The effect of treatment response on endothelial function and arterial stiffness in depression. A prospective study

Effects of citalopram on blood pressure control in depressive patients with hypertension: A randomized clinical trial

Introduction

Since there is a bi-directional interaction between hypertension and depression, we aimed to evaluate the effects of citalopram administration in the management of hypertension.

Methods

A randomized clinical trial was conducted on 72 patients with concomitant depression and hypertension. The intervention group (n=41) received citalopram 20 mg daily plus anti-hypertensive standard treatment, while the control group (n=31) received only the standard treatment. The study's primary endpoint was in-office blood pressure (BP) measurement at baseline and home BP monitoring in the first and second months after entering the study.

Results

There were no significant differences in baseline systolic BP (163.3±19.6 vs.164.2±20.3 mm Hg; P=0.910) and diastolic BP (94.5±13.8 vs. 88.2±14.4; P=0.071). After one month, diastolic BP (82.7±11.7 vs. 77.09±12.2; P=0.023) was significantly higher in the control group compared to the intervention group. Two months after the intervention, systolic BP (133.8±16.5 vs. 124.5±12.4; P=0.009) and diastolic BP (80.7±10.3 vs. 73.7±9.7; P=0.002) were significantly decreased in the intervention group compared to the control group.

Conclusion

This study supported the beneficial effects of citalopram in lowering BP in patients with concomitant depression and hypertension.

Reduction of arterial stiffness in depressive individuals responding to multimodal treatment

BACKGROUND

Depressive individuals are at higher risk for cardiovascular diseases (CVD). Thus, cardiovascular parameters such as arterial stiffness, often measured by pulse wave velocity (PWV), should be monitored. Recent research indicated that depressive individuals exhibit higher PWV, but there is little data on the changeability of PWV through multimodal treatment. This study investigated PWV in moderately to severe depressive individuals before and after undergoing treatment in dependence on responding or not responding to treatment.

METHODS

47 participants (31 females, 16 males) underwent a PWV measurement and filled out a questionnaire surveying depressive symptom severity before and after a six-week psychiatric rehabilitation treatment including multimodal interventions. Subjects were divided in responders and non-responders, depending on their treatment success.

RESULTS

A mixed ANCOVA analysis indicated no significant main effect of responder status, but a significant main effect of measurement time and a significant interaction between responder status and measurement time. Responders exhibited a significant decrease in PWV across time, while no significant change in PWV across time was found for non-responders.

LIMITATIONS

Results are limited by the lack of a control group. The influence of medication duration or medication type was not considered in the analyses. Causality of the relationship between PWV and depression cannot be determined.

CONCLUSION

These findings show that PWV can be positively modified in depressive individuals responding to treatment. This effect cannot solely be attributed to pharmacological interventions but rather the combination of multimodal interventions, thus highlighting the clinical relevance of multimodal treatment in depression and comorbid disorders.

Exploring the role of adult attachment, major depression and childhood trauma in arterial stiffness: A preliminary study

OBJECTIVE

Prior research indicates a noteworthy and intricate connection between depression and subclinical atherosclerosis. Nevertheless, the biological and psychological mechanisms that underlie this association are not yet fully understood. To address this gap, this exploratory study aimed to examine the relationship between active clinical depression and arterial stiffness (AS), with a particular focus on the potential mediating roles of attachment security and childhood trauma.

METHODS

In this cross-sectional study, we examined 38 patients with active major depression free of dyslipidemia, diabetes mellitus, hypertension, and obesity and 32 healthy controls. All participants underwent blood tests, psychometric assessments, and AS measurements using the Mobil-O-Graph arteriograph system. AS severity was evaluated using an augmentation index (AIx) normalized to 75 beats/min.

RESULTS

In the absence of defined clinical cardiovascular risk factors, there was no significant difference in AIx between individuals with depression and healthy controls (p = .75). Patients with longer intervals between depressive episodes had lower AIx (r = -0.44, p < .01). Insecure attachment and childhood trauma did not significantly associate with AIx in patients. Whereas insecure attachment was positively correlated with AIx only in healthy controls (r = 0.50, p = 01).

CONCLUSIONS

Our analysis of established risk factors for atherosclerosis revealed that depression and childhood trauma had no significant relationship with AS. However, we did identify a novel finding: insecure attachment was significantly associated with AS severity in healthy adults without defined cardiovascular risk factors for the first time. To our knowledge, this is the first study to demonstrate this relationship.

A systematic review and meta-analysis on the effect of selective serotonin reuptake inhibitors on endothelial function

AIMS

Depression and atherosclerotic cardiovascular disease (ASCVD) are commonly clustered in affected patients. Endothelial dysfunction is an early marker of ASCVD while also reported in patients with depression. Emerging evidence suggests that selective serotonin receptor inhibitors (SSRIs) may improve endothelial function. However, clinical studies assessing flow-mediated dilation (FMD), the gold-standard method to evaluate conduit artery endothelial function, in response to SSRIs treatment included limited number of patients and did not provide consistent results. In the present study we aim to evaluate the effect of SSRIs treatment on endothelial function assessed by longitudinal changes in FMD.

