Tyrosine hydroxylase gene microsatellite polymorphism associated with insulin resistance in depressive disorder

Implementation Planning for Integrating Depression Screening in Diabetes Mellitus and HIV Clinics in Botswana

Depression is highly prevalent and, when comorbid with other medical conditions, can worsen health outcomes. Implementing routine depression screening within medical clinics can ensure that patients receive suitable treatment and improve overall health outcomes. Unfortunately, depression screening within medical settings is rare, particularly in low- and middle-income countries. This qualitative study evaluated patient and clinician perspectives on implementing depression screening within HIV and diabetes clinics in Botswana. Seven clinicians and 23 patients within these clinics were purposively selected and interviewed using a guide informed by the Consolidated Framework for Implementation Research (CFIR) to understand barriers and facilitators to depression screening in medical clinics in Botswana. Interviews were recorded, transcribed, and analyzed using NVivo. Three general themes emerged: (1) Appropriateness and Acceptability: attitudes and beliefs from clinicians and patients about whether depression screening should occur in this setting; (2) Stigma as an important barrier: the need to address the negative associations with depression to facilitate screening; and (3) Recommendations to facilitate screening including improving knowledge and awareness about depression, offering incentives to complete the screening, providing staff training, ensuring resources for treatment, the need to preserve confidentiality, and utilizing leadership endorsement. These results offer insights into how to implement depression screening within medical clinics in Botswana. These results can help design implementation strategies to increase depression screening in these clinics, which can be tested in future studies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-022-00062-3.

Forensic Autosomal Short Tandem Repeats and Their Potential Association With Phenotype

Forensic DNA profiling utilizes autosomal short tandem repeat (STR) markers to establish identity of missing persons, confirm familial relations, and link persons of interest to crime scenes. It is a widely accepted notion that genetic markers used in forensic applications are not predictive of phenotype. At present, there has been no demonstration of forensic STR variants directly causing or predicting disease. Such a demonstration would have many legal and ethical implications. For example, is there a duty to inform a DNA donor if a medical condition is discovered during routine analysis of their sample? In this review, we evaluate the possibility that forensic STRs could provide information beyond mere identity. An extensive search of the literature returned 107 articles associating a forensic STR with a trait. A total of 57 of these studies met our inclusion criteria: a reported link between a STR-inclusive gene and a phenotype and a statistical analysis reporting a p-value less than 0.05. A total of 50 unique traits were associated with the 24 markers included in the 57 studies. TH01 had the greatest number of associations with 27 traits reportedly linked to 40 different genotypes. Five of the articles associated TH01 with schizophrenia. None of the associations found were independently causative or predictive of disease. Regardless, the likelihood of identifying significant associations is increasing as the function of non-coding STRs in gene expression is steadily revealed. It is recommended that regular reviews take place in order to remain aware of future studies that identify a functional role for any forensic STRs.

Schizophrenia, antipsychotics and diabetes: Genetic aspects

The relatively high comorbidity of type 2 diabetes and schizophrenia may suggest a shared biological susceptibility to these twoconditions. Family studies have demonstrated an increased risk of diabetes in unaffected relatives of patients with schizophrenia, consistent with a heritable susceptibility trait. Linkage analyses have identified several loci that are associated with schizophrenia and some of these, notably those on chromosomes 2p22.1-p13.2 and 6g21-824.1 have also been observed in linkage studies in type 2 diabetes. In addition, the dopamine D5 receptor on chromosome 5 and the tyrosine hydroxylase gene on chromosome 11 have both been suggested as candidate genes in schizophrenia and may also be implicated in susceptibility to poor glycaemic control. In addition, an increased rate of type II diabetes has been observed in some patients treated with antipsychotics. Potential neurochemical substrates of this effect include the histamine H1 receptor, the 5-HT2C serotonin receptor or the β3 adrenoreceptor. However, the search for a genetic basis to the association between diabetes and schizophrenia is still in its infancy, and much further work needs to be performed, including the systematic screening of all confirmed susceptibility loci and quantitative trait locus mapping of glycaemic control.

Comorbidities Among Persons With Incident Psychiatric Condition

OBJECTIVE

I sought to determine how medical comorbidities co-exist with incident psychiatric condition.

METHOD

I used data from all 11 available waves (1992-2012) of the Health and Retirement Study (HRS). I identified 4,358 index participants with self-reported incident psychiatric condition. I collected comorbidity data from participants preceding, including, and succeeding that incident wave. Comorbidities assessed included high blood pressure (HBP), diabetes mellitus, cancer, lung disease, heart disease, stroke, and arthritis. Modified Poisson regression combined with log-linked binomial regression was used to estimate relative risks (RRs) of reporting a comorbidity preceding and following the incident wave. Multiple comparison testing dictated significance of RRs with p < .007.

RESULTS

For the waves preceding the index wave, the RRs of reporting all comorbidities except HBP and cancer were significantly (p < .007) increased. For the waves following incident psychiatric condition, the risks of reporting heart disease, diabetes, and lung disease were significantly (p < .007) increased. These results were adjusted for participant age, race, gender, other comorbidities listed, and the wave in which a comorbidity was reported.

CONCLUSION

The bidirectional association between a psychiatric condition and medical illnesses could only be statistically confirmed for lung disease, diabetes, and heart disease. It is of interest to determine how reporting a psychiatric condition may affect the sequelae of health care use and treatment outcomes for patients with either of these comorbidities or a combination of them.

Evaluation of affective temperament and anxiety-depression levels of patients with polycystic ovary syndrome

BACKGROUND

Women with polycystic ovary syndrome (PCOS) are reported to experience depressive episodes at a higher rate than healthy controls (HC). Affective temperament features are psychiatric markers that may help to predict and identify vulnerability to depression in women with PCOS. Our aim was to evaluate the affective temperaments of women with PCOS and to investigate the association with depression and anxiety levels and laboratory variables in comparison with HC.

METHODS

The study included 71 women with PCOS and 50 HC. Hormonal evaluations were performed for women with PCOS. Physical examination, clinical history, Hospital Anxiety and Depression Scale (HADS) and TEMPS-A were performed for all subjects. Differences between groups were evaluated using Student's t-tests and Mann-Whitney U tests. Correlations and logistic regression tests were performed.

RESULTS

All temperament subtype scores, except hyperthymic, and HADS anxiety, depression, and total scores were significantly higher in patients with PCOS compared to HC. A statistically significant positive correlation was found between BMI and irritable temperament, and insulin and HADS depression scores in patients with PCOS. Additionally, hirsutism score and menstrual irregularity were correlated with HADS depression, anxiety and total scores in PCOS patients. In logistic regression analysis, depression was not affected by PCOS, hirsutism score or menstrual irregularity. However, HADS anxiety score was associated with hirsutism score.

CONCLUSIONS

Our study is the first to evaluate the affective temperament features of women with PCOS. Consequently, establishing affective temperament properties for women with PCOS may help clinicians predict those patients with PCOS who are at risk for depressive and anxiety disorders.

Putative role for insulin resistance in depression risk in polycystic ovary syndrome

OBJECTIVE

To evaluate whether insulin resistance is associated with depression risk in women with polycystic ovary syndrome (PCOS), independent of other factors, including body mass index (BMI).

DESIGN

Cross-sectional.

SETTING

Tertiary university center.

PATIENT(S)

A total of 301 women, aged 14-52 years, with PCOS by Rotterdam criteria, consecutively examined between 2006 and 2013.

INTERVENTION(S)

Complete history and physical examinations, including endovaginal ultrasounds, dermatologic assessments, completion of Beck Depression Inventory Fast Screen (BDI-FS), and serum testing.

MAIN OUTCOME MEASURE(S)

Scores >4 on BDI-FS indicated a positive screen for depression. Scores were further subdivided into mild (5-8), moderate (9-12), and severe (>12) depression risk. Insulin resistance was assessed using the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR).

RESULT(S)

A total of 131 women (44%) were at risk for depression, determined by positive BDI-FS screening. These patients had higher BMI (32.3 vs. 28.5), and elevated insulin resistance, assessed by HOMA-IR (5.2 vs. 2.6), compared with patients with negative depression screening. In a stratified analysis by BMI category, obese women with positive depression screens had elevated HOMA-IR, compared with obese women with normal BDI-FS scores (7.4 vs. 4.1). In a multivariate logistic regression analysis, HOMA-IR was independently related to the odds of depression risk after controlling for age, ethnicity, BMI, and exercise (odds ratio: 1.07).

CONCLUSION(S)

Depression is common in PCOS. After controlling for confounders in multivariate regression analyses, we found HOMA-IR to be significantly associated with depression risk. Our data suggest a complex interplay among insulin resistance, obesity, and depression in PCOS, warranting additional investigation. Mental health assessment is indicated in comprehensive care of patients with PCOS.

Diabetes mellitus and severe mental illness: mechanisms and clinical implications

The prevalence of diabetes mellitus is twofold to threefold higher in people with severe mental illness (SMI) than in the general population, with diabetes mellitus affecting ∼12% of people receiving antipsychotics. The consequences of diabetes mellitus are more severe and frequent in people with SMI than in those without these conditions, with increased rates of microvascular and macrovascular complications, acute metabolic dysregulation and deaths related to diabetes mellitus. Multiple complex mechanisms underlie the association between diabetes mellitus and SMI; these mechanisms include genetic, environmental and disease-specific factors, and treatment-specific factors. Although antipsychotics are the mainstay of treatment in SMI, a causative link, albeit of uncertain magnitude, seems to exist between antipsychotics and diabetes mellitus. The principles of managing diabetes mellitus in people with SMI are similar to those for the general population and should follow currently established treatment algorithms. Lifestyle interventions are needed to reduce incident diabetes mellitus. In addition, improved uptake of opportunities to screen for this disease will reduce the high prevalence of undiagnosed diabetes mellitus. Currently, people with SMI receive poorer treatment for diabetes mellitus than the general population. Thus, health-care professionals in primary care, diabetes mellitus services and mental health teams have a responsibility to ensure that patients with SMI are not disadvantaged.

Biological correlates of major depression and generalized anxiety disorder in women with polycystic ovary syndrome

OBJECTIVE

We aimed to compare the levels of serum androgens in women with polycystic ovary syndrome (PCOS) who had a diagnosis of only major depressive disorder (MDD), only generalized anxiety disorder (GAD) or who had no psychiatric disorder, as determined by a structured clinical interview. Another objective of the study was to examine whether an association exists between these psychiatric diagnoses and insulin resistance or body mass index via a comparison among the study groups in terms of these parameters.

METHOD

This study was performed between March 2011 and February 2012. A total of 73 patients were included in the study. The study sample consisted of three groups: PCOS patients with only major depressive disorder (n=23), PCOS patients with only generalized anxiety disorder (n=20), and PCOS patients without any diagnosed psychiatric disorders (not diagnosed - ND group, n=30).

RESULTS

Significant difference was found among the three groups with regard to the serum levels of 17-OHP and DHEAS. When multiple comparisons were performed among the groups, 17-OHP levels were significantly higher in the MDD group than in the ND group. DHEAS levels were significantly higher in the MDD group and the GAD group than in the ND group.

CONCLUSION

The present study suggests that MDD and GAD appear to be associated with higher DHEAS levels.

A systematic review and meta-analysis of the association between depression and insulin resistance

OBJECTIVE

Depression is associated with the onset of type 2 diabetes. A systematic review and meta-analysis of observational studies, controlled trials, and unpublished data was conducted to examine the association between depression and insulin resistance (IR).

RESEARCH DESIGN AND METHODS

Medline, EMBASE, and PsycINFO were searched for studies published up to September 2011. Two independent reviewers assessed the eligibility of each report based on predefined inclusion criteria (study design and measure of depression and IR, excluding prevalent cases of diabetes). Individual effect sizes were standardized, and a meta-analysis was performed to calculate a pooled effect size using random effects. Subgroup analyses and meta-regression were conducted to explore any potential source of heterogeneity between studies.

RESULTS

Of 967 abstracts reviewed, 21 studies met the inclusion criteria of which 18 studies had appropriate data for the meta-analysis (n = 25,847). The pooled effect size (95% CI) was 0.19 (0.11-0.27) with marked heterogeneity (I(2) = 82.2%) using the random-effects model. Heterogeneity between studies was not explained by age or sex, but could be partly explained by the methods of depression and IR assessments.

CONCLUSIONS

A small but significant cross-sectional association was observed between depression and IR, despite heterogeneity between studies. The pathophysiology mechanisms and direction of this association need further study using a purposively designed prospective or intervention study in samples at high risk for diabetes.

A review of the association between depression and insulin resistance: pitfalls of secondary analyses or a promising new approach to prevention of type 2 diabetes?

We review the validity of the evidence for an association between depression and the risk of insulin resistance (IR). We describe the potentially plausible biological and behavioral mechanisms that explain how depression increases the risk of IR and consequent overt diabetes. We have identified gaps in the literature to guide future research. Evidence for bidirectional associations between depression and IR is inconsistent. Results showing positive associations between depression and IR are derived from cross-sectional studies, whereas negative findings are typically reported in cohort studies. On the other hand, tentative trial evidence suggests that the effective treatment of depression can improve IR, and that lifestyle programs improve IR and reduce depressive symptoms. These emerging themes could lead to potential new multidisciplinary approaches to preventing diabetes.

A test for common genetic and environmental vulnerability to depression and diabetes

Molecular genetic research has provided some evidence for the association between depression and metabolic disorders. We sought to determine if molecular findings are reflected in twin analyses testing if common genetic and environmental risk factors contribute to the co-occurrence of diabetes and depression. Data to derive depression and diabetes were collected from 1,237 male-male twins who participated in the 2005 Vietnam Era Twin Study of Aging (VETSA). The 1,237 twins were comprised of 347 MZ pairs, 3 MZ singletons, 267 DZ pairs and 6 unpaired twins. Depression was defined as a score below 46 on the Short Form-36 mental component summary score. Diabetes was defined by self report, use of anti-diabetic medications and insulin. Twin models were fit to estimate the correlation of genetic and environmental contributions to depression and diabetes. Consistent with other studies these data support the association between depression and diabetes (OR = 1.7; 95%CI: 1.1-2.7). Genetic vulnerability accounted for 50% (95%CI: 32%-65%) of the variance in risk for depression and 69% (95%CI: 52%-81%) of the variance in risk for diabetes. The genetic correlation between depression and diabetes was r = 0.19 (95%CI: 0-0.46) and the non-shared environmental correlation was r = 0.09 (95% CI: 0-0.45). Overall there is little evidence that common genetic and environmental factors account for the co-occurrence of depression and diabetes in middle aged men. Further research in female twins and larger cohorts is warranted.

Rethinking the genetic basis for comorbidity of schizophrenia and type 2 diabetes

The co-occurrence of schizophrenia (SCZ) and type 2 diabetes mellitus (T2D) has been well documented. This review article focuses on the hypothesis that the co-occurrence of SCZ and T2D may be, at least in part, driven by shared genetic factors. Previous genetic studies of T2D and SCZ evidence have disclosed a number of overlapped risk loci. However, the putative common genetic factors for SCZ and T2D remain inconclusive due to inconsistent findings. A systemic review of methods of identifying genetic loci contributing to the comorbidity link between SCZ and T2D is hence needed. In the current review article, we have discussed several different approaches to localizing the shared susceptibility genes for these two diseases. To begin with, one could start with probing the gene involved in both glucose and dopamine metabolisms. Additionally, hypothesis-free genome-wide association studies (GWAS) may provide more clues to the common genetic basis for these two diseases. Genetic similarities inferred from GWAS may shed some light on the genetic mechanism underlying the comorbidity link between SCZ and T2D. Meanwhile, endophenotypes (e.g., adiponectin level in T2D and working memory in SCZ) may serve as alternative phenotypes that are more directly influenced by genes than target diseases. Hence, endophenotypes of these diseases may be more tractable to identification. To summarize, novel approaches are needed to dissect the complex genetic basis of the comorbidity of SCZ and T2D.

Independent factors associated with depression in type 1 diabetes mellitus

Diabetes has been associated with depression since Thomas Willis' work in 1684 (Rubin and Peyrot in Diabetes Metab Rev 18:173-175, 2002). The aim of this study is to identify social and clinical factors independently associated with depression in individuals with type 1 diabetes. We carried out a descriptive transversal study with 110 type 1 diabetes patients, administered a questionnaire and obtained demographical and diabetes-related data (number of years from diagnosis, initial admission at diagnosis, glycated hemoglobin, number of complications, insulin dose, number of insulin injections per day, admission for ketoacidosis or hypoglycemia at diagnosis, and specific diabetes complications such as nephropathy, retinopathy, peripheral neuropathy, coronariopathy, and amputation). Depressive symptoms were quantified using the Hamilton Score. We used T tests to investigate potential relations between the covariates and depression (Hamilton score). We concluded the following: as few as 10% of our patients had glycated hemoglobin under 7%; women had more symptoms of depression, and there are four independent factors associated with depression in individuals with type 1 diabetes mellitus: age, Graffar score, admission for ketoacidosis, and insulin dose.

Depressive symptoms and diabetes mellitus in an Asian multiracial population

INTRODUCTION

Singapore has one of the world's highest rates of diabetes mellitus (DM). DM is also associated with depression, the nature of this relation is possibly bidirectional and complex and there are a number of putative associated factors.

AIMS

To establish the prevalence of depressive symptoms in an Asian multiracial population with diabetes and identify some of these putative risk factors including ethnicity for depressive symptoms while controlling for multiple confounding variables.

METHODS

This is a cross-sectional epidemiological study in an Asian multiracial population with DM. The subjects were 537 outpatients (aged 21 years and above) attending a specialist diabetes treatment centre in a general hospital. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) with a cut-off score of 16 or more indicating the presence of depressive symptoms.

RESULTS

The prevalence of depressive symptoms was 31.1%. Following a logistic regression with depression as the dependent variable, Indian race, type of treatment, activity level and marital status (divorced/separated) were significantly associated with a high risk of depression.

CONCLUSIONS

This is the first study done among 3 ethnic groups Chinese, Malays and Indians within the same geographical location, and the findings show that depressive symptoms are common among diabetic patients and highest among those of Indian ethnicity.

Does metabolic syndrome have an impact on the quality of life and mood of hemodialysis patients?

OBJECTIVE

Little is known about the association between metabolic syndrome (MetSyn), health-related quality of life (HRQoL), and depressive symptoms in hemodialysis (HD) patients. We hypothesized that MetSyn may be associated with lower HRQoL and depression in HD patients.

DESIGN

This was a cross-sectional study.

SETTING

The trial involved HD patients at a tertiary-care hospital.

PATIENTS

We evaluated 115 patients (41 women and 74 men; mean age, 48.4 +/- SD 11.9 years SD).

METHODS

MetSyn was defined according to National Cholesterol Education Panel criteria. The Medical Outcomes Study Short Form-36 (SF-36) and Beck Depression Inventory (BDI) were used to assess HRQoL and signs of depression, respectively. We compared HRQoL and clinical and psychosocial characteristics among participants with and without MetSyn.

RESULTS

Fifty patients (43.5%) had MetSyn, and 65 patients (56.5%) were free of MetSyn. Comparisons of SF-36 and BDI scores between HD patients with and without MetSyn revealed no statistically significant differences. The Physical Component Summary Score (PCS) of SF-36 was independently associated with HD duration (beta = -0.274, P = .002), age (beta = -0.206, P = .024), sleep disturbance (beta = -0.175, P = .045), albumin (beta = +0.252, P = .006), and hemoglobin (beta = +0.270, P = .002) in stepwise linear regression analysis. The MetSyn was not associated with PCS. The Mental Component Summary Score of SF-36 was independently associated with hemoglobin (beta = +0.235, P = .016) and BDI score (beta = -0.218, P = .025).

CONCLUSIONS

The presence of MetSyn was not associated with HRQoL according to the Mental Component Summary Score. In HD patients, HRQoL and depressive behaviors were not influenced by MetSyn, but by various other factors.

Insulin resistance and depressive symptoms in middle-aged and elderly Chinese: findings from the Nutrition and Health of Aging Population in China Study

BACKGROUND

Depression is associated with an increased risk of incident diabetes, and insulin resistance is thought to be the underlying link between them. Nevertheless, only a few studies have explored the association between insulin resistance and depression with contradictory results, and none have been conducted in Chinese populations.

METHODS

We aimed to determine the association between insulin resistance and depressive symptoms among middle-aged and elderly Chinese using data from the Nutrition and Health of Aging Population in China Study, a population-based cross-sectional study conducted in 2005 in China. Participants included 3285 community residents aged 50-70 years. Depressive symptoms were defined as a Center for Epidemiological Studies of Depression Scale (CES-D) score of 16 or higher. Insulin resistance was calculated using the updated homeostasis model assessment (HOMA2-IR) methods.

RESULTS

Value of HOMA2-IR was significantly higher in participants with depressive symptoms (0.284 vs. 0.261, P=0.008), even after adjustment for various confounding factors in the regression model (0.311 vs. 0.291, P=0.026). Logistical regression analyses showed that participants with depressive symptoms had a higher risk of having insulin resistance (defined as in the top quartile of HOMA2-IR values, odds ratio=1.54, 95% confidence intervals=1.17-2.04).

LIMITATIONS

Due to the cross-sectional study design, causal relation remains unknown.

CONCLUSIONS

The present study found positive associations between depressive symptoms and insulin resistance among Chinese populations. Further prospective studies are needed to validate the results and find the temporal and causal relation between them.

Experiential and genetic contributions to depressive- and anxiety-like disorders: clinical and experimental studies

Stressful events have been implicated in the precipitation of depression and anxiety. These disorders may evolve owing to one or more of an array of neuronal changes that occur in several brain regions. It seems likely that these stressor-provoked neurochemical alterations are moderated by genetic determinants, as well as by a constellation of experiential and environmental factors. Indeed, animal studies have shown that vulnerability to depressive-like behaviors involve mechanisms similar to those associated with human depression (e.g., altered serotonin, corticotropin releasing hormone and their receptors, growth factors), and that the effects of stressors are influenced by previous stressor experiences, particularly those encountered early in life. These stressor effects might reflect sensitization of neuronal functioning, phenotypic changes of processes that lead to neurochemical release or receptor sensitivity, or epigenetic processes that modify expression of specific genes associated with stressor reactivity. It is suggested that depression is a life-long disorder, which even after effective treatment, has a high rate of re-occurrence owing to sensitized processes or epigenetic factors that promote persistent alterations of gene expression.

Insulin resistance and self-rated symptoms of depression in Swedish women with risk factors for diabetes: the Women's Health in the Lund Area study

Previous studies have suggested that depression increases the risk for diabetes and that this may be mediated through insulin resistance. The study aimed to analyze if self-rated symptoms of depression are related to insulin resistance among middle-aged and older Swedish women with features of the metabolic syndrome and being at risk for type 2 diabetes mellitus. We analyzed data from 1047 Swedish women aged 50 to 64 years without a history of diabetes and living in the southern part of Sweden. A variable self-rated symptoms of depression (SRSD) was defined by using the Gothenburg Quality of Life instrument. We estimated odds ratios (ORs) to determine whether or not SRSD was associated with the homeostasis model assessment of insulin resistance. The variable SRSD was not associated with insulin resistance. However, it was positively associated with waist-hip ratio (OR, 1.95; 95% confidence interval, 1.28-3.00) and negatively associated with physical exercise (OR, 1.29; 95% confidence interval, 0.99-1.68) after multivariate adjustment. In conclusion, lifestyle factors such as physical inactivity and abdominal obesity, but not insulin resistance, seem to be related to self-rated symptoms of depression in women with risk factors for diabetes mellitus. The relationship between insulin resistance and major depression needs to be further examined.

History of major depressive disorder and diabetes outcomes in diet- and tablet-treated post-menopausal women: a case control study

AIMS

Little is known about the long-term associations between remitted major depressive disorder (MDD) and clinical diabetes outcomes. This study investigated associations between a remote history of fully remitted MDD and (i) glycaemic control, (ii) diabetes symptoms, and (iii) physical and emotional functioning in post-menopausal women with Type 2 diabetes (T2DM).

METHODS

Forty-four post-menopausal women with diet- or tablet-treated T2DM participated. Twenty-three had never experienced depression and 21 had a history of MDD. All participants had been free of MDD and antidepressant treatment for > or = 1 year.

RESULTS

Compared with their never-depressed counterparts, women with a history of MDD had significantly higher HbA(1c) (7.0 vs. 6.5%), more diabetes symptoms, and worse emotional functioning, after controlling for confounding variables. Differences in HbA(1c) and diabetes symptoms were not accounted for by the higher current subclinical depressive symptoms observed in the previously depressed group. Differences in emotional functioning were accounted for by current subclinical depressive symptoms.

CONCLUSIONS

Most health-care providers overlook fully remitted depression. However, previously depressed patients, who outnumber currently depressed patients, may still have poorer glycaemic control than never-depressed patients.

The metabolic effects of antipsychotic medications

OBJECTIVES

To review current evidence for the hypothesis that treatment with antipsychotic medications may be associated with increased risks for weight gain, insulin resistance, hyperglycemia, dyslipidemia, and type 2 diabetes mellitus (T2DM) and to examine the relation of adiposity to medical risk.

METHODS

We identified relevant publications through a search of MEDLINE from the years 1975 to 2006, using the following primary search parameters: "diabetes or hyperglycemia or glucose or insulin or lipids" and "antipsychotic." Meeting abstracts and earlier nonindexed articles were also reviewed. We summarized key studies in this emerging literature, including case reports, observational studies, retrospective database analyses, and controlled experimental studies.

RESULTS

Treatment with different antipsychotic medications is associated with variable effects on body weight, ranging from modest increases (for example, less than 2 kg) experienced with amisulpride, ziprasidone, and aripiprazole to larger increases during treatment with agents such as olanzapine and clozapine (for example, 4 to 10 kg). Substantial evidence indicates that increases in adiposity are associated with decreases in insulin sensitivity in individuals both with and without psychiatric disease. The effects of increasing adiposity, as well as other effects, may contribute to increases in plasma glucose and lipids observed during treatment with certain antipsychotics.

CONCLUSION

Treatment with certain antipsychotic medications is associated with metabolic adverse events that can increase the risk for metabolic syndrome and related conditions such as prediabetes, T2DM, and cardiovascular disease.

Impact of depression on utilization patterns of oral hypoglycemic agents in patients newly diagnosed with type 2 diabetes mellitus: a retrospective cohort analysis

BACKGROUND

Oral hypoglycemic agents (OHAs) are an important component in the management of type 2 diabetes mellitus (DM). Large-scale studies have demonstrated that tight glycemic control with such agents can reduce the frequency and severity of long-term DM-related complications.

OBJECTIVES

The main goal of this study was to examine the impact of depression on utilization patterns of OHAs in patients newly diagnosed with type 2 DM. A secondary objective was to estimate the impact of depression on discontinuation and modification of pharmacotherapy for DM in these patients.

METHODS

Patients newly diagnosed with type 2 DM during a 3-year period (1998-2000) were identified from a Medicaid claims database. Presence of preexisting depression was determined on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The patient cohort was followed up until they received their first prescription for an OHA (1998-2001); this date was treated as the index date for the study. Utilization patterns (ie, discontinuation, augmentation, switching, non-modification) for OHAs were computed for a 12-month follow-up period after the index date. A multivariate framework was used to estimate the impact of depression on utilization patterns, controlling for confounders such as demographics, comorbidity, provider interaction, drug regimen complexity, and DM severity.

RESULTS

A total of 1237 newly diagnosed type 2 DM patients were identified (depressed, n=446; nondepressed, n=791). A higher number of depressed patients (23.32%) switched or augmented therapy compared with nondepressed patients (16.18%). Also, a higher fraction of depressed patients (39.46%) discontinued OHA therapy compared with nondepressed patients (32.87%). Results of a multinomial logistic regression indicated that, controlling for covariates, patients with depression were 1.72 times more likely to switch (P=0.046) and 1.89 times more likely to augment therapy (P=0.004) compared with nondepressed patients. Logistic regression analysis also indicated that, controlling for confounding covariates, patients with depression were 1.72 times more likely to modify initial OHA therapy compared with patients without depression (P=0.003).

CONCLUSION

Depression was significantly associated with utilization patterns of OHAs in these patients newly diagnosed with type 2 DM, thus possibly affecting their disease management.

Insulin resistance in depressive disorders and Alzheimer's disease: Revisiting the missing link hypothesis

Several lines of evidence suggest an association between depressive disorders and Alzheimer's disease (AD). We previously suggested central nervous system (CNS) effects of insulin resistance (IR) to be an important link between depressive disorders and AD. Although the exact mechanism of central IR is not known, it is thought that central IR results in inadequate glucose metabolism in the brain. According to our hypothesis, inadequate glucose utilization resulting from IR underlies neuronal changes in crucial brain regions (i.e. limbic system) observed among patients with depressive disorders, the same brain regions affected in AD. Further, in patients with undetected and/or untreated IR, such changes in glucose utilization, if unresolved, may lead to neurodegeneration. Our studies have demonstrated a high prevalence of IR in patients with depressive disorders, and reciprocally, a high prevalence of depression in patients with the primary IR disorder polycystic ovary syndrome (PCOS), and we believe these populations have significantly increased risk of cognitive decline. Herein, we review the IR link in depressive disorders and AD and describe the results of our studies and others in support of this hypothesis.

Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review

Increasing numbers of reports concerning diabetes, ketoacidosis, hyperglycaemia and lipid dysregulation in patients treated with second-generation (or atypical) antipsychotics have raised concerns about a possible association between these metabolic effects and treatment with these medications. This comprehensive literature review considers the evidence for and against an association between glucose or lipid dysregulation and eight separate second-generation antipsychotics currently available in the US and/or Europe, specifically clozapine, olanzapine, risperidone, quetiapine, zotepine, amisulpride, ziprasidone and aripiprazole. This review also includes an assessment of the potential contributory role of treatment-induced weight gain in conferring risk for hyperglycaemia and dyslipidaemia during treatment with different antipsychotic medications. Substantial evidence from a variety of human populations, including some recent confirmatory evidence in treated psychiatric patients, indicates that increased adiposity is associated with a variety of adverse physiological effects, including decreases in insulin sensitivity and changes in plasma glucose and lipid levels. Comparison of mean weight changes and relative percentages of patients experiencing specific levels of weight increase from controlled, randomised clinical trials indicates that weight gain liability varies significantly across the different second generation antipsychotic agents. Clozapine and olanzapine treatment are associated with the greatest risk of clinically significant weight gain, with other agents producing relatively lower levels of risk. Risperidone, quetiapine, amisulpride and zotepine generally show low to moderate levels of mean weight gain and a modest risk of clinically significant increases in weight. Ziprasidone and aripiprazole treatment are generally associated with minimal mean weight gain and the lowest risk of more significant increases. Published studies including uncontrolled observations, large retrospective database analyses and controlled experimental studies, including randomised clinical trials, indicate that the different second-generation antipsychotics are associated with differing effects on glucose and lipid metabolism. These studies offer generally consistent evidence that clozapine and olanzapine treatment are associated with an increased risk of diabetes mellitus and dyslipidaemia. Inconsistent results, and a generally smaller effect in studies where an effect is reported, suggest limited if any increased risk for treatment-induced diabetes mellitus and dyslipidaemia during risperidone treatment, despite a comparable volume of published data. A similarly smaller and inconsistent signal suggests limited if any increased risk of diabetes or dyslipidaemia during quetiapine treatment, but this is based on less published data than is available for risperidone. The absence of retrospective database studies, and little or no relevant published data from clinical trials, makes it difficult to draw conclusions concerning risk for zotepine or amisulpride, although amisulpride appears to have less risk of treatment-emergent dyslipidaemia in comparison to olanzapine. With increasing data from clinical trials but little or no currently published data from large retrospective database analyses, there is no evidence at this time to suggest that ziprasidone and aripiprazole treatment are associated with an increase in risk for diabetes, dyslipidaemia or other adverse effects on glucose or lipid metabolism. In general, the rank order of risk observed for the second-generation antipsychotic medications suggests that the differing weight gain liability of atypical agents contributes to the differing relative risk of insulin resistance, dyslipidaemia and hyperglycaemia. This would be consistent with effects observed in nonpsychiatric samples, where risk for adverse metabolic changes tends to increase with increasing adiposity. From this perspective, a possible increase in risk would be predicted to occur in association with any treatment that produces increases in weight and adiposity. However, case reports tentatively suggest that substantial weight gain or obesity may not be a factor in up to one-quarter of cases of new-onset diabetes that occur during treatment. Pending further testing from preclinical and clinical studies, limited controlled studies support the hypothesis that clozapine and olanzapine may have a direct effect on glucose regulation independent of adiposity. The results of studies in this area are relevant to primary and secondary prevention efforts that aim to address the multiple factors that contribute to increased prevalence of type 2 diabetes mellitus and cardiovascular disease in populations that are often treated with second-generation antipsychotic medications.

Metabolic risk during antipsychotic treatment

BACKGROUND

Compared with the general population, individuals with schizophrenia demonstrate an increased prevalence of obesity, type 2 diabetes mellitus (T2DM), and cardiovascular disease (CVD). Increased adiposity is associated with decreases in insulin sensitivity, leading to an increased risk of hyperglycemia and hyperlipidemia. Antipsychotic medications can increase adiposity, and a range of evidence from case reports, observational studies, retrospective database analyses, and controlled experimental studies (including randomized clinical trials) suggests that treatment with antipsychotic medications may be associated with an increased risk for insulin resistance, hyperglycemia, dyslipidemia, and T2DM.

OBJECTIVE

This article reviews current evidence for the hypothesis that treatment with antipsychotic medications may be associated with increased risks for weight gain, insulin resistance, hyperglycemia, dyslipidemia, and T2DM, and examines the relationship of adiposity to medical risk.

METHODS

Relevant publications were identified through a search of MEDLINE from 1975 to the present using the primary search parameters "diabetes or hyperglycemia or glucose or insulin or lipids" and "antipsychotic." Meeting abstracts and earlier nonindexed articles concerning antipsychotic-associated weight gain and metabolic disturbance were also reviewed. Key studies in this emerging literature were summarized, including case reports, observational studies, retrospective database analyses, and controlled experimental studies.

RESULTS

Individual antipsychotic medications are associated with different degrees of treatment-induced increases in body weight and adiposity, ranging from modest effects (<2 kg) with amisulpride, ziprasidone, and aripiprazole to clinically significant increases with olanzapine (4-10 kg). In addition to strong evidence concerning the effect of adiposity on insulin sensitivity in nonpsychiatric populations, increased adiposity in patients with schizophrenia has been associated with decreases in insulin sensitivity; this and other effects may contribute to increases in plasma glucose concentrations and lipid levels.

CONCLUSION

Metabolic changes in psychiatric patients who receive antipsychotic agents can contribute to the development of the metabolic syndrome and increase the risk for T2DM and CVD.

Bipolar disorder and diabetes mellitus: epidemiology, etiology, and treatment implications

INTRODUCTION

Bipolar disorder (BD) is a highly prevalent and disabling condition with significant mortality risk from suicide and other unnatural causes. This ignominious description is alongside recent observations that the majority of excess deaths in BD are secondary to medical comorbidity. The medical burden in BD is associated with a clustering of risk factors (e.g., obesity, smoking, unhealthy dietary habits) and inadequate utilization of preventative and primary healthcare. Diabetes mellitus (DM) is also a prevalent multifactorial disease which imparts substantial illness burden. Preliminary investigations indicate that patients who suffer from BD with comorbid DM have a more severe course and outcome, lower quality of life, higher prevalence of medical comorbidity and higher cost of illness.

METHODS

We conducted a MedLine search of all English-language articles 1966-2004 using the key words: bipolar disorder, major depressive disorder, diabetes mellitus, glucose metabolism, mortality, overweight, obesity, body mass index. The search was supplemented with manual review of relevant references. Priority was given to randomized controlled data, when unavailable; studies of sufficient sample size are presented.

RESULTS

Subpopulations of BD patients should be considered at high risk for DM. The prevalence of DM in BD may be three times greater than in the general population.

CONCLUSIONS

Bipolar disorder populations may be an at-risk group for glucose metabolic abnormalities. Opportunistic screening and vigilance for clinical presentations suggestive of DM is encouraged.

Depression-related hyperglycemia in type 1 diabetes: a mediational approach

OBJECTIVE

Depression is linked with hyperglycemia and with an increased risk for diabetes complications, but the mechanisms underlying these relationships have not been established. In this study, we applied mediational analysis methods to determine whether the hyperglycemic effect of depression could be mediated by poor diabetes self-care.

METHODS

Depression symptoms and diabetes self-care activity were assessed in a primary care sample of 188 patients with type 1 diabetes by using the Hopkins Symptom Checklist-90 (SCL-90) and the Summary of Diabetes Self-Care Activities (SDSCA). A composite score of self-care activity was formed from SDSCA ratings for diet amount, exercise, and glucose testing. Degree of hyperglycemia (level of glycosylated hemoglobin [HbA1c]), weight, insulin dose, and other clinical characteristics were obtained from electronic medical records. Ordinary least-squares regression was used to determine the effect of depression on HbA1c level controlling for weight and insulin dose. The SDSCA score was then added to the regression model to determine whether it attenuated the effect of depression symptoms on HbA1c level, thus providing suggestive evidence of mediation from these cross-sectional data.

RESULTS

Depression symptoms, poor diabetes self-care, and hyperglycemia were correlated with one another in univariate analyses (p <.05). Depression symptoms were associated with higher HbA1c after controlling for weight and insulin dose (parameter estimate for depression 0.53, t = 3.6, p <.001). Inclusion of SDSCA in the model minimally attenuated the effect of depression symptoms (adjusted parameter estimate for depression 0.50, t = 3.3, p = .001).

CONCLUSIONS

These findings do not support mediation of the depression-hyperglycemia relationship by diabetes self-care behavior. Other pathways, including psychophysiological mechanisms, should be investigated.

Depressive symptoms, insulin resistance, and risk of diabetes in women at midlife

OBJECTIVE

To examine depression and 3-year change in insulin resistance and risk of diabetes and whether associations vary by race.

RESEARCH DESIGN AND METHODS

We analyzed data from 2,662 Caucasian, African-American, Hispanic, Japanese-American, and Chinese-American women without a history of diabetes from the Study of Women's Health Across the Nation. We estimated regression coefficients and odds ratios to determine whether depression (Center for Epidemiological Studies Depression Scale score > or =16) predicted increases in homeostasis model assessment of insulin resistance (HOMA-IR) and greater risk of incident diabetes, respectively, over 3 years.

RESULTS

Mean baseline HOMA-IR was 1.31 (SD 0.86) and increased 0.05 units per year for all women (P <0.0001). A total of 97 incident cases of diabetes occurred. Depression was associated with absolute levels of HOMA-IR (P <0.04) but was unrelated to changes in HOMA-IR; associations did not vary by race. The association between depression and HOMA-IR was eliminated after adjustment for central adiposity (P=0.85). Depression predicted a 1.66-fold greater risk of diabetes (P <0.03), which became nonsignificant after adjustment for central adiposity (P=0.12). We also observed a depression-by-race interaction (P <0.05) in analyses limited to Caucasians and African Americans, the only groups with enough diabetes cases to reliably test this interaction. Race-stratified models showed that depression predicted 2.56-fold greater risk of diabetes in African Americans only, after risk factor adjustment (P=0.008).

CONCLUSIONS

Depression is associated with higher HOMA-IR values and incident diabetes in middle-aged women. These associations are mediated largely through central adiposity. However, African-American women with depression experience increased risk of diabetes independent of central adiposity and other risk factors.

The individuality of mice

Mutant mice simulating human CNS disorders are used as models for therapeutic drug development. Drug evaluation requires a coherent correlation between behavioral phenotype and drug status. Variations in behavioral responses could mask such correlations, a problem highlighted by the three-site studies of Crabbe et al. (1999) and Wahlsten et al. (2003a). Factors contributing to variation are considered, focusing on differences between individual animals. Genetic differences due to minisatellite variation suggest that each mouse is genetically distinct. Effects during gestation, including maternal stress, influence later life behavior; while endocrine exchanges between fetus and parent, and between male and female fetuses dependent on intrauterine position, also contribute. Pre and perinatal nutrition and maternal attention also play a role. In adults, endocrine cyclicity in females is a recognized source of behavioral diversity. Notably, there is increasing recognition that groups of wild and laboratory mice have complex social structures, illustrated through consideration of Crowcroft (1966). Dominance status can markedly modify behavior in test paradigms addressing anxiety, locomotion and aggressiveness, to an extent comparable to mutation or drug status. Understanding how such effects amplify the behavioral spectrum displayed by otherwise identical animals will improve testing.

A prospective study of Type 2 diabetes and depressive symptoms in the elderly: the Rancho Bernardo Study

AIMS

The association between Type 2 diabetes and depressive symptoms was examined prospectively to assess possible causal relationships between the two diseases.

METHODS

A cohort of 971 men and women aged 50 and older from the adult population of Rancho Bernardo, California had an oral glucose tolerance test and completed the Beck Depression Inventory (BDI) at two clinic visits, 1984-87 and 1992-96.

RESULTS

Depressive symptoms at baseline were associated with higher follow-up levels of non-fasting plasma glucose (P = 0.001) and an increased risk of developing Type 2 diabetes [odds ratio (OR) = 2.50; 95% confidence interval (CI) = 1.29-4.87], independent of sex, age, exercise and body mass index. Conversely, baseline non-fasting plasma glucose was not significantly associated with follow-up depressive symptoms and Type 2 diabetes at baseline was not significantly associated with the onset of BDI scores > or = 11 by the second visit (OR = 0.73; 95% CI = 0.41-1.30).

CONCLUSIONS

Depressed mood is more likely to be a risk factor for Type 2 diabetes in older adults than the reverse.

Insulin resistance, affective disorders, and Alzheimer's disease: review and hypothesis

Affective disorders (ad) and Alzheimer's disease (AD) have been associated for almost a century, and various neurophysiologic factors have been implicated as common biologic markers. Yet, links between ad and AD still await elucidation. We propose that insulin resistance (IR) is one of the missing links between ad and AD. IR with hyperinsulinemia and subsequent impairment of glucose metabolism especially in ad patients may promote neurodegeneration and facilitate the onset of AD. According to our hypothesis, IR may persist even into ad remission in some patients. Persistent regional hypometabolism and vascular changes resulting from long-standing IR may lead to currently irreversible structural changes. Evidence in support of the hypothesis is reviewed and clinical implications suggested.

Depression in women with polycystic ovary syndrome: clinical and biochemical correlates

BACKGROUND

We assessed the prevalence of mood disturbance among women with prospectively documented polycystic ovary syndrome (PCOS).

METHODS

Thirty-two women with PCOS completed the Center for Epidemiological Studies-Depression Rating Scale (CES-D). Clinical and biochemical characteristics were assessed.

RESULTS

Sixteen women had CES-D scores indicative of depression. Depression was associated with greater insulin resistance (P=0.02) and higher body mass index (P=0.05). Women receiving oral contraceptives for the treatment of PCOS were less depressed than patients not receiving treatment (P=0.03).

LIMITATIONS

Possible selection bias, use of a screening tool alone without further diagnostic evaluation of depression, small samples size and lack of direct comparison with an age matched control group, should be considered in interpretation of these results.

CONCLUSION

Findings suggest a high prevalence of depression among women with PCOS, and an association between depression and PCOS markers.

Insulin resistance: a metabolic link between depressive disorder and atherosclerotic vascular diseases

The association of depression with insulin resistance (IR) and athersclerotic vascular diseases has been well documented. This review examines the relevance of IR as a link between depressive disorder and atherosclerotic vascular diseases. Relevant articles collected from Medline database over the period of 1966-2001 were reviewed. Studies have shown that IR is a state-dependent abnormality in depression and depression increases the risk of vascular morbidity and mortality. Given that IR is a central component of cardiovascular risk factors, depression-related IR might play a role in the development and progression of coronary and cerebral atherosclerosis in chronic-resistant depression. Further, IR may contribute to the pathophysiology of depressive disorder. In conclusion IR could account for the linkage between depression and atherosclerotic vascular diseases. More studies are needed to examine the importance of improving insulin sensitivity in the treatment of chronic-resistant depression and prevention of depression-related vascular morbidity and mortality.

Epidemiologic evidence on the comorbidity of depression and diabetes

Data from population-based studies are important for the study of comorbidity. Cross-sectional research shows a consistent positive association of diabetes and depression. Prospective population-based studies are reviewed, showing that the temporal order may be from diabetes to depression, or from depression to diabetes, depending to some extent on the type of diabetes. The size of the effects is fairly consistent among the small number of studies and not trivial. Possibilities for future epidemiologic research on comorbidity are discussed.

Post-genomic era and gene discovery for psychiatric diseases: there is a new art of the trade? The example of the HUMTH01 microsatellite in the Tyrosine Hydroxylase gene

The microsatellite HUMTH01, located in the first intron of the Tyrosine Hydroxylase (TH) gene (encoding the rate-limiting enzyme in the synthesis of catecholamines), is characterized by a TCAT repeated motif and has been used in genetic studies of neuropsychiatric and other complex diseases, in which catecholaminergic neurotransmission is implicated. After reporting a positive association between HUMTH01 and bipolar disorder as well as schizophrenia, the authors established that HUMTH01 alleles display the features of regulatory elements. Thereafter, they cloned two proteins (ZNF191 and HBP1), specifically binding to HUMTH01, and demonstrated that allelic variations of HUMTH01 have a quantitative silencing effect on TH gene expression in vitro, and correlate with quantitative and qualitative changes in the binding by ZNF191. The authors aim to characterize the transduction pathway impinging on the HUMTH01 microsatellite and establish its relevance for TH gene regulation in vivo. Since the TCAT repeated sequence is widespread throughout the genome, their approach may lead to the dissection of the mechanisms underlying the quantitative expression of several genes implicated in complex genetic traits, both normal and pathological. Thus, these investigations on the possible contribution and potential role of the HUMTH01 microsatellite in neuro-pathological conditions may represent an example of the different approaches needed to validate genetic targets in the "post-genomic era."