Platelet hyperactivity in clinical depression and the beneficial effect of antidepressant drug treatment: how strong is the evidence?

Examining Depression as a Risk Factor for Cardiovascular Disease in People with HIV: A Systematic Review

BACKGROUND

People with human immunodeficiency virus (HIV) have an increased risk of cardiovascular disease (CVD) not fully accounted for by traditional or HIV-specific risk factors. Successful management of HIV does not eliminate this excess risk. Thus, there is a need to identify novel risk factors for CVD among people with HIV (PWH).

PURPOSE

Our objective was to systematically review the literature on one such candidate CVD risk factor in PWH-depression.

METHODS

A systematic literature search of PubMed, PsycINFO, EMBASE, Web of Science, and CINAHL was performed to identify published English-language studies examining associations of depression with clinical CVD, subclinical CVD, and biological mechanisms (immune activation, systemic inflammation, altered coagulation) among PWH between the earliest date and June 22, 2021.

RESULTS

Thirty-five articles were included. For clinical CVD (k = 8), findings suggests that depression is consistently associated with an increased risk of incident CVD. For subclinical CVD (k = 5), one longitudinal analysis reported a positive association, and four cross-sectional analyses reported null associations. For immune activation (k = 13), systemic inflammation (k = 17), and altered coagulation (k = 5), findings were mixed, and there was considerable heterogeneity in sample characteristics and methodological quality across studies.

CONCLUSIONS

Depression may be an independent risk factor for CVD among PWH. Additional research is needed to confirm depression's association with clinical CVD and to determine whether depression is consistently and meaningfully associated with subclinical CVD and biological mechanisms of CVD in HIV. We propose a research agenda for this emerging area.

The combined role of obesity and depressive symptoms in the association with ischaemic heart disease and its subtypes

This cross-sectional study aimed to explore the combined effects of depression and obesity on ischemic heart disease and its subtypes. Data from the National Health and Nutrition Examination Survey 2007–2018 were used. A total of 29,050 participants aged 20 years or older were included in the analyses. Logistic regression models and restricted cubic spline models were applied to evaluate the associations between depression symptom and ischemic heart disease. There were significant correlations between depressive symptoms and ischemic heart disease [OR and 95% CI 2.44 (1.91, 3.10)] and its subtypes: coronary heart disease [2.32 (1.67, 3.23)], heart attack [2.18 (1.71, 2.78)], and angina [2.72 (1.96, 3.79)].The synergistic effects of depression with obesity (BMI ≥ 30) and central obesity (waist ≥ 102/88 cm for men/women) on ischemic heart disease were estimated and expressed using the relative excess risk due to interaction (RERI) and the attributable proportion due to interaction (AP). The RERI and AP with 95% CIs of depression and central obesity for ischemic heart disease were 1.10 (0.01, 2.19) and 0.35 (0.06, 0.64). When we analysed the other three subtypes of ischemic heart disease, we only found depressive symptoms and central obesity could have a meaningful synergistic effect on heart attack (RERI: 0.84 (− 0.28, 1.96) AP: (0.31 (0.00, 0.69)).

Is there a relationship between morphological and functional platelet changes and depressive disorder?

BACKGROUND

Blood platelets, due to shared biochemical and functional properties with presynaptic serotonergic neurons, constituted, over the years, an attractive peripheral biomarker of neuronal activity. Therefore, the literature strongly focused on the investigation of eventual structural and functional platelet abnormalities in neuropsychiatric disorders, particularly in depressive disorder. Given their impact in biological psychiatry, the goal of the present paper was to review and critically analyze studies exploring platelet activity, functionality, and morpho-structure in subjects with depressive disorder.

METHODS

According to the PRISMA guidelines, we performed a systematic review through the PubMed database up to March 2020 with the search terms: (1) platelets in depression [Title/Abstract]"; (2) "(platelets[Title]) AND depressive disorder[Title/Abstract]"; (3) "(Platelet[Title]) AND major depressive disorder[Title]"; (4) (platelets[Title]) AND depressed[Title]"; (5) (platelets[Title]) AND depressive episode[Title]"; (6) (platelets[Title]) AND major depression[Title]"; (7) platelet activation in depression[All fields]"; and (8) platelet reactivity in depression[All fields]."

RESULTS

After a detailed screening analysis and the application of specific selection criteria, we included in our review a total of 106 for qualitative synthesis. The studies were classified into various subparagraphs according to platelet characteristics analyzed: serotonergic system (5-HT2A receptors, SERT activity, and 5-HT content), adrenergic system, MAO activity, biomarkers of activation, responsivity, morphological changes, and other molecular pathways.

CONCLUSIONS

Despite the large amount of the literature examined, nonunivocal and, occasionally, conflicting results emerged. However, the findings on structural and metabolic alterations, modifications in the expression of specific proteins, changes in the aggregability, or in the responsivity to different pro-activating stimuli, may be suggestive of potential platelet dysfunctions in depressed subjects, which would result in a kind of hyperreactive state. This condition could potentially lead to an increased cardiovascular risk. In line with this hypothesis, we speculated that antidepressant treatments would seem to reduce this hyperreactivity while representing a potential tool for reducing cardiovascular risk in depressed patients and, maybe, in other neuropsychiatric conditions. However, the problem of the specificity of platelet biomarkers is still at issue and would deserve to be deepened in future studies.

High Perceived Stress May Shorten Activated Partial Thromboplastin Time and Lead to Worse Clinical Outcomes in Patients With Coronary Heart Disease

Objective: To determine the association of perceived stress with coagulation function and their predictive values for clinical outcomes. Methods: This prospective cohort study derived from a cross-sectional study for investigating the psychological status of inpatients with suspicious coronary heart disease (CHD). In this study, the 10-item Perceived Stress Scale (PSS-10) as an optional questionnaire was used to assess the severity of perceived stress. Coagulation function tests, such as activated partial thromboplastin time (APTT), prothrombin time (PT), and fibrinogen were measured within 1 h after admission. Furthermore, 241 patients with CHD out of 705 consecutive inpatients were included in the analyses and followed with a median of 26 months for the clinical outcomes. Results: The patients in high perceived stress status (PSS-10 score > 16) were with shorter APTT (36.71 vs. 38.45 s, p = 0.009). Shortened APTT ( ≤ 35.0 s) correlated with higher PSS-10 score (14.67 vs. 11.22, p = 0.003). The association of APTT with depression or anxiety was not found. Multiple linear models adjusting for PT estimated that every single point increase in PSS-10 was relevant to approximately 0.13 s decrease in APTT (p = 0.001) regardless of the type of CHD. APTT (every 5 s increase: hazard ratio (HR) 0.68 [0.47-0.99], p = 0.041) and perceived stress (every 5 points increase: HR 1.31 [1.09-1.58], p = 0.005) could predict the cardiovascular outcomes. However, both predictive values would decrease when they were simultaneously adjusted. After adjusting for the physical clinical features, the associated of perceived stress on cardiac (HR 1.25 [1.04-1.51], p = 0.020) and composite clinical outcomes (HR 1.24 [1.05-1.47], p = 0.011) persisted. Conclusions: For the patients with CHD, perceived stress strongly correlates with APTT. The activation of the intrinsic coagulation pathway is one of the mechanisms that high perceived stress causes cardiovascular events. This hints at an important role of the interaction of mental stress and coagulation function on cardiovascular prognosis. More attention needs to be paid to the patients with CHD with high perceived stress.

Anticoagulants and the Hemostatic System: A Primer for Occupational Stress Researchers

Anticoagulation, the body’s mechanism to prevent blood clotting, is an internal biomarker of an individual’s response to stress. Research has indicated that understanding the causes, processes, and consequences of anticoagulation can provide important insight into the experience of individuals facing emotional and occupational strain. Unfortunately, despite their importance, the mechanisms and implications of anticoagulation are unfamiliar to many researchers and practitioners working with trauma-exposed professionals. This paper provides an accessible primer on the topic of anticoagulation, including an overview of the biological process, the research connecting these processes with emotional and occupational functioning, as well as some potential methods for assessment.

Beyond Haemostasis and Thrombosis: Platelets in Depression and Its Co-Morbidities

Alongside their function in primary haemostasis and thrombo-inflammation, platelets are increasingly considered a bridge between mental, immunological and coagulation-related disorders. This review focuses on the link between platelets and the pathophysiology of major depressive disorder (MDD) and its most frequent comorbidities. Platelet- and neuron-shared proteins involved in MDD are functionally described. Platelet-related studies performed in the context of MDD, cardiovascular disease, and major neurodegenerative, neuropsychiatric and neurodevelopmental disorders are transversally presented from an epidemiological, genetic and functional point of view. To provide a complete scenario, we report the analysis of original data on the epidemiological link between platelets and depression symptoms suggesting moderating and interactive effects of sex on this association. Epidemiological and genetic studies discussed suggest that blood platelets might also be relevant biomarkers of MDD prediction and occurrence in the context of MDD comorbidities. Finally, this review has the ambition to formulate some directives and perspectives for future research on this topic.

Antidepressants: bleeding or thrombosis?

The contribution of depression to the pathogenesis of cardiovascular disease includes autonomic disturbances, endothelial dysfunction, inflammation, smoking, sedentary lifestyle, carbohydrate craving, and impaired fibrinolysis. There is evidence that serotonergic antidepressants (selective serotonin reuptake inhibitors and serotonin and noradrenaline reuptake inhibitors) restore the fibrinolytic profile. Contrary to common belief, such antidepressants do not affect platelet aggregation induced by adenosine diphosphate or adrenaline but reduce platelet adhesion to collagen. Since platelet collagen receptor glycoprotein VI binds to fibrin, it is possible that fibrinolytic properties of serotonergic antidepressants could impair platelet adhesion to collagen. The profibrinolytic and antiplatelet properties of serotonergic antidepressants help explain the increased risk of gastrointestinal, intracranial, and surgical bleeding in patients using these medications. Studies evaluating the impact of antidepressants on thrombotic and cardiovascular risk have yielded contradictory results. Corroborating the hypothesis that serotonergic antidepressants have profibrinolytic and antiplatelet properties, some authors showed that these medications prevent both cardiovascular and thromboembolic events. Others showed an increased risk of ischemic stroke, cardiac events and thromboembolic disease. Silent brain infarction may present in some elders with depressive symptoms, so it is presumed that antidepressants are prescribed for subclinical stroke patients. Another explanation for the increased risk of cardiovascular and thromboembolic events reported by some authors in individuals taking antidepressants includes antidepressant side effects such as sedation and weight gain and depression comorbidities such as anxiety, obesity and hyperhomocysteinemia. In conclusion, we suggest that serotonergic antidepressants be considered weak anticoagulants. We also suggest that depressed patients with comorbidities increasing the risk of cardiovascular and thromboembolic disease be recommended to follow a balanced diet and engage in physical activity, such as daily walking.

Are Cardiovascular Risk Factors Stronger Predictors of Incident Cardiovascular Disease in U.S. Adults With Versus Without a History of Clinical Depression?

Background

Several mechanisms underlying the depression-to-cardiovascular disease (CVD) relationship have been proposed; however, few studies have examined whether depression promotes CVD through potentiating traditional cardiovascular risk factors.

Purpose

To test the combined influence of three cardiovascular risk factors and lifetime depressive disorder on incident CVD in a large, diverse, and nationally representative sample of U.S. adults.

Methods

Respondents were 26,840 adults without baseline CVD who participated in Waves 1 (2001-2002) and 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions. Lifetime depressive disorder, tobacco use, hypertension, and incident CVD were determined from structured interviews, and body mass index (BMI) was computed from self-reported height and weight.

Results

Logistic regression models predicting incident CVD (1,046 cases) revealed evidence of moderation, as the interactions between lifetime depressive disorder and current tobacco use (p = .002), hypertension (p < .001), and BMI (p = .031) were significant. The Former Tobacco Use × Lifetime Depressive Disorder interaction was not significant (p = .85). In models stratified by lifetime depressive disorder, current tobacco use (OR = 1.78, 95% CI = 1.36-2.32, p < .001 vs. OR = 1.41, 95% CI = 1.24-1.60, p < .001), hypertension (OR = 2.46, 95% CI = 1.98-3.07, p < .001 vs. OR = 1.39, 95% CI = 1.28-1.51, p < .001), and BMI (OR = 1.10, 95% CI = 1.01-1.20, p = .031 vs. OR = 1.03, 95% CI = 0.99-1.07, p = .16) were stronger predictors of incident CVD in adults with versus without a lifetime depressive disorder.

Conclusions

Our findings suggest that amplifying the atherogenic effects of traditional cardiovascular risk factors may be yet another candidate mechanism that helps to explain the excess CVD risk of people with depression.

Proteomic Analysis of the Antidepressant Effects of Shen-Zhi-Ling in Depressed Patients: Identification of Proteins Associated with Platelet Activation and Lipid Metabolism

Shen-Zhi-Ling (SZL) is a Chinese medicine formulated from a Kai-Xin-San decoction that is commonly used to treat depression caused by dual deficiencies in the heart and spleen. However, the underlying mechanisms remain unclear. We investigated biological changes in depression patients (DPs) exhibiting antidepressant responses to SZL treatment using proteomic techniques. We performed label-free quantitative proteomic analysis and liquid chromatography-tandem mass spectrometry to discover and examine altered proteins involved in depression and antidepressant treatment. Serum samples were collected from DPs, DPs who underwent 8 weeks of SZL treatment and healthy controls (HCs). The proteins that differed among the three groups were further validated by Western blot analysis. By performing multivariate analyses, we identified 12 potential serum biomarkers that were differentially expressed among the HC, DP, and SZL groups. We then confirmed the significant changes in alpha-1-antitrypsin, von Willebrand factors, apolipoprotein C-III, and alpha-2-macroglobulin among the three groups by performing Western blot analysis, which supported the proteomic results. Profiling the proteomic changes in DPs treated with SZL could improve our understanding of the pathways involved in SZL responses, such as alterations in platelet activation, inflammatory regulation, and lipid metabolism. Future studies involving larger patient cohorts are necessary to draw more definitive conclusions.

Platelet haemostatic function in psychiatric disorders: Effects of antidepressants and antipsychotic drugs

Objectives Platelets, the smallest anucleated blood cells, play an essential role in the first step of complex haemostatic process. This review presents the haemostatic function of blood platelets related to their activation in psychiatric disorders (schizophrenia, depression), the role of antipsychotic and antidepressant medication, and introduces the mechanisms by which activated platelets may be involved in the pathophysiology of these disorders. Methods Platelets are interesting and easily accessible blood cells to study biochemical pathways related to schizophrenia and other psychiatric disorders, and their complex activation process might be useful as a diagnostic peripheral marker for studying psychiatric disorders and haemostatic complications. Results The excessive activation of platelets observed in patients with depression and schizophrenia is involved in cardiovascular diseases, stroke and increased risk of thrombotic complications that may be major causes of morbidity and mortality of patients. The use of antidepressants or antipsychotic drugs in depression and schizophrenia treatment is often associated with haematological side effects such as bleeding, venous thromboembolism and impaired platelet function. Conclusions Understanding the role of platelet activation in psychiatric disorders such as schizophrenia or depression and medication may improve therapies in the future.

Intervention of the Nuss Procedure on the Mental Health of Pectus Excavatum Patients

Pectus excavatum (PE) is the most common congenital chest wall deformity, but little is known about the influence of the Nuss surgical procedure on mental health of patients with PE. In this study, we aimed to evaluate the influence of the PE Nuss surgical procedure on mental health in Chinese patients and identify the predictors of psychological status for PE. Patients with PE (n = 266) underwent a standard surgical procedure by the same surgeon and did the Symptom Checklist 90 (SCL-90) and the Self-rating Depression Scale (SDS) questionnaires before and 1 year after surgery. Additionally, platelet reactivity of postoperative PE patients was assessed. We found that PE patients after surgery performed better in the questionnaires and the frequency of mental health problems in the patients was lower than before. Most significantly, four mental disorders were alleviated after surgery, namely somatization, interpersonal sensitivity, depression, and anxiety. What is more, age, suffering year, and platelet aggregation responses to serotonin and epinephrine of PE patients partially were involved with the postoperative alleviation of mental disorders. In conclusion, the mental health level of PE patients could be effectively improved via the Nuss surgical procedure, and the earlier surgery might turn out better.

Behavioral, emotional and neurobiological determinants of coronary heart disease risk in women

Women have more of the stress-related behavioral profile that has been linked to cardiovascular disease than men. For example, women double the rates of stress-related mental disorders such as depression and posttraumatic stress disorder (PTSD) than men, and have higher rates of exposure to adversity early in life. This profile may increase women's long-term risk of cardiometabolic conditions linked to stress, especially coronary heart disease (CHD). In addition to having a higher prevalence of psychosocial stressors, women may be more vulnerable to the adverse effects of these stressors on CHD, perhaps through altered neurobiological physiology. Emerging data suggest that young women are disproportionally susceptible to the adverse effects of stress on the risk of cardiovascular disease, both in terms of initiating the disease as well as worsening the prognosis in women who have already exhibited symptoms of the disease. Women's potential vulnerability to psychosocial stress could also help explain their higher propensity toward abnormal coronary vasomotion and microvascular disease compared with men.

BDNF val66met polymorphism and depressive disorders in patients with acute coronary syndrome

INTRODUCTION

Brain-derived neurotrophic factor (BDNF) may be the key to understanding the development of depression in patients with acute coronary syndrome (ACS), as it is associated with both conditions. Because the expression of BDNF is influenced by genetic polymorphisms, in this study we investigated the association between the BDNF polymorphism val66met and both the risk of depression in ACS and the treatment response.

METHODS

Among the 969 patients with recent ACS at baseline, 711 were re-evaluated after 1 year of follow-up. Depressive disorder status was assessed according to the DSM-IV criteria both at baseline and at follow-up. Baseline prevalence, follow-up incidence, and the persistence of depression were also determined. Of the 378 patients diagnosed with depression at baseline, 255 were randomized to a 24-week double-blind placebo-controlled trial of escitalopram; the remaining 123 received the usual care. Associations between the BDNF val66met polymorphism and both depression status and treatment response were investigated using logistic regression models.

RESULTS

The prevalence and persistence, but not the incidence of depressive disorders were significantly associated with BDNF met alleles. Patients in the escitalopram group who carried the met allele had a significantly higher rate of remission than those who did not. Depressive disorders tended to persist at 1 year in patients managed with placebo or medical treatment only, and particularly those patients positive for BDNF met alleles, although the difference was not statistically significant.

LIMITATIONS

The generalizability should be considered since this study conducted in a single center.

CONCLUSIONS

ACS patients positive for BDNF met alleles are vulnerable to depressive disorders at baseline and to its persistence. Antidepressant treatment may be effective in this subgroup of patients and may prevent the persistence of depression.

Enhanced platelet reactivity in pediatric depression: an observational study

Depression is associated with poor prognosis for cardiovascular disease (CVD) including mortality. Among multiple mechanisms linking depression and CVD, changes in platelet reactivity are known to be one of the major confounders of such adverse association. However, there are very limited data in children. Thus, we evaluated some conventional hemostatic indices including whole blood platelet aggregation in patients with documented pediatric depression and compared these data with those obtained from healthy children. The pediatric patients fulfilled criteria for major depression with a minimum score of 19 on the 21-item Beck Depression Inventory Scale. Plasma fibrinogen, D-dimer, platelet count, mean platelet volume, and platelet aggregation induced by ADP and collagen were measured in 67 pediatric patients with depression and matched by age and sex with 78 healthy controls. As expected, the depressed children had significantly higher BECK scales (P = 0.001) compared with the normal subjects. Platelet aggregation induced by ADP and collagen (P = 0.0001 for both) was significantly higher in depressed children. BECK scale scores correlated significantly with platelet aggregation induced by ADP (r = 0.3, P = 0.001) and collagen (r = 0.4, P = 0.01). In contrast, platelet counts, fibrinogen, D-dimer, mean platelet volume, and antithrombin-III levels were almost identical between both groups. Children with depression exhibit mostly intact hemostatic parameters, with the exception of significantly higher platelet activity when compared with healthy controls. These data match well with prior evidence from depressed adults supporting the hypothesis that platelets participate in the pathogenesis of depression. However, beyond pure assessment of platelet activity, other elements including serotonin content and cell receptor changes in pediatric depression should be elucidated before randomized trial(s) can be justified.

Bioprofiling of platelets in medicated patients with depression

BACKGROUND

Changes in platelet bioactivity and aggregation are of interest when studying patients with depression as this could help to explain the statistically observed association of depression and chronic somatic, especially cardiovascular disease. This link could potentially be mediated through serotonergic signaling or immunological changes.

METHODS

38 medicated patients with major depressive disorder (MDD) and 30 mentally healthy controls, both without a diagnosis of cardiovascular disease, were included in this naturalistic study. Demographic and psychometric data were obtained. Platelet aggregability was measured by PFA-100 and bioactive compounds and serotonin levels were quantified in platelet sonicate.

RESULTS

The comparison of patients with controls revealed no changes in platelet aggregability, but significant differences in platelet content of several bioactive compounds. In a second analysis, patients were grouped according to the receptors and transporters influenced by their medication and again compared to controls. A significant effect of MDD was found for platelet content of serotonin, CD40L, interleukin-1β, and platelet factor-4, independent of medication. These markers can thus be classified as sensitive to MDD. The effect of medication on platelet parameters was also evaluated. Platelet content of matrix metalloproteinase-2 and β-thromboglobulin was normalized in MDD patients by medication acting on the serotonin transporter.

LIMITATIONS

Owing to the naturalistic study design, patients were on a variety of different medications and combination therapies. This was accounted for by a novel analysis method.

CONCLUSION

Platelet serotonin levels and content of immunomodulatory compounds are significantly altered in patients with MDD, even if treatment effects are taken into account.

Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association

BACKGROUND

Although prospective studies, systematic reviews, and meta-analyses have documented an association between depression and increased morbidity and mortality in a variety of cardiac populations, depression has not yet achieved formal recognition as a risk factor for poor prognosis in patients with acute coronary syndrome by the American Heart Association and other health organizations. The purpose of this scientific statement is to review available evidence and recommend whether depression should be elevated to the status of a risk factor for patients with acute coronary syndrome.

METHODS AND RESULTS

Writing group members were approved by the American Heart Association's Scientific Statement and Manuscript Oversight Committees. A systematic literature review on depression and adverse medical outcomes after acute coronary syndrome was conducted that included all-cause mortality, cardiac mortality, and composite outcomes for mortality and nonfatal events. The review assessed the strength, consistency, independence, and generalizability of the published studies. A total of 53 individual studies (32 reported on associations with all-cause mortality, 12 on cardiac mortality, and 22 on composite outcomes) and 4 meta-analyses met inclusion criteria. There was heterogeneity across studies in terms of the demographic composition of study samples, definition and measurement of depression, length of follow-up, and covariates included in the multivariable models. Despite limitations in some individual studies, our review identified generally consistent associations between depression and adverse outcomes.