METHODS AND RESULTS

We performed a systematic review to retrieve and subsequently meta-analyze eligible studies in patients with depression who received SSRIs and had available measurements of FMD change before and after treatment. In 5 studies and 323 individuals in total, SSRIs were associated with increased FMD at the end of follow-up compared to baseline measurement (pooled mean change 1.97 %, 95 % CI 0.17, 3.77, P = 0.032, I² = 87.4 %). These results did not substantially change when analysis was restricted to patients with history of atherosclerotic cardiovascular disease (ASCVD). Similarly, FMD changes were higher in individuals receiving SSRIs compared to not-treated subjects (pooled mean difference 2.5 %. 95 % CI 0.7, 4.2, P < 0.001, I² = 82.7 %).

LIMITATIONS

Substantial heterogeneity regarding with respect to follow-up duration, demographics, and SSRIs agents.

CONCLUSION

SSRIs significantly improve FMD, the gold-standard marker of endothelial function. Further investigation is warranted for the role of FMD as a possible therapeutic biomarker in patients with depression and established or subclinical ASCVD.

PROSPERO REGISTRATION

CRD42021252241.

Depression and cardiovascular risk in primary care patients

OBJECTIVE

This study assessed the relationship of both depression diagnosis and clinically significant depressive symptoms with individual cardiovascular risk factors and estimated total cardiovascular risk in primary care patients.

METHODS

This study used a cross-sectional and retrospective design. Patients who had a primary care encounter between January 2016 and September 2018 and completed depression screening (PHQ-9) during the year prior to their appointment (N = 70,980) were included in this study. Data examining estimated total cardiovascular risk, specific cardiovascular risk factors, and relevant clinical diagnoses (including depression diagnosis) were extracted from the electronic health record. Patients were categorized into three groups: no depression (PHQ-9 < 10 and no depression diagnosis), controlled depression (PHQ-9 < 10 with previous depression diagnosis), and current depression (PHQ-9 ≥ 10). Groups were compared on estimated total risk and specific cardiovascular risk factors (e.g., body mass index [BMI], smoking status, lipids, blood pressure, and glucose).

RESULTS

In adjusted analyses, patients with current depression (n = 18,267) demonstrated significantly higher 10-year and 30-year cardiovascular risk compared to patients with controlled depression (n = 33,383; 10-year: b = 0.59 [95% CI = 0.44,0.74]; 30-year: OR = 1.32 [95% CI = 1.26,1.39]) and patients without depression (n = 19,330; 10-year: b = 0.55 [95% CI = 0.37,0.73]; 30-year: OR = 1.56 [95% CI = 1.48,1.65]). Except for low-density lipoprotein (LDL), patients with current depression had the greatest cardiovascular risk across specific risk factors.

CONCLUSIONS

Individuals who had a depression diagnosis and clinically significant depressive symptoms had the greatest cardiovascular risk. Pathways to prevent cardiovascular disease in those with depression might focus on treating depressive symptoms as well as specific uncontrolled cardiovascular risk factors.

Cerebral blood flow self-regulation in depression

BACKGROUND

Depression is a common neuropsychiatric disease with a high prevalence rate. Sleep problems, memory decline, dizziness and headaches are the most common neurological symptoms in depressed patients. Abnormality of cerebral blood flow (CBF) has been observed in depressive patients, but those patients did not have intracranial structural damage. Both of those phenomena might be related to cerebral blood flow self-regulation (CBFSR: cerebral blood flow self-regulation). CBFSR can maintain CBF relatively stable in response to changes in neurological and metabolic factors. Therefore, this review aimed to discuss CBFSR in depression.

METHODS

We searched for keywords such as "depression", "cerebral blood flow", "cerebral autoregulation", "cerebrovascular reactivity" and the words related to depression. We analyzed whether there is a change in the CBFSR in depression, further explored whether there is a relationship between the pathogenesis of depression and the CBFSR, and discussed the possible mechanism of impaired CBFSR in patients with depression.

RESULTS

Discovered by the literature review, CBFSR is significantly impaired in depressed patients. The level of circulating markers of endothelial dysfunction, nitric oxide, inflammatory cytokines, glucocorticoid and monoamine neurotransmitters is mostly abnormal in depression, which affected the CBFSR to varying degrees.

LIMITATIONS

Limitations include the small number of direct studies about depression and CBFSR mechanisms.

CONCLUSION

CBFSR is impaired in depression. The underlying mechanisms include endothelial dysfunction, overactivation of microglia and changes of cytokines, hyperactivation of the HPA axis, increased oxidative stress, monoamine neurotransmitter disorders, etc. These deepened our understanding of the clinical symptoms of depressed patients.

Off-Target Effects of Antidepressants on Vascular Function and Structure

Depression emerges as a risk factor for cardiovascular disease, and it is thought that successful antidepressant treatment may reduce such a risk. Therefore, antidepressant treatment embodies a potential preventive measure to reduce cardiovascular events in patients with depression. Accumulating evidence indicates that antidepressants have off-target effects on vascular dysfunction and in the early stages of atherosclerosis, which form the basis for cardiovascular disease (CVD) pathogenesis. In this context, we performed a thorough review of the evidence pertaining to the effects of different classes of antidepressant medications on hemodynamic and early atherosclerosis markers. The preclinical and clinical evidence reviewed revealed a preponderance of studies assessing selective serotonin reuptake inhibitors (SSRI), whereas other classes of antidepressants are less well-studied. Sufficient evidence supports a beneficial effect of SSRIs on vascular inflammation, endothelial function, arterial stiffening, and possibly delaying carotid atherosclerosis. In clinical studies, dissecting the hypothesized direct beneficial antidepressant effect of SSRIs on endothelial health from the global improvement upon remission of depression has proven to be difficult. However, preclinical studies armed with appropriate control groups provide evidence of molecular mechanisms linked to endothelial function that are indeed modulated by antidepressants. This suggests at least a partial direct action on vascular integrity. Further research on endothelial markers should focus on the effect of antidepressants on treatment responders versus non-responders in order to better ascertain the possible beneficial vascular effects of antidepressants, irrespective of the underlying course of depression.

Regional Brain Perfusion Is Associated with Endothelial Dysfunction Markers in Major Depressive Disorder

BACKGROUND

Major depressive disorder (MDD) is an important independent risk factor for cardiovascular disease. Cumulative data suggest that depressive patients exhibit derangement in regional cerebral blood flow (rCBF), although underlying mechanisms remain mostly unknown. Endothelial dysfunction (ED), defined as different forms of abnormal endothelial activity, plays a key role in the pathogenesis of vascular disease. ED is associated with several clinical conditions characterized by high cardiovascular risk. Diverse ED markers have been found in mood disorders.

PURPOSE

To evaluate the association between rCBF and peripheral ED markers in MDD patients, at baseline and after selective serotonin receptor inhibitors (SSRIs) therapy.

PATIENTS AND METHODS

Twenty-seven untreated unipolar MDD patients in their first episode were evaluated with the Hamilton Depression Rating Scale (HAM-D) and brain perfusion SPECT at baseline and after 2 months of SSRIs. Statistical Parametric Mapping (SPM) was employed to evaluate rCBF; circulating endothelial cells (CECs), plasma soluble intercellular adhesion molecule (sICAM), and high-sensitivity C-reactive protein (hsCRP) were used as independent covariates.

RESULTS

Baseline CECs and sICAM were increased in MDD patients compared with matching controls (p = 0.0001) and hsCRP (p = 0.03). HAM-D scores (21 items) and CECs diminished after SSRI therapy in MDD patients (p < 0.0001). There was a significant rCBF decrease, mainly in deep central structures. HAM-D change was associated with rCBF decrease at the left amygdala, right striatum levels, and Brodmann area 25. CEC change was associated with rCBF at deep brain level and sICAM with large rCBF areas at the left caudate and tectum; hsCRP was associated, to a lesser extent, with the left dorsal striatum and mesencephalic tectum.

CONCLUSION

ED markers in patients with MDD are associated with significant changes in rCBF which are features of depression. These findings suggest that systemic damage/activation of the endothelium may contribute to the abnormal rCBF observed in MDD patients.

Antidepressant Drugs Effects on Blood Pressure

Individuals suffering from depressive disorders display a greater incidence of hypertension compared with the general population, despite reports of the association between depression and hypotension. This phenomenon may depend, at least in part, on the use of antidepressant drugs, which may influence blood pressure through different effects on adrenergic and serotoninergic pathways, as well as on histaminergic, dopaminergic, and cholinergic systems. This review summarizes extant literature on the effect of antidepressant drugs on blood pressure. Selective serotonin reuptake inhibitors are characterized by limited effects on autonomic system activity and a lower impact on blood pressure. Thus, they represent the safest class—particularly among elderly and cardiovascular patients. Serotonin–norepinephrine reuptake inhibitors, particularly venlafaxine, carry a greater risk of hypertension, possibly related to greater effects on the sympathetic nervous system. The norepinephrine reuptake inhibitor reboxetine is considered a safe option because of its neutral effects on blood pressure in long-term studies, even if both hypotensive and hypertensive effects are reported. The dopamine–norepinephrine reuptake inhibitor bupropion can lead to blood pressure increases, usually at high doses, but may also cause orthostatic hypotension, especially in patients with cardiovascular diseases. The norepinephrine–serotonin modulators, mirtazapine and mianserin, have minimal effects on blood pressure but may rarely lead to orthostatic hypotension and falls. These adverse effects are also observed with the serotonin-reuptake modulators, nefazodone and trazodone, but seldomly with vortioxetine and vilazodone. Agomelatine, the only melatonergic antidepressant drug, may also have limited effects on blood pressure. Tricyclic antidepressants have been associated with increases in blood pressure, as well as orthostatic hