplitude (TWA) and QT-interval.

Methods: Data was obtained from the Netherlands Study of Depression and Anxiety (n = 1,383). Depression/anxiety was diagnosed with the DSM-IV based Composite International Diagnostic Interview. The use of tricyclic antidepressants (TCAs), selective serotonin and noradrenalin reuptake inhibitors (SNRIs), and selective serotonin reuptake inhibitors (SSRIs) was established. T-wave amplitude and QT-interval corrected for heart rate (QTc) were obtained from an ECG measured in a type II axis configuration.

Results: Compared to controls, persons with depression or anxiety disorders did not show a significantly different TWA (p = 0.58; Cohen's d = 0.046) or QTc (p = 0.48; Cohen's d = −0.057). In spite of known sympathomimetic effects, TCA use (p = 0.26; Cohen's d = −0.162) and SNRI use (p = 0.70; Cohen's d = −0.055) were not significantly associated with a lower TWA. TCA use (p = 0.12; Cohen's d = 0.225) and SNRI use (p = 0.11; Cohen's d = 0.227) were also not significantly associated with a prolonged QTc.

Conclusion: We did not find evidence that either depressive/anxiety disorder or antidepressant use is associated with abnormalities in TWA or QTc. Earlier found sympathomimetic effects of TCAs and SNRIs are not evident in these measures of cardiac repolarization.

Potential Effect of Pharmacotherapy on Sympathetic Arousal in Autism

Background: Autism spectrum disorder (ASD) is a serious neurodevelopmental disorder associated with autonomic nervous system (ANS) abnormalities. Moreover, at least 50% of children with ASD suffer from other comorbid diseases such as anxiety, depression, and attention deficit hyperactivity disorder (ADHD) associated with receiving psychotropic medication. From this context we aimed to evaluate changes in sympathetic arousal using analysis of electrodermal activity (EDA) as an index of sympathetic cholinergic activity in treated and non-treated autistic children under resting conditions.

Methods: We examined 23 children with ASD and 14 healthy age- and gender-matched children at the age of 7–15 years. The ASD patients were divided into ASD non-treated group (n=12) and ASD treated group (n=11). The EDA was continuously monitored during resting phase in a supine position. The EDA amplitude (μS) was computed as an average of 5 min baseline period.

Results: We found significantly lower EDA in ASD non-treated subgroup compared to controls indicating subtle abnormalities in the regulation of the sympathetic nervous system. Although no significant differences were found between the ASD treated and non-treated subgroups the ASD treated group showed comparable sympathetic activity relative to controls indicating a potential ameliorated treatment effect on sympathetic arousal in ASD.

Conclusions: These findings could help to determine differences in sympathetic arousal in treated and non-treated children with ASD, which is important for assessment of autism-linked cardiovascular risk depending on pharmacotherapy.

Risk of Cardiac Events Associated With Antidepressant Therapy in Patients With Long QT Syndrome

Patients with long QT syndrome (LQTS) are at a high risk of cardiac events. Many patients with LQTS are treated with antidepressant drugs (ADs). We investigated the LQTS genotype-specific risk of recurrent cardiac arrhythmic events (CAEs) associated with AD therapy. The study included 59 LQT1 and 72 LQT2 patients from the Rochester-based LQTS Registry with corrected QT (QT_c) prolongation and a history of AD therapy. Using multivariate Anderson-Gill models, we estimated the LQTS genotype-specific risk of recurrent CAEs (ventricular tachyarrhythmias, aborted cardiac arrest, or sudden cardiac death) associated with time-dependent ADs. Specifically, we examined the risk associated with all ADs, selective serotonin reuptake inhibitor (SSRI), and ADs classified on the CredibleMeds list (www.CredibleMeds.org) as "Conditional" or "Known risk of Torsades de pointes (TdP)." After adjusting for baseline QT_c duration, sex, and time-dependent beta-blocker usage, there was an increased risk of recurrent CAEs associated with ADs in LQT1 patients (hazard ratio = 3.67, 95% confidence interval 1.98-6.82, p < 0.001) but not in LQT2 patients (hazard ratio = 0.89, 95% confidence interval 0.49-1.64, p = 0.716; LQT1 vs LQT2 interaction, p < 0.001). Similarly, LQT1 patients who were on SSRIs or ADs with "Known risk of TdP" had a higher risk of recurrent CAEs than those patients off all ADs, whereas there was no association in LQT2 patients. ADs with "Conditional risk of TdP" were not associated with the risk of recurrent CAEs in any of the groups. In conclusion, the risk of recurrent CAEs associated with time-dependent ADs is higher in LQT1 patients but not in LQT2 patients. Results suggest a LQTS genotype-specific effect of ADs on the risk of arrhythmic events.