CONCLUSIONS

Despite the heterogeneity of published studies included in this review, the preponderance of evidence supports the recommendation that the American Heart Association should elevate depression to the status of a risk factor for adverse medical outcomes in patients with acute coronary syndrome.

Newly diagnosed depression is associated with increased beta-thromboglobulin levels and increased expression of platelet activation markers and platelet derived CD40-CD40L

BACKGROUND

Inflammation plays a key role in atherosclerotic disease. Up until now only limited evidence exists on the mechanism of cardiovascular complications in patients with depression. In addition depression was also linked to an increase in cardiovascular mortality. The present study was designed to evaluate the extent of platelet activation and platelet-derived markers of atherosclerotic disease in patients with newly diagnosed depression.

METHODS

This study used whole blood aggregometry, flow cytometry and ELISA to investigate platelet CD62P (P-selectin) expression and atherosclerotic markers (CD40, CD40L) as well as serum platelet factor 4 (PF-4) and beta-thromboglobulin (β-TG) levels in 46 participants. Patients with newly diagnosed, but not yet medically treated depression (n = 21) were compared to healthy control patients.

RESULTS

The platelet activation marker CD62P was significantly higher in patients with depression (2.62% depression versus 1.27% controls; p = 0.006). Further we found basal CD40 (6.7% vs. 4.8%; p = 0.002) and basal CD40L (31.0% vs. 22.0%; p = 0.025) to be elevated in patients with depression as compared to control persons. In addition sCD40L (52.7 vs. 44.4 ng/ml; p = 0.023) and β-TG differed significantly in depressed patients (206.9 vs. 182.8 ng/ml; p = 0.001). However, basal CD41 (97.0% vs. 96.3%; p = 0.57), CD42b (96.7% vs. 94.7%; p = 0.28) and PF-4 (89.61 vs. 81.75 IU/ml; p = 0.10) and the aggregometry results did not differ significantly between the study groups.

CONCLUSIONS

Our findings with elevated CD40 and CD40L as well as CD62P and β-TG in newly diagnosed patients emphasize that depression is linked to a prothrombotic and proinflammatory state and this possibly contributes to accelerated atherosclerosis.

Depression and chronic diseases: it is time for a synergistic mental health and primary care approach

OBJECTIVE

To identify the growing significance of depression as a global leading cause of years lost to disability and its role as a major independent risk factor in many chronic illnesses. The distinct effects of depression on morbidity and mortality in cancer, diabetes, heart disease, and stroke are investigated, including behavioral factors and plausible biological mechanisms (psychoneuroimmunology of depression).

DATA SOURCES

PubMed articles in English were searched from 1992 to 2012 (20-year span) using the following search criteria: psychoneuroimmunology of depression, immune-mediated inflammation, depression treatment recommendations, depression screening, years lost to disability, underserved populations and depression, chronic illnesses and depression, and selective serotonin reuptake inhibitors and immune system.

DATA SYNTHESIS

Evidence of the robust bidirectional relationship between depression and individual chronic diseases is presented and discussed. A brief overview of currently recommended psychotherapeutic and psychopharmacologic treatment approaches in regard to depression in chronic diseases is provided.

RESULTS

Discordance between mental health and primary care within the US public health system is a systematic problem that must be addressed. This situation leads to a potentially high hidden prevalence of underdiagnosed and undertreated depression, especially in the underserved populations.

CONCLUSION

Measures must be implemented across the communities of mental health and primary care practitioners in order to achieve a synergistic approach to depression.

Influence of mental stress on platelet bioactivity

It is well established that various mental stress conditions contribute, or at least influence, underlying pathophysiological mechanisms in somatic, as well as in psychiatric disorders; blood platelets are supposed to represent a possible link in this respect. The anculeated platelets are the smallest corpuscular elements circulating in the human blood. They display different serotonergic markers which seem to reflect the central nervous serotonin metabolism. They are known as main effectors in haematological processes but recent research highlights their role in the innate and adaptive immune system. Platelets are containing a multitude of pro-inflammatory and immune-modulatory bioactive compounds in their granules and are expressing immune-competent surface markers. Research gives hint that platelets activation and reactivity is increased by mental stress. This leads to enhanced cross talk with the immune system via paracrine secretion, receptor interaction and formation of platelet leucocyte-aggregates. Recently it has been demonstrated that the immune system can have a remarkable impact in the development of psychiatric disorders. Therefore platelets represent an interesting research area in psychiatry and their role as a possible biomarker has been investigated. We review the influence of mental stress on what is termed platelet bioactivity in this article, which subsumes the mainly immune-modulatory activity of platelets in healthy volunteers, elderly persons with chronic care-giving strain, patients with cardiovascular diseases who are prone to psychosocial stress, as well as in patients with posttraumatic stress disorder. Research data suggest that stress enhances platelet activity, reactivity and immune-modulatory capacities.

Biological understanding of the cardiovascular risk associated with major depression and panic disorder is important

INTRODUCTION

Panic disorder (PD) and major depressive disorders (MDD) are serious mental disorders but the mechanisms underlying the pathophysiology are poorly understood. Nitric oxide (NO) is a gas considered to play an important role in mediating anxiety and stress response and is synthesised from nitric oxide synthase (NOS). The endothelial isoform (eNOS) has been found also in platelets. Homocysteine (Hcy) is an amino acid which naturally occurs in the human body. Elevated levels are linked to increased risk of cardiovascular, neurological and psychiatric diseases. In this study we aimed to evaluate NO, platelet aggregation and Hcy levels in PD and MDD patients.

MATERIALS AND METHODS

Nineteen PD and 18 MDD patients participated in this study. NO levels were measured spectrophotometrically, platelet aggregation levels were measured in an aggregometer and Hcy levels were measured by HPLC.

RESULTS

NO levels were significantly lower in patients with MDD and PD than in control subjects (P < 0.05). Hcy and platelet aggregation levels were significantly higher in patients with MDD and PD than in control subjects (P < 0.05).

CONCLUSION

Further more detailed studies are needed to find out the effects of drugs on these parameters or to disclose the exact mechanism underlying the alteration of these parameters.

Association of depression with increased risk of dementia in patients with type 2 diabetes: the Diabetes and Aging Study

CONTEXT

Although depression is a risk factor for dementia in the general population, its association with dementia among patients with diabetes mellitus has not been well studied.

OBJECTIVE

To determine whether comorbid depression in patients with type 2 diabetes increases the risk of development of dementia.

DESIGN

The Diabetes and Aging Study was a cohort investigation that surveyed a racially/ethnically stratified random sample of patients with type 2 diabetes.

SETTING

A large, integrated, nonprofit managed care setting in Northern California.

PARTICIPANTS

A sample of 19,239 diabetes registry members 30 to 75 years of age.

MAIN OUTCOME MEASURES

The Patient Health Questionnaire 8, International Classification of Diseases, Ninth Revision (ICD-9) diagnoses of depression, and/or antidepressant prescriptions in the 12 months prior to baseline were used to identify prevalent cases of depression. Clinically recognized dementia was identified among subjects with no prior ICD-9 Clinical Modification (ICD-9-CM) diagnoses of dementia. To exclude the possibility that depression was a prodrome of dementia, dementia diagnoses were only based on ICD-9-CM diagnoses identified in years 3 to 5 postbaseline. The risk of dementia for patients with depression and diabetes relative to patients with diabetes alone was estimated using Cox proportional hazard regression models that adjusted for sociodemographic, clinical, and health risk factors and health use.

RESULTS

During the 3- to 5-year period, 80 of 3766 patients (2.1%) with comorbid depression and diabetes (incidence rate of 5.5 per 1000 person-years) vs 158 of 15,473 patients (1.0%) with diabetes alone (incidence rate of 2.6 per 1000 person-years) had 1 or more ICD-9-CM diagnoses of dementia. Patients with comorbid depression had a 100% increased risk of dementia during the 3 to 5 years postbaseline (adjusted hazard ratio, 2.02; 95% confidence interval, 1.73-2.35).

CONCLUSION

Depression in patients with diabetes was associated with a substantively increased risk for development of dementia compared with those with diabetes alone.

[Psychiatric and behavioral aspects of cardiovascular disease: epidemiology, mechanisms, and treatment]

Psychosocial and behavioral factors, including mood (depression, anxiety, anger, and stress), personality (Type A, Type D, and hostility), and social support, are associated with both the development and progression of cardiovascular disease. "Negative" emotions have been associated with increased rates of cardiovascular death and recurrent cardiac events, although the mechanisms responsible for this association remain unclear. A number of pathophysiological mechanisms have been proposed to explain these relationships, including hypothalamic-pituitary-adrenal axis dysregulation, platelet activation, and inflammation. Behavioral factors also have been implicated, such as nonadherence to prescribed medical therapies and physical inactivity. Several randomized trials of patients with cardiovascular disease have examined the impact of pharmacologic and behavioral treatments on hard cardiovascular disease events as well as on cardiovascular disease biomarkers of risk. Although psychological treatments generally have been shown to improve quality of life and psychological functioning among cardiac patients, the benefit of psychological interventions with respect to improving clinical outcomes has not been conclusively demonstrated.

[Psychiatric and behavioral aspects of cardiovascular disease: epidemiology, mechanisms, and treatment]

Psychosocial and behavioral factors, including mood (depression, anxiety, anger, and stress), personality (Type A, Type D, and hostility), and social support, are associated with both the development and progression of cardiovascular disease. "Negative" emotions have been associated with increased rates of cardiovascular death and recurrent cardiac events, although the mechanisms responsible for this association remain unclear. A number of pathophysiological mechanisms have been proposed to explain these relationships, including hypothalamic-pituitary-adrenal axis dysregulation, platelet activation, and inflammation. Behavioral factors also have been implicated, such as nonadherence to prescribed medical therapies and physical inactivity. Several randomized trials of patients with cardiovascular disease have examined the impact of pharmacologic and behavioral treatments on hard cardiovascular disease events as well as on cardiovascular disease biomarkers of risk. Although psychological treatments generally have been shown to improve quality of life and psychological functioning among cardiac patients, the benefit of psychological interventions with respect to improving clinical outcomes has not been conclusively demonstrated.

Coagulation activation and fibrinolysis impairment are reduced in patients with anxiety and depression when medicated with serotonergic antidepressants

AIMS

Anxiety disorders have been shown to be correlated with an activation of coagulation and impairment of fibrinolysis. The aim of the study was to assess whether medication with a serotonergic antidepressant, which has been associated with abnormal bleeding, may modify this effect.

METHODS

Thirty-one anxiety patients, mostly with comorbid depression, and 31 healthy controls were included in the study. Group differences between anxiety patients medicated with a serotonergic antidepressant, patients without serotonergic antidepressant and controls were assessed for activated partial thromboplastin time, fibrinogen, factor VII, factor VIII, von Willebrand factor, von Willebrand ristocetin cofactor activity, prothrombin fragment 1 + 2, thrombin-antithrombin complex, d-dimer, α2-antiplasmin, plasmin-α2-antiplasmin complex (PAP), tissue plasminogen activator and plasminogen activator inhibitor. Intervening variables, such as age, sex, body mass index and smoking, were accounted for.

RESULTS

We found lower coagulation measures for fibrinogen (P = 0.03) and plasminogen activator inhibitor (P = 0.01), and higher levels of PAP (P = 0.046) in patients with serotonergic antidepressant than in patients without serotonergic antidepressant. When controlling for smoking and body mass index, differences between the two groups were significant for PAP (P = 0.02), von Willebrand ristocetin cofactor activity (P = 0.02) and activated partial thromboplastin time (P = 0.046). Coagulation scores were similar in patients with serotonergic antidepressant to those of healthy controls.

CONCLUSIONS

Serotonergic antidepressants may counteract a procoagulant effect of anxiety and/or depression in anxiety patients.

Hormones, heart disease, and health: individualized medicine versus throwing the baby out with the bathwater

It is increasingly axiomatic that depression has widespread adverse physiological effects and, conversely, that a variety of physiological systems impact the risk for developing depression. This convergence of depression and altered physiology is particularly dramatic during midlife--a time during which reproductive failure presages dramatic increases in prevalence of both heart disease and depression. The potentially meaningful and illuminating links between estrogen deficiency, cardiovascular disease (CVD), and depression have largely been obscured, first by assertions, subsequently repudiated, that the perimenopause was not a time of increased risk of depression, and more recently by the denegration of hormone replacement therapy by initial reports of the Women's Health Initiative. Increasingly, however, research has led to unavoidable conclusions that CVD and depression share common, mediating pathogenic processes and that these same processes are dramatically altered by the presence or absence of estrogen (E2). This review summarizes data supporting these contentions with the intent of placing depression and estrogen therapy in their proper physiologic context.

Somatic/affective symptoms, but not cognitive/affective symptoms, of depression after acute coronary syndrome are associated with 12-month all-cause mortality

BACKGROUND

Symptom dimensions of post myocardial infarction (MI) depression may be differently related to prognosis. Somatic/affective symptoms appear to be associated with a worse cardiac outcome than cognitive/affective symptoms. We examined the relationship between depressive symptom dimensions following acute coronary syndrome (ACS) and both disease severity and all-cause mortality.

METHODS

Patients (n=913) who had unstable angina pectoris or MI were recruited from 12 coronary care units between 1997 and 1999. Measurements included sociodemographic and clinical data and the Beck Depression Inventory (BDI). Endpoint was all-cause mortality at 12-month follow-up.

RESULTS

Principal component analysis revealed two components, somatic/affective and cognitive/affective symptoms of depression. Somatic/affective symptoms of depression (odds ratio (OR): 1.49; 95% confidence interval (CI): 1.23-1.81; p<0.001) but not cognitive/affective symptoms (OR: 0.92; 95% CI: 0.75-1.12; p=0.40) were related to a higher Killip class. Fifty-one patients died during the follow-up period. When controlling for index event, history of MI, Killip class, diabetes, gender and age, there was a significant association between the somatic/affective component (OR: 1.92; 95% CI: 1.36-2.71; p<0.001) and mortality. The cognitive/affective component was not related to mortality (OR: 1.07; 95% CI: 0.75-1.52; p=0.73).

LIMITATIONS

Time to death was not available.

CONCLUSIONS

This study showed that only somatic/affective depressive symptoms were associated with disease severity and all-cause mortality in ACS patients. More research is needed to evaluate the differential associations of somatic/affective and cognitive/affective depressive symptoms with cardiac outcomes and the underlying mechanisms.

Epidemiology and treatment of depression in patients with chronic medical illness

There is a bidirectional relationship between depression and chronic medical disorders. The adverse health risk behaviors and psychobiological changes associated with depression increase the risk for chronic medical disorders, and biological changes and complications associated with chronic medical disorders may precipitate depressive episodes. Comorbid depression is associated with increased medical symptom burden, functional impairment, medical costs, poor adherence to self-care regimens, and increased risk of morbidity and mortality in patients with chronic medical disorders. Depression may worsen the course of medical disorders because of its effect on proinflammatory factors, hypothalamic-pituitary axis, autonomic nervous system, and metabolic factors, in addition to being associated with a higher risk of obesity, sedentary lifestyle, smoking, and poor adherence to medical regimens. Both evidence-based psychotherapies and antidepressant medication are efficacious treatments for depression. Collaborative depression care has been shown to be an effective way to deliver these treatments to large primary care populations with depression and chronic medical illness.

Hormones, heart disease, and health: individualized medicine versus throwing the baby out with the bathwater

It is increasingly axiomatic that depression has widespread adverse physiological effects, and conversely that a variety of physiological systems impact the risk for developing depression. This convergence of depression and altered physiology is particularly dramatic during midlife-a time during which reproductive failure presages dramatic increases in prevalence of both heart disease and depression. The potentially meaningful and illuminating links between estrogen (E2) deficiency, cardiovascular disease (CVD), and depression have largely been obscured, first by assertions, subsequently repudiated that the perimenopause was not a time of increased risk of depression, and more recently by the denegration of hormone replacement therapy by initial reports of the Women's Health Initiative. Increasingly, however, research has led to unavoidable conclusions that CVD and depression share common and mediating pathogenic processes and that these same processes are dramatically altered by the presence or absence of E2. This review summarizes data supporting this contention with the intent of placing depression and E2 therapy in their proper physiologic context.

Risk of placental abruption in relation to maternal depressive, anxiety and stress symptoms

BACKGROUND

Little is known about the influence of psychiatric factors on the etiology of placental abruption (PA), an obstetrical condition that complicates 1-2% of pregnancies. We examined the risk of PA in relation to maternal psychiatric symptoms during pregnancy.

METHODS

This case-control study included 373 PA cases and 368 controls delivered at five medical centers in Lima, Peru. Depressive, anxiety and stress symptoms were assessed using the Patient Health Questionnaire (PHQ-9) and the Depression Anxiety Stress Scales (DASS-21). Multivariable logistic regression models were fit to calculate odds ratios (aOR) and 95% confidence intervals (CI) adjusted for confounders.

RESULTS

Depressive symptoms of increasing severity (using the DASS depression subscale) was associated with PA (p for trend=0.02). Compared with women with no depressive symptoms, the aOR (95%CI) for PA associated with each level of severity of depression symptoms based on the DASS assessment were as follows: mild 1.84 (0.91-3.74); moderate 1.25 (0.67-2.33); and severe 4.68 (0.98-22.4). The corresponding ORs for mild, moderate, and moderately severe depressive symptoms based on the PHQ assessment were 1.10 (0.79-1.54), 3.31 (1.45-7.57), and 5.01 (1.06-23.6), respectively. A positive gradient was observed for the odds of PA with severity of anxiety (p for trend=0.002) and stress symptoms (p for trend=0.002).

LIMITATIONS

These cross-sectionally collected data may be subject to recall bias.

CONCLUSIONS

Maternal psychiatric disorders may be associated with an increased occurrence of AP. Larger studies that allow for more precise evaluations of maternal psychiatric health in relation to PA risk are warranted.

Exaggerated platelet reactivity to physiological agonists in war veterans with posttraumatic stress disorder

An association between traumatic stress and cardiovascular disease (CVD) is supported by various epidemiological studies. Platelet activation and binding of activated platelets to leukocytes contributes to the pathophysiology of CVD. Evidence of hyperactive sympathetic nervous system, altered expression of platelet α(2)-adrenoreceptors (α(2)AR), and altered platelet adenylate cyclase activity in patients with posttraumatic stress disorder (PTSD) suggest that platelet reactivity in PTSD may be altered as well. We tested whether platelet reactivity to increasing doses of adenosine-diphosphate (ADP), epinephrine (EPI), or their combination differs between war veterans with PTSD (n=15) and healthy controls (n=12). For this purpose, citrated whole blood was incubated with increasing concentrations of ADP (0.1, 1, 10 μM), EPI alone (10 nM, 100 nM, 1000 nM), or EPI (10 nM, 100 nM, 1000 nM) in combination with 0.1 μM ADP. A subset of samples was also incubated with 10 μM yohimbine (YOH), α(2)AR antagonist, to distinguish receptor-specific effects. Platelet CD62P expression and formation of platelet-leukocyte aggregates (PLA) [platelet-monocyte (P-Mo), -lymphocyte (P-Ly), and -neutrophil (P-Ne) aggregates] were measured using three-color flow cytometry. Platelet reactivity was higher in war veterans with PTSD when compared to controls, as determined by greater CD62P expression and formation of PLA in response to ADP alone or in combination with EPI. Platelet reactivity also correlated with the severity of PTSD symptoms. Preliminary experiments with YOH indicate that stress-associated EPI elevations may contribute to platelet activation through a α(2)AR-dependent mechanism. The enhanced platelet reactivity observed in our study may be the underlying mechanism contributing to the development of CVD in PTSD patients.

Association between intimate partner violence, migraine and probable migraine

OBJECTIVE

Intimate partner violence (IPV) among women is a global public health problem. The association between childhood maltreatment and migraine is well established, but not the association between IPV and migraine. The aim of this cross-sectional study was to evaluate the relationship between type and severity of IPV and migraine in a large cohort of Peruvian women.

METHODS

Women who delivered singleton infants (n = 2066) at the Instituto Nacional Materno Perinatal, Lima, Peru were interviewed during their postpartum hospital stay. Participants were queried about their lifetime experiences with headaches and migraine, and with physical and sexual violence. The International Classification of Headache Disorders (ICHD-2) diagnostic criteria were used to classify participants according to their migraine status. Questions on physical and sexual violence were adapted from the protocol of Demographic Health Survey Questionnaires and Modules: Domestic Violence Module and the World Health Organization (WHO) Multi-Country Study on Violence against Women. Depressive symptoms were assessed using a modified version of the Patient Health Questionnaire-9. Logistic regression was used to estimate multivariate adjusted odds ratios (aOR) and 95% confidence intervals (CI).

RESULTS

Compared with women without a history of violence, women with experiences of lifetime physical or sexual violence (aOR = 1.44, 95% CI 1.19-1.75), physical violence only (aOR = 1.36, 95% CI 1.10-1.68), sexual violence only (aOR = 1.76, 95% CI 0.97-3.21), and both physical and sexual violence (aOR = 1.61, 95% CI 1.12-2.31) had increased odds of any migraine after adjusting for maternal age, parity, and access to basic foods. There was no gradient of increased odds of any migraine with severity of physical violence. The relationship between IPV and any migraine was strongest among women with moderate to severe levels of depressive symptoms. The odds of any migraine was increased 2.25-fold (95% CI 1.75-2.28) among abused women who also had moderate to severe levels of depressive symptomology compared with women who were not abused and had none or mild levels of depressive symptomology. Associations from sensitivity analyze that segregated women according to probable migraine (ICHD-2 category 1.6.1) and migraine (ICHD-2 category 1.1) diagnoses were of similar magnitudes as those reported here for women with any migraine diagnoses. IPV, particularly sexual violence, appears to be a risk factor for migraine.

CONCLUSION

Our findings suggest the potential importance of considering a history of violence among migraineurs.

Ultrastructural changes and immunolocalization of P-selectin in platelets from patients with major depression

Depression is considered an important risk factor in patients with cardiovascular disease (CVD). Although the biological mechanism is unknown, it has been suggested that hyperactivity of platelets may have an important role in the onset and evolution of cardiovascular damage. The goals of this study were to evaluate by transmission electron microscopy and immunohistochemistry the presence of ultra-structural variations in platelets from individuals with recent diagnosis of major depression disease (MDD, patients without previous anti-depressant treatment and from healthy control subjects.). Platelets from depressed patients had a greater proportion of dendritic forms compared with those obtained from control subjects. Morphological changes, such as dilation of open canalicular and dense tubular systems, platelet vacuolization, electrodense pattern of membranes, and a different immunolocalization of P-selectin were observed in the platelets from depressed patients compared with those isolated from healthy subjects. Our results revealed ultra-structural changes in platelets isolated from patients with MDD suggestive of enhanced platelet activation.

[Depression and cardiovascular disease--is there an association?]

BACKGROUND

Depression is associated with an increased risk of cardiovascular events. This review presents data from recent cohort- and interventional studies, and possible pathogenetic mechanisms.

MATERIAL AND METHODS

The article is based on literature from the period 1998 - 2008 identified through a non-systematic search in Medline.

RESULTS

Epidemiological studies of patients (outside of hospitals) with clinical depression suggest they have an increased risk of cardiovascular events. Possible mechanisms responsible for this increased cardiovascular risk are: an increased prevalence of unhealthy lifestyle factors, systemic inflammation, endocrine or autonomic dysfunction, increased platelet reactivity or endothelial dysfunction. Treatment with antidepressive drugs has not reduced the risk of cardiovascular events.

INTERPRETATION

Clinicians should be aware of the influence of depression on cardiovascular risk.

Relationship between psychological distress and endogenous anticoagulants in patients with a previous venous thromboembolic event

BACKGROUND

Psychological distress, particularly anxiety and depression, has been associated with a prothrombotic state. However, the relationship between psychosocial factors and endogenous anticoagulants protein S (PS) and protein C (PC) has not previously been investigated. We explored the association between psychological distress, PS, and PC in patients with an objectively diagnosed venous thromboembolic event (VTE).

METHODS

We investigated 126 consecutively enrolled patients ≥3 months after VTE (ie, deep venous thrombosis and/or pulmonary embolism) and ≥1 month of discontinuation of oral anticoagulants. Approximately 10 days before blood collection for thrombophilia workup, anxiety and depression scores were assessed using the Hospital Anxiety and Depression scale (HADS). Protein C and S were determined by routine laboratory assays.

RESULTS

After controlling for demographic and medical factors, PC, as measured by the PC-activated partial thromboplastin time (aPTT) method and the PC-chromatin substrate method, was positively associated with psychological distress (sum of anxiety plus depression symptoms; P ≤ .027), anxiety (P ≤ .055), and depression (P ≤ .031), explaining between 3% and 6% of the variance. Total PS antigen showed a direct relationship with psychological distress (P = .025) and depression (P = .005), explaining 5% and 7% of respective variances. Free PS showed a positive association with depression (P = .046), explaining 3% of the variance. Anxiety showed no independent association with either PS measure.

CONCLUSIONS

Psychological distress is independently associated with enhanced endogenous anticoagulant potential. This might reflect a counterregulatory mechanism to outweigh the previously observed hypercoagulability in individuals under chronic stress and with elevated symptoms of anxiety and depression.

The first- and second-generation antipsychotic drugs affect ADP-induced platelet aggregation

OBJECTIVE

Blood platelets play an important role in haemostasis and their hyperaggregability may lead to thrombosis and cardiovascular diseases. Increased incidence of mortality, caused by cardiovascular disease, and the increased risk of thrombotic complication in schizophrenic patients treated with antipsychotics have been reported. The effects of antipsychotic drugs on blood platelet function are not fully explained, therefore the purpose of the present study was to examine and compare the effects of the second-generation antipsychotic drugs used in schizophrenia (clozapine, risperidone and olanzapine), with the effects of the first generation antipsychotic, haloperidol, on the platelet aggregation induced by ADP in vitro.

METHODS

Blood obtained from healthy volunteers (n=25) collected into sodium citrate was centrifuged (250xg, 10 min) at room temperature to obtain platelet-rich plasma. Aggregation of blood platelets (10 microM ADP) was recorded (Chrono-log aggregometer) in platelet-rich plasma preincubated with antipsychotic drugs (final concentration: clozapine 420 ng/ml, risperidone 65 ng/ml, olanzapine 40 ng/ml, haloperidol 20 ng/ml) for 30 min.

RESULTS

Our results showed that all tested drugs inhibit platelet aggregation induced by ADP in vitro. Among studied antipsychotic drugs clozapine and olanzapine significantly reduced platelet aggregability in vitro. In comparison with control platelets (without the drug), clozapine inhibited ADP-induced platelet aggregation by 21% (P=3.7x10(-6)) and olanzapine by 18% (P=2.8x10(-4)), respectively.

CONCLUSION

The obtained results indicate that antipsychotic drugs, especially clozapine and olanzapine, contrary to haloperidol, reduced response of blood platelets to ADP measured as platelet aggregation. This suggests that therapy with such antipsychotics, particularly with second-generation antipsychotics, may partly reduce prothrombotic events associated with the increased platelet activation observed in schizophrenic patients. The mechanism of antiaggregatory influence of antipsychotics requires further studies.

Depression and platelet activation in outpatients with stable coronary heart disease: findings from the Heart and Soul Study

Depression is associated with increased morbidity and mortality in patients with coronary heart disease (CHD). Increased platelet activation has been proposed as a potential mechanism by which depression may lead to adverse cardiovascular outcomes. In this cross-sectional study, we measured platelet activation in 104 patients with stable CHD, including 58 with a current episode of major depression and 46 without past or current major depression. Participants were instructed not to take aspirin for 7 days prior to the study appointment. Platelet activation was measured by plasma concentrations of platelet factor 4 (PF4) and beta-thromboglobulin (beta-TG), and by 24-h urinary concentrations of 11-dehydro-thromboxane B(2) (TBXB2). We observed no differences in the mean levels of PF4, B-TG or TBXB2 in patients with and without major depression. Results were unchanged after adjustment for age, smoking, use of aspirin, and use of any psychotropic medication. We found no evidence of an association between major depression and platelet activation as measured by plasma concentrations of PF4 and beta-TG, or urinary TBXB2 in 104 outpatients with stable CHD. These findings do not support a role for platelet activation in the association between depression and cardiovascular disease among patients with stable CHD.

Anxiety is a better predictor of platelet reactivity in coronary artery disease patients than depression

AIMS

Depression and anxiety are linked to coronary events but the mechanism(s) remains unclear. We investigated the associations of depression and anxiety with serotonin-mediated platelet hyperactivity in coronary artery disease (CAD) patients in a cross-sectional study.

METHODS AND RESULTS

Three months after an acute coronary event, stable CAD patients (n = 83) on aspirin and clopidogrel were evaluated for depression (beck depression inventory) and anxiety (hospital anxiety and depression scale), and their platelet reactivity was measured (optical aggregometry and flow cytometric fibrinogen binding in response to adenosine diphosphate (ADP = 5 microM) and two serotonin + epinephrine doses [5HT:E (L) = 4 microM + 4 microM and 5HT:E (H) = 10 microM + 4 microM]. Platelet reactivity was significantly higher in depressed and anxious than in depressed only or non-depressed-and-non-anxious patients. Aggregation (mean +/- SE) was 41.9 +/- 2.6% vs. 32.2 +/- 2.6% vs. 30.4 +/- 3.7% with 5HT:E (L) and 46.9 +/- 2.7% vs. 35.6 +/- 2.7% vs. 31.7 +/- 3.8% with 5HT:E (H) (P < 0.05 for both). Differences in ADP aggregations were not significant, perhaps because of clopidogrel therapy. Flow cytometry findings were similar. In a multivariate linear regression model adjusted for age, body mass index, and each other, anxiety symptoms independently predicted all 5HT:E-mediated platelet reactivity measures, whereas depression predicted none.

CONCLUSION

Anxiety is associated with elevated serotonin-mediated platelet reactivity in stable CAD patients and symptoms of anxiety show strong, independent correlations with platelet function.

[Correlation of depression with stroke. Pathophysiological mechanisms]

Stroke is the third leading cause of death, just after heart disease and cancer. Its incidence will probably increase dramatically in the coming decades. For prevention it is urgently necessary to gain fundamental knowledge about the risk factors and pathophysiological mechanisms. It is now widely accepted that depression and stroke are correlated with each other. There is little knowledge, however, about the links that might connect both diseases. This review discusses different mechanisms that lead to an increased stroke risk and can be influenced by depression as well thus possibly linking depression and stroke.

Longitudinal platelet reactivity to acute psychological stress among older men and women

Platelet reactivity to acute stress is associated with increased cardiovascular disease risk; however, little research exists to provide systematic methodological foundations needed to generate strong longitudinal research designs. Study objectives were: 1) to evaluate whether markers of platelet function increase in response to an acute psychological stress test among older adults, 2) to establish whether reactivity remains robust upon repeated administration (i.e. three occasions approximately 1 year apart), and 3) to evaluate whether two different acute speech stress tasks elicit similar platelet responses. The 149 subjects (mean age 71 years) gave a brief impromptu speech on one of two randomly assigned topics involving interpersonal conflict. Blood samples drawn at baseline and post-speech were assayed using flow cytometry for platelet responses on three outcomes (% aggregates, % P-selectin expression, and % fibrinogen receptor expression). Three-level hierarchical linear modeling analyses revealed significant stress-induced increases in platelet activation on all outcomes (p < 0.001). No significant habituation on any measure was found. Additional reactivity differences were associated with male gender, history of myocardial infarction, and use of aspirin, statins, and antidepressants. The results demonstrate that laboratory acute stress tests continued to produce robust platelet reactivity on three activation markers among older adults over 3 years.

The changes of aggregability of blood platelets in schizophrenia

OBJECTIVE

Oxidative stress in schizophrenia may be responsible for the changes of platelet function and reactivity. Therefore, the aim of our present study was to evaluate the response of platelets from patients with schizophrenia to platelet agonists such as ADP and collagen.

RESULTS

Platelet aggregation of schizophrenic patients and healthy subjects stimulated by collagen or ADP showed significant differences. Aggregation of platelets stimulated by collagen was significantly lower in schizophrenic patients (about 86%) than in healthy subjects (P=0.022), but when this process was induced by ADP, aggregation of platelets was significantly higher in schizophrenic patients (increase to about 112%) than in healthy subjects (P=0.018). We also observed that antipsychotic drugs (clozapine, risperidone, olanzapine, haloperidol) reduce aggregation of platelets of schizophrenic patients and healthy group in vitro.

CONCLUSION

The obtained results indicate that the response of platelets from schizophrenic patients to ADP and collagen is different than in healthy subjects.

Persistent versus transient depressive symptoms in relation to platelet hyperactivation: a longitudinal analysis of dementia caregivers

BACKGROUND

Depressive symptoms and caregiving stress may contribute to cardiovascular disease (CVD) via chronic platelet activation; however, it remains unclear whether this elevated activation constitutes a trait or state marker. The primary objective was to investigate whether persistent depressive symptoms would relate to elevated platelet activation in response to acute psychological stress over a three-year period.

METHODS

Depressive symptoms (Brief Symptom Inventory) were assessed among 99 spousal dementia caregivers (52-88 years). Platelet P-selectin expression was assessed in vivo using flow cytometry at three time-points over the course of an acute stress test: baseline, post-stress, and after 14 min of recovery. Two competing structural analytic models of depressive symptoms and platelet hyperactivity with three yearly assessments were compared.

RESULTS

Although depressive symptoms were generally in the subclinical range, their persistent elevation was associated with heightened platelet reactivity and recovery at all three-years while the change in depressive symptoms from the previous year did not predict platelet activity.

LIMITATIONS

These results focus on caregivers providing consistent home care, while future studies may extend these results by modeling major caregiving stressors.

CONCLUSIONS

Enduring aspects of negative affect, even among those not suffering from clinical depression are related to hemostatic changes, in this case platelet reactivity, which might be one mechanism for previously reported increase in CVD risk among elderly Alzheimer caregivers.

Preeclampsia risk in relation to maternal mood and anxiety disorders diagnosed before or during early pregnancy

BACKGROUND

Mood and anxiety disorders are common, debilitating psychiatric illnesses that disproportionally affect women of childbearing age. Relatively few studies have evaluated the extent to which, if at all, maternal mood and anxiety disorders are risk factors for preeclampsia, and results from available studies are inconsistent. We examined the risk of preeclampsia in relation to maternal medical history of mood and anxiety disorders.

METHODS

We used data from a cohort study of 2,601 pregnant women. Maternal pregestational and early pregnancy (before completion of 20 weeks gestation) psychiatric diagnoses were ascertained from medical records. Generalized linear regression procedures were used to derive relative risk (RR) estimates and 95% confidence intervals (CIs).

RESULTS

A positive history of maternal mood or anxiety disorder was associated with a 2.12-fold increased risk of preeclampsia after adjustment for age, race/ethnicity, and pre-pregnancy body mass index (95% CI 1.02-4.45). The risk of preeclampsia appeared to be more strongly related with maternal mood or anxiety disorders first diagnosed during the index pregnancy (adjusted RR = 3.64; 95% CI 1.13-11.68). The corresponding RR for maternal mood and anxiety disorders diagnosed before pregnancy was 1.73 (95% CI 0.71-4.20).

CONCLUSIONS

Maternal mood and anxiety disorders are associated with increased preeclampsia risk. These observations must be explored in larger pharmacoepidemiological studies that allow precise evaluations of independent and joint effects of maternal psychopathologies and the use of psychotropic medications on preeclampsia risk.

The association of depression with platelet activation: evidence for a treatment effect

BACKGROUND

Depression is associated with an increased risk of cardiovascular disease (CVD). Although the mechanism is uncertain, prothrombotic and inflammatory factors may play a role.

OBJECTIVES

As platelets play a key role in CVD, we determined first, whether depressed individuals had more activated platelets than non-depressed individuals and second, whether treatment of depression reduced platelet activation levels.

PATIENTS/METHODS

We recruited 108 depressed outpatients and 45 control subjects all without a history of CVD. After psychological assessment, the depressed patients were offered treatment with medication and/or psychotherapy. Flow cytometric markers of platelet activation and level of depression were assessed at baseline and at 4 weeks and 6 months after treatment.

RESULTS

Depression was associated with increased platelet activation with a higher number of circulating CD62p (0.76x10(9) L(-1) vs. 0.46, P=0.019) and CD63 (P=0.05) positive platelets compared with controls. Patients with depression also had more circulating platelet-leukocyte aggregates than controls (P<0.001). There was a positive correlation between the severity of depression and the level of platelet activation. Platelets from depressed patients were also hyperreactive to adenosine 5 -diphosphate (ADP) stimulation with increased CD62p and CD63 exposure (P=0.003 and 0.019, respectively). Six months of treatment resulted in a reduced number of circulating CD62p and CD63 positive platelets (29.84% and 53.38% decrease) and a 20.9% reduction in CD63 exposure after ADP activation.

CONCLUSIONS

Depression is associated with increased in vivo platelet activation and resolution of depression using psychotherapy and/or medication reduces platelet activation. These findings provide insights into the link between depression and cardiovascular risk.

Antidepressant drugs and cardiovascular pathology: a clinical overview of effectiveness and safety

OBJECTIVE

To review data examining the relationships between depression, antidepressants and cardiovascular disease.

METHOD

Structured searches of PubMed, Medline and Embase conducted in March 2008.

RESULTS

Depression and cardiovascular disease are closely associated clinical entities. Depression appears both to cause and worsen cardiovascular disease. Cardiovascular disease is in turn associated with a high incidence of depression. Depression is associated with increased mortality in cardiovascular disease, and after myocardial infarction (MI) and stroke. Many antidepressants have cardiotoxic properties. Tricyclic drugs are highly cardiotoxic in overdose and may induce cardiovascular disease and worsen outcome in established cardiovascular disease. Reboxetine, duloxetine and venlafaxine are known to increase blood pressure. Other antidepressants have neutral or beneficial effects in various cardiovascular disorders.

CONCLUSION

Sertraline, fluoxetine, citalopram, bupropion and mirtazapine appear to be safe to use after MI; the use of sertraline, and response to citalopram and mirtazapine may improve mortality. Paroxetine and citalopram appear to be safe to use in patients with established coronary artery disease. Limited data suggest that a variety of antidepressants are effective and safe to use after stroke.