Diminution of Heart Rate Variability in Bipolar Depression

Autonomic nervous system (ANS) dysregulation in depression is associated with symptoms associated with the ANS. The beat-to-beat pattern of heart rate defined as heart rate variability (HRV) provides a noninvasive portal to ANS function and has been proposed to represent a means of quantifying resting vagal tone. We quantified HRV in bipolar depressed (BDD) patients as a measure of ANS dysregulation seeking to establish HRV as a potential diagnostic and prognostic biomarker for treatment outcome. Forty-seven BDD patients were enrolled. They were randomized to receive either escitalopram-celecoxib or escitalopram-placebo over 8 weeks in a double-blind study design. Thirty-five patients completed the HRV studies. Thirty-six healthy subjects served as controls. HRV was assessed at pretreatment and end of study and compared with that of controls. HRV was quantified and corrected for artifacts using an algorithm that incorporates time and frequency domains to address non-stationarity of the beat-to-beat heart rate pattern. Baseline high frequency-HRV (i.e., respiratory sinus arrhythmia) was lower in BDD patients than controls, although the difference did not reach significance. Baseline low-frequency HRV was significantly lower in BDD patients (ln4.20) than controls (ln = 5.50) (p < 0.01). Baseline heart period was significantly shorter (i.e., faster heart rate) in BDD patients than controls. No significant change in HRV parameters were detected over the course of the study with either treatment. These findings suggest that components of HRV may be diminished in BDD patients.

Systolic blood pressure decline in very old individuals is explained by deteriorating health: Longitudinal changes from Umeå85+/GERDA

Declining systolic blood pressure (SBP) is common in very old age and is associated with adverse events, such as dementia. Knowledge of factors associated with SBP changes could explain the etiology of this decline in SBP. This study investigated longitudinal changes in socioeconomic factors, medical conditions, drug prescriptions, and assessments and their associations with SBP changes among very old followed individuals.The study was based on data from the Umeå85+/Gerontological Regional Database (GERDA) cohort study, which provided cross-sectional and longitudinal data on participants aged 85, 90, and ≥95 years from 2000 to 2015. Follow-up assessments were conducted after 5 years. The main outcome was a change in SBP. Factors associated with SBP changes were assessed using multivariate linear regression models.In the Umeå85+/GERDA study, 454 surviving individuals underwent follow-up assessment after 5 years. Of these, 297 had SBP measured at baseline and follow-up. The mean change ± standard deviation in SBP was -12 ± 25 mm Hg. SBP decline was associated independently with later investigation year (P = .009), higher baseline SBP (P < .001), baseline antidepressant prescription (P = .011), incident acute myocardial infarction during follow-up (P = .003), new diuretic prescription during follow-up (P = .044), and a decline in the Barthel Activities of Daily Living index at follow-up (P < .001).In conclusion, SBP declines among very old individuals. This decline seems to be associated with initial SBP level, investigation year, and health-related factors.

The Effect of Depression, Generalized Anxiety, and Selective Serotonin Reuptake Inhibitors on Change in Bone Metabolism in Adolescents and Emerging Adults

The purpose of this study was to prospectively examine the independent contribution of major depressive disorder (MDD), generalized anxiety disorder (GAD), and selective serotonin reuptake inhibitors (SSRIs) use to changes in bone metabolism in older adolescents and emerging adults. Medically healthy 15- to 20-year-olds who were unmedicated or within 1 month of starting an SSRI were prospectively followed. Psychiatric functioning and medication treatment were assessed monthly. Every 4 months, trabecular and cortical volumetric bone mineral density (vBMD) at the radius and markers of bone metabolism were evaluated. Every 8 months, total body less head areal bone mineral content and lumbar spine (LS) areal BMD (aBMD) were determined. Linear mixed-effects regression analysis examined associations between bone measures on the one hand and MDD, GAD, and SSRI indices on the other. A total of 264 participants were followed for 1.51 ± 0.76 years. After adjusting for age, sex, vitamin D concentration, physical activity, lean mass or grip strength, and time in the study, MDD severity was associated with increasing LS aBMD. Similarly, SSRI use was associated with increasing LS aBMD and bone formation in female participants. In contrast, SSRI use was associated with decreasing LS aBMD in males. After accounting for depression, GAD was independently, albeit weakly, associated with increased bone mineralization. In older adolescents and emerging adults, MDD and GAD are associated with increasing bone mass, particularly in the lumbar spine and in females, whereas SSRIs are associated with increasing bone mass in females but decreasing bone mass in males. © 2017 American Society for Bone and Mineral Research.

Positive affect and parasympathetic activity: Evidence for a quadratic relationship between feeling safe and content and heart rate variability

There has been an increased interest in the study of underlying autonomic correlates of emotions. This study tests the hypothesis that high levels of high-frequency heart rate variability (HF HRV) are associated with positive emotions. In addition, we hypothesize that this association will differ according to the type of positive emotion. Also, based on recent findings, we tested the hypothesis that this relationship would be nonlinear. Resting-state HRV was collected and self-report measures of different positive emotions were administered to a sample of 124 volunteers.

RESULTS

Results suggested that there was a quadratic relationship between high-frequency heart rate variability and positive emotions associated with safeness and contentment, but not with positive emotions associated with excitement or lack of arousal. Our data suggests that different positive emotions may be characterized by qualitatively distinct profiles of autonomic activation. Also, given the role of positive emotions in social affiliation, and particularly positive emotions associated with a quiescence motivational state, results are interpreted in light of theoretical accounts that highlight the importance of vagal regulation for social behavior.

Differences of sympathetic and parasympathetic modulation in major depression

Inconsistent results have been reported with respect to cardiac autonomic function in major depression. The aim of our study was to investigate autonomic function in various branches of the autonomic nervous system in order to better understand parasympathetic and sympathetic modulation in the disease. We investigated 29 unmedicated patients suffering from major depression (MD) in comparison to matched control subjects (gender, age, BMI). The autonomic assessment at rest included values of heart rate variability (HRV), blood pressure variability (BPV), baroreflex sensitivity (BRS), respiration, skin conductance (SC) as well as the calculation of pupillary diameter and the unrest index (PUI). Results were compared by means of a multivariate analysis of variance. In a classification analysis, we identified suitable parameters for patient - control separation. Finally, to analyze interrelations of pupillometric parameters and autonomic indices, we estimated Pearson correlation coefficients and fitted a linear regression model. Apart from a significantly increased heart rate (75±12 vs. 65±6min^-1, p<0.001) and decreased BRS (14±13 vs. 20±15ms/mmHg, p<0.05), we observed a lack of significant differences in HRV and BPV analysis between patients and controls. However, pupillary diameter (left: 4.3±0.9 vs. 3.8±0.6, p<0.01; right: 4.3±0.9 vs. 3.7±0.6mm, p<0.01) and PUI (left: 14.8±6.0 vs. 10.7±4.5mm/min, p<0.01; right: 14.1±5.5 vs. 10.7±4.8mm/min, p<0.01), as well as the level (left: 7.3±6.2 vs. 4.3±4.4 μS, p<0.05) and fluctuations of skin conductance (left: 4.2±4.1 vs. 2.5±3.6, p<0.05; right: 4.2±4.4 vs. 2.6±3.2, p<0.05) were significantly different. The classification accuracy was 88.5% with high specificity (e=92.9%) and sensitivity (s=83.3%) including heart rate, PUI and skin conductance. HRV indices correlated to PUI in controls but not in patients. Our data add evidence to the current debate on autonomic function in major depression. We suggest that diverse results are mainly caused by methodological shortcomings, in particular by the application of HRV assessment only, which misses changes of sympathetic modulation. The application of broader analyzing tools will clarify the pattern of autonomic function in depression and ultimately its role in cardiac morbidity and mortality.

Suicidal Ideation Is Associated with Altered Variability of Fingertip Photo-Plethysmogram Signal in Depressed Patients

Physiological and psychological underpinnings of suicidal behavior remain ill-defined and lessen timely diagnostic identification of this subgroup of patients. Arterial stiffness is associated with autonomic dysregulation and may be linked to major depressive disorder (MDD). The aim of this study was to investigate the association between arterial stiffness by photo-plethysmogram (PPG) in MDD with and without suicidal ideation (SI) by applying multiscale tone entropy (T-E) variability analysis. Sixty-one 10-min PPG recordings were analyzed from 29 control, 16 MDD patients with (MDDSI+) and 16 patients without SI (MDDSI-). MDD was based on a psychiatric evaluation and the Mini-International Neuropsychiatric Interview (MINI). Severity of depression was assessed using the Hamilton Depression Rating Scale (HAM-D). PPG features included peak (systole), trough (diastole), pulse wave amplitude (PWA), pulse transit time (PTT) and pulse wave velocity (PWV). Tone (Diastole) at all lags and Tone (PWA) at lags 8, 9, and 10 were found to be significantly different between the MDDSI+ and MDDSI- group. However, Tone (PWA) at all lags and Tone (PTT) at scales 3-10 were also significantly different between the MDDSI+ and CONT group. In contrast, Entropy (Systole), Entropy (Diastole) and Tone (Diastole) were significantly different between MDDSI- and CONT groups. The suicidal score was also positively correlated (r = 0.39 ~ 0.47; p < 0.05) with systolic and diastolic entropy values at lags 2-10. Multivariate logistic regression analysis and leave-one-out cross-validation were performed to study the effectiveness of multi-lag T-E features in predicting SI risk. The accuracy of predicting SI was 93.33% in classifying MDDSI+ and MDDSI- with diastolic T-E and lag between 2 and 10. After including anthropometric variables (Age, body mass index, and Waist Circumference), that accuracy increased to 96.67% for MDDSI+/- classification. Our findings suggest that tone-entropy based PPG variability can be used as an additional accurate diagnostic tool for patients with depression to identify SI.

Which biopsychosocial variables contribute to more weight gain in depressed persons?

Depression appears to be associated with weight gain. Little is known about whether this association is independent of, or partly due to, several biopsychosocial variables. This study aims to investigate which biopsychosocial variables contribute to weight gain over a 4-year period in persons with major depressive disorder (MDD) or high depressive symptoms. Data from 1658 adults who participated in the Netherlands Study of Depression and Anxiety were used. Baseline depression was measured with a DSM-IV based psychiatric interview and with a depressive symptom measure. Four year weight gain was classified as stable weight (within 5% gain or loss) versus weight gain (>5% gain). Twenty-one baseline psychological, lifestyle and biological variables and antidepressant use were considered as potential contributing variables. In sociodemographic adjusted models, MDD and depressive symptoms were associated with subsequent weight gain. None of the biopsychosocial variables or antidepressants was associated with weight gain, thus did not contribute to the observed increased weight gain risk in depression, except for alcohol intake and TCA use. Future research should explore other potential factors that may be responsible for the increased risk for subsequent weight gain in depression, e.g. unhealthy dietary patterns or eating styles, or underlying intrinsic factors such as genetics.

Temporal stability and drivers of change in cardiac autonomic nervous system activity

OBJECTIVES

This study determined temporal stability of ambulatory measured cardiac autonomic activity for different time periods and investigated potential drivers of changes in this activity.

METHODS

Data was drawn from baseline (n=2379), 2-year (n=2245), and 6-year (n=1876) follow-up from the Netherlands Study of Depression and Anxiety. Cardiac autonomic activity was measured with heart rate (HR), respiratory sinus arrhythmia (RSA) and pre-ejection period (PEP). Autonomic temporal stability was determined across 2, 4, and 6year intervals. We subsequently examined the association between sociodemographics, lifestyle, mental health, cardiometabolic health, and the use of antidepressant and cardiac medication with change in cardiac autonomic activity.

RESULTS

Over 2years, stability was good for HR (ICC=0.703), excellent for RSA (ICC=0.792) and moderate for PEP (ICC=0.576). Stability decreased for a 4- (HR ICC=0.688, RSA ICC=0.652 and PEP ICC=0.387) and 6-year interval (HR ICC=0.633, RSA ICC=0.654 and PEP ICC=0.355). The most important determinants for increase in HR were (increase in) smoking, increase in body mass index (BMI) and (starting) the use of antidepressants. Beta-blocking/antiarrhythmic drug use led to a decrease in HR. Decrease in RSA was associated with age, smoking and (starting) antidepressant use. Decrease in PEP was associated with age and (increase in) BMI.

CONCLUSIONS

Cardiac autonomic measures were rather stable over 2years, but stability decreased with increasing time span. Determinants contributing to cardiac autonomic deterioration were older age, (increase in) smoking and BMI, and (starting) the use of antidepressants. (Starting) the use of cardiac medication improved autonomic function.

Heart Rate Variability: A Novel Modality for Diagnosing Neuropathic Pain after Spinal Cord Injury

Background: Heart rate variability (HRV), the physiological variance in the heart's R-R interval length, can be analyzed to produce various parameters reflective of one's autonomic balance. HRV analysis may be used to capture those autonomic aberrations associated with chronic neuropathic pain (NP) in spinal cord injury (SCI). This study assesses the capacity of HRV parameters to diagnose NP in an SCI cohort.

Methods: An electrocardiogram (ECG) was collected at rest from able bodied participants (AB, n = 15), participants with SCI only (SCI-NP, n = 11), and those with SCI and NP (SCI+NP, n = 20). HRV parameters were analyzed using conventional time and frequency analysis.

Results: At rest, there were no heart rate differences amongst groups. However, SCI+NP participants demonstrated lower overall HRV, as determined by the SDNN time domain parameter, compared to either AB (p < 0.01) or SCI-NP (p < 0.05) groups. Moreover, AB and SCI-NP participants were statistically comparable for all HRV time and frequency domain parameters. Additional analyses demonstrated no differences in HRV parameters between T4, above vs. T5, below SCI groups (for all parameters: p > 0.15) or between C8, above vs. T1, below SCI groups (p > 0.30).

Conclusions: Participants with SCI and NP exhibit a lower overall HRV, which can be determined by HRV time domain parameter SDNN. HRV analysis is an innovative modality with the capacity for objective quantification of chronic NP in participants with SCI.

The association between three major physiological stress systems and oxidative DNA and lipid damage

BACKGROUND

Increased activity of the three major physiological stress systems (immune-inflammatory system, hypothalamic-pituitary-adrenal-axis [HPA-axis], and autonomic nervous system [ANS]) is part of the pathophysiology of various somatic and psychiatric diseases. Oxidative damage is a key mechanism in both ageing and disease. Elucidating the relationship between these stress systems and oxidative damage would contribute to the understanding of the role of physiological stress in disease. This study therefore investigates associations between various measures of physiological stress and oxidative DNA (8-hydroxy-2'-deoxyguanosine, 8-OHdG) and lipid (F2-isoprostanes) damage.

METHODS

Plasma 8-OHdG and F2-isoprostanes were measured using LC-MS/MS in 2858 subjects (aged 18-65). Plasma inflammation markers, salivary cortisol and ANS markers (three for each stress system) were determined. Linear regression analyses were adjusted for sociodemographics, sampling factors and medication.

RESULTS

8-OHdG was positively associated with all inflammation markers (β=0.047-0.050, p<0.01), evening cortisol (β=0.073, p<0.001), and unexpectedly with low respiratory sinus arrhythmia (RSA) reflecting low ANS stress (β=0.073, p<0.001). F2-isoprostanes were associated with higher C-reactive protein (β=0.072, p<0.001), high ANS stress reflected in heart rate (β=0.064, p<0.001) and RSA (β=-0.076, p=0.001), but not with cortisol. Analyses investigating the cumulative impact of the stress systems demonstrated that the number of systems with ≥1 marker in the high risk quartile showed a positive linear trend with both 8-OHdG (p=0.030) and F2-isoprostanes (p=0.009).

CONCLUSION

This large-scale study showed that markers of inflammation, the HPA-axis and ANS are associated with oxidative DNA damage. Oxidative lipid damage is associated with inflammation and the ANS. Increased physiological stress across systems is associated with increasing oxidative damage in a dose-response fashion.

Basal autonomic activity, stress reactivity, and increases in metabolic syndrome components over time

CONTEXT

Basal autonomic nervous system (ANS) functioning has been linked to the metabolic syndrome (MetS), but the role of ANS reactivity in response to stress remains unclear.

OBJECTIVE

To examine cross-sectionally and longitudinally to what extent ANS basal level and stress reactivity are related to MetS.

DESIGN

2-year and 6-year data from a prospective cohort: the Netherlands Study of Depression and Anxiety.

SETTING

Participants were recruited from the general community, primary care, and mental health care organizations.

PARTICIPANTS

1922 respondents (mean age=43.7years).

MAIN OUTCOME MEASURES

Indicators of ANS functioning were heart rate (HR), respiratory sinus arrhythmia (RSA) and pre-ejection period (PEP). ANS stress reactivity was measured during a cognitively challenging stressor and a personal-emotional stressor. MetS components included triglycerides, high-density lipoprotein cholesterol, blood pressure, glucose and waist circumference.

RESULTS

Cross-sectional analyses indicated that higher basal HR, lower basal values of RSA and PEP, and higher RSA reactivity during cognitive challenge were related to less favorable values of almost all individual MetS components. Longitudinal analyses showed that higher basal HR and shorter basal PEP predicted 4-year increase in many MetS abnormalities. Higher RSA stress reactivity during cognitive challenge predicted 4-year increase in number of MetS components.

CONCLUSION

Higher basal sympathetic, lower basal parasympathetic activity, and increased parasympathetic withdrawal during stress are associated with multiple MetS components, and higher basal sympathetic activity predicts an increase in metabolic abnormalities over time. These findings support a role for ANS dysregulation in the risk for MetS and, consequently, the development of cardiovascular disease.

Depression and cardiovascular disease: Epidemiological evidence on their linking mechanisms

Depression's burden of disease goes beyond functioning and quality of life and extends to somatic health. Results from longitudinal cohort studies converge in illustrating that major depressive disorder (MDD) subsequently increases the risk of cardiovascular morbidity and mortality with about 80%. The impact of MDD on cardiovascular health may be partly explained by mediating mechanisms such as unhealthy lifestyle (smoking, excessive alcohol use, physical inactivity, unhealthy diet, therapy non-compliance) and unfavorable pathophysiological disturbances (autonomic, HPA-axis, metabolic and immuno-inflammatory dysregulations). A summary of the literature findings as well as relevant results from the large-scale Netherlands Study of Depression and Anxiety (N=2981) are presented. Persons with MDD have significantly worse lifestyles as well as more pathophysiological disturbances as compared to healthy controls. Some of these differences seem to be specific for (typical versus 'atypical', or antidepressant treated versus drug-naive) subgroups of MDD patients. Alternative explanations are also present, namely undetected confounding, iatrogenic effects or 'third factors' such as genetics.

Differential Autonomic Nervous System Reactivity in Depression and Anxiety During Stress Depending on Type of Stressor

OBJECTIVES

It remains unclear whether depressive and anxiety disorders are associated with hyporeactivity or hyperreactivity of the autonomic nervous system (ANS) and whether deviant reactivity occurs in all types of stressors. This study compared ANS reactivity in people with current or remitted depression/anxiety with reactivity in healthy controls during two stress conditions.

METHODS

From the Netherlands Study of Depression and Anxiety, data of 804 individuals with current depression/anxiety, 913 individuals with remitted depression/anxiety, and 466 healthy controls (mean age = 44.1 years; 66.4% female) were available. Two conditions were used to evoke stress: a) an n-back task, a cognitively challenging stressor, and 2) a psychiatric interview, evoking personal-emotional stress related to the occurrence of symptoms of depression/anxiety. Indicators of ANS activity were heart rate (HR), root mean square of differences between successive interbeat intervals (RMSSD), respiratory sinus arrhythmia (RSA), and preejection period.

RESULTS

As compared with controls, participants with psychopathology had significant hyporeactivity of HR (controls = 4.1 ± 4.2 beats/min; remitted = 3.5 ± 3.5 beats/min; current psychopathology = 3.1 ± 3.4 beats/min), RMSSD (controls = -6.2 ± 14.5 milliseconds; remitted = -5.4 ± 17.8 milliseconds; current psychopathology = -3.5 ± 15.4 milliseconds), and RSA (controls = -9.3 ± 17.0 milliseconds; remitted = -7.4 ± 16.5 milliseconds; current psychopathology = -6.9 ± 15.0 milliseconds) during the n-back task. In contrast, during the psychiatric interview, they showed significant hyperreactivity of HR (controls = 2.7 ± 3.4 beats/min; remitted = 3.5 ± 3.4 beats/min; current psychopathology = 4.0 ± 3.3 beats/min), RMSSD (controls = -3.4 ± 12.2 milliseconds; remitted = -4.1 ± 12.1 milliseconds; current psychopathology = -5.6 ± 11.8 milliseconds), and RSA (controls = -3.8 ± 8.1 milliseconds; remitted = -4.3 ± 7.9 milliseconds; current psychopathology = -5.0 ± 7.9 milliseconds). The lack of group differences in preejection period reactivity suggests that the found effects were driven by altered cardiac vagal reactivity in depression/anxiety.

CONCLUSIONS

The direction of altered ANS reactivity in depressed/anxious patients is dependent on the type of stressor, and only the more ecologically valid stressors may evoke hyperreactivity in these patients.

Anxiety and new onset of cardiovascular disease: critical review and meta-analysis

BACKGROUND

Anxiety has been associated with new-onset cardiovascular disease (CVD), but the quality of this relationship is unclear. Only if anxiety is a causal, independent cardiovascular risk factor might it be a target for CVD prevention.

AIMS

To determine and examine the independent association and causality between anxiety and incident CVD.

METHOD

PubMed, EMBASE and PsycINFO databases were searched up to October 2013. A review of Hill's criteria for causality and random effects meta-analysis were conducted of prospective, population-based studies examining anxiety and incident CVD in people free from CVD at baseline.

RESULTS

The meta-analysis comprised 37 papers (n = 1 565 699). The follow-up ranged from 1 to 24 years. Anxiety was associated with a 52% increased incidence of CVD (hazard ratio = 1.52, 95% CI 1.36-1.71). The risk seemed independent of traditional risk factors and depression. The evaluation of Hill's criteria largely argued in favour of causality.

CONCLUSIONS

Anxiety may be of interest for CVD prevention. Future research should examine biological and behavioural underpinnings of the association in order to identify targets for intervention.

[Treatment of depression in coronary heart disease]

Depression and coronary heart disease (CHD) are leading causes of disability and show a high comorbidity. Furthermore, depression is an independent risk factor for an unfavorable course and increased mortality in patients with CHD. In contrast, successful treatment of depression can reduce the risk of cardiac events. Currently, there are several treatment options for the management of depression in CHD, including self-management strategies, psychotherapy, pharmacotherapy and collaborative care models. This article provides an overview of the epidemiology of depression in CHD, the mechanisms of association and the current state of evidence with respect to the different treatment options.

CNS- and ANS-arousal predict response to antidepressant medication: Findings from the randomized iSPOT-D study

Arousal systems are one of the recently announced NIMH Research Domain Criteria to inform future diagnostics and treatment prediction. In major depressive disorder (MDD), altered central nervous system (CNS) wakefulness regulation and an increased sympathetic autonomic nervous system (ANS) activity have been identified as biomarkers with possible discriminative value for prediction of antidepressant treatment response. Therefore, the hypothesis of a more pronounced decline of CNS and ANS-arousal being predictive for a positive treatment outcome to selective-serotonin-reuptake-inhibitor (SSRI) treatment was derived from a small, independent exploratory dataset (N = 25) and replicated using data from the randomized international Study to Predict Optimized Treatment Response in Depression (iSPOT-D). There, 1008 MDD participants were randomized to either a SSRI (escitalopram or sertraline) or a serotonin-norepinephrine-reuptake-inhibitor (SNRI-venlafaxine) arm. Treatment response was established after eight weeks using the 17-item Hamilton Rating Scale for Depression. CNS-arousal (i.e. electroencephalogram-vigilance), ANS-arousal (heart rate) and their change across time were assessed during rest. Responders and remitters to SSRI treatment were characterized by a faster decline of CNS-arousal during rest whereas SNRI responders showed a significant increase of ANS-arousal. Furthermore, SSRI responders/remitters showed an association between ANS- and CNS-arousal regulation in comparison to non-responders/non-remitters while this was not the case for SNRI treatment arm. Since positive treatment outcome to SSRI and SNRI was linked to distinct CNS and ANS-arousal profiles, these predictive markers probably are not disorder specific alterations but reflect the responsiveness of the nervous system to specific drugs.

Antidepressant use and risk for mortality in 121,252 heart failure patients with or without a diagnosis of clinical depression

BACKGROUND

Depression is a risk factor for mortality in patients with heart failure (HF), however, treating depression with antidepressant therapy does not seem to improve survival. We examined the prevalence of antidepressant use in HF patients, the correlates of antidepressant use subsequent to hospital discharge and the relation between antidepressant use, clinical depression and mortality in patients with HF.

METHODS

121,252 HF patients surviving first hospitalization were stratified by antidepressant use and a diagnosis of clinical depression.

RESULTS

In total, 15.6% (19,348) received antidepressants at baseline, of which 86.7% (16,780) had no diagnosis of clinical depression. Female gender, older age, higher socio-economic status, more comorbidities, increased use of statins, spironolactone and aspirin, lower use of beta-blockers and ACE-inhibitors, greater HF severity and a diagnosis of clinical depression were independently associated with antidepressant use. Patients using no antidepressants with clinical depression and patients using antidepressants, with or without clinical depression, had a significantly higher risk for all-cause mortality (HR, 1.25; 95% CI, 1.15-1.36; HR, 1.24; 95% CI, 1.22-1.27; HR, 1.21; 95% CI, 1.16-1.27, respectively) and CV-mortality (HR: 1.17; 95% CI, 1.14-1.20, P<.001; HR: 1.20; 95% CI, 1.08-1.34, P<.001; HR: 1.21; 95% CI, 1.12-1.29, P<.001, respectively) as compared to patients not using antidepressants without depression in adjusted analysis.

CONCLUSION

Patients with HF taking antidepressants had an increased risk for all-cause and CV-mortality, irrespectively of having clinical depression. These results highlight the importance of further examining the antidepressant prescription pattern in patients with HF, as this may be crucial in understanding the antidepressant effects on cardiac function and mortality.

The association between depressive disorder and cardiac autonomic control in adults 60 years and older

BACKGROUND

Altered cardiac autonomic control has often been reported in depressed persons and might play an important role in the increased risk for cardiovascular disease (CVD). A negative association between cardiac autonomic control and depression might become specifically clinically relevant in persons 60 years or older as CVD risk increases with age.

METHODS

This study included data of 321 persons with a depressive disorder and 115 controls participating in the Netherlands Study of Depression in Older Persons (mean age = 70.3 years, 65.7% female). Respiratory sinus arrhythmia (RSA), heart rate (HR), and preejection period (PEP) were measured and compared between depressed persons and controls. In addition, the role of antidepressants and clinical characteristics (e.g., age of depression onset and comorbid anxiety) was examined.

RESULTS

Compared with controls, depressed persons had lower RSA (mean [standard error of the mean] = 23.5 [1.2] milliseconds versus 18.6 [0.7] milliseconds, p = .001, d = 0.373) and marginally higher HR (73.1 [1.1] beats/min versus 75.6 [0.6] beats/min, p = .065, d = 0.212), but comparable PEP (113.9 [2.1] milliseconds versus 112.0 [1.2] milliseconds, p = .45, d = 0.087), fully adjusted. Antidepressants strongly attenuated the associations between depression and HR and RSA. Antidepressant-naïve depressed persons had similar HR and RSA to controls, whereas users of antidepressants showed significantly lower RSA. In addition, tricyclic antidepressant users had higher HR (p < .001, d = 0.768) and shorter PEP (p = .014, d = 0.395) than did controls.

CONCLUSIONS

Depression was not associated with cardiac autonomic control, but antidepressants were in this sample. All antidepressants were associated with low cardiac parasympathetic control and specifically tricyclic antidepressants with high cardiac sympathetic control.

Pain in dementia: prevalence and associated factors: protocol of a multidisciplinary study

Background

Pain is a common problem in people with dementia, however the exact prevalence of pain in dementia subtypes, e.g. Alzheimer’s Disease (AD), Vascular Dementia (VaD), Frontotemporal Dementia (FTD) and dementia with Lewy Bodies (DLB), is unknown, as is the relation between pain and the different subtypes of dementia. In this study, the prevalence of pain in people with dementia will be investigated per dementia subtype and the relationship between the various subtypes of dementia and the presence of specific types of pain (i.e. musculoskeletal pain, neuropathic pain and orofacial pain) will be examined. Secondly, associations between various types of pain, cognitive functioning, neuropsychiatric symptoms and quality of life in people with dementia will be examined. A third purpose is to study the value of the assessment of autonomic responses in assessing pain in people with dementia. Finally, the effect of feedback to the attending physician on the presence of pain, based on examination by investigators with backgrounds in neuropsychology, geriatric dentistry and elderly care medicine, will be evaluated.

Methods/Design

A cross-sectional, partially longitudinal observational study in 400 participants with dementia, aged 60 years and older. Participants will be recruited from an outpatient memory clinic and dementia special care units. All participants will be examined by an elderly care medicine trainee, a dentist with experience in geriatric dentistry, and a neuropsychologist. The primary outcome is presence of pain. Secondary outcomes will include oral health, autonomic responses to pain stimulus, vital sensibility and gnostic sensibility, musculoskeletal examination, cognitive functioning, neuropsychiatric symptoms, and quality of life.

Discussion

This study will help to enhance our knowledge regarding the prevalence of different types of pain in different dementia subtypes i.e. AD, VaD, FTD and DLB. This study also aims to contribute to a better understanding of oral health status in people with dementia, the use of autonomic responses in the assessment of pain in people with dementia and the relationships between pain and cognitive symptoms, neuropsychiatric symptoms and quality of life in people with various dementia subtypes and in different stages of the disease.

Tricyclic and SSRI usage influences the association between BMI and health risk factors

To determine if selective-serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) influence the association between obesity and cardiovascular disease risk, participants from the Third National Health and Nutrition Examination Survey (NHANES III; 1988-1992) and continuous NHANES (1999-2009, n = 18 274) were used. For a given body mass index (BMI), individuals taking SSRIs (n = 219) tended to have significantly better health risk profiles with lower systolic blood pressure (P = 0.002) and higher high-density lipoprotein (P = 0.003) compared with non-users. Conversely, those who used TCAs (n = 116) had significantly worse health risk profiles with higher diastolic blood pressure (P ≤ 0.0001) and triglycerides (P = 0.023) as compared with non-users for a given BMI. Insulin resistance (HOMA-IR) was higher in TCA users and those with larger BMIs, whereby the differences in insulin resistance between TCA users and non-users was greater with higher BMIs (interaction effect: P = 0.013). Furthermore, individuals taking SSRIs were less likely to have cardiovascular disease than non-users (odds ratio, 95% confidence interval = 0.50, 0.33-0.75) for a given BMI, with no differences by TCA use (odds ratio = 0.74, 0.44-1.24). SSRI and TCA use may alter how body weight relates with cardiovascular risk. When prescribing antidepressant medications, it may be necessary to monitor and consider body weight and cardiovascular risk profile of individual patients.

Antidepressants, autonomic function and mortality in patients with coronary heart disease: data from the Heart and Soul Study

BACKGROUND

Antidepressants reduce depressive symptoms in patients with coronary heart disease, but they may be associated with increased mortality. This study aimed to examine whether the use of tricyclic antidepressants (TCA) or selective serotonin reuptake inhibitors (SSRI) is associated with mortality in patients with coronary heart disease, and to determine whether this association is mediated by autonomic function.

METHOD

A total of 956 patients with coronary heart disease were followed for a mean duration of 7.2 years. Autonomic function was assessed as heart rate variability, and plasma and 24-h urinary norepinephrine.

RESULTS

Of 956 patients, 44 (4.6%) used TCA, 89 (9.3%) used SSRI, and 823 (86.1%) did not use antidepressants. At baseline, TCA users exhibited lower heart rate variability and higher norepinephrine levels compared with SSRI users and antidepressant non-users. At the end of the observational period, 52.3% of the TCA users had died compared with 38.2% in the SSRI group and 37.3% in the control group. The adjusted hazard ratio (HR) for TCA use compared with non-use was 1.74 [95% confidence interval (CI) 1.12-2.69, p = 0.01]. Further adjustment for measures of autonomic function reduced the association between TCA use and mortality (HR = 1.27, 95% CI 0.67-2.43, p = 0.47). SSRI use was not associated with mortality (HR = 1.15, 95% CI 0.81-1.64, p = 0.44).

CONCLUSIONS

The use of TCA was associated with increased mortality. This association was at least partially mediated by differences in autonomic function. Our findings suggest that TCA should be avoided in patients with coronary heart disease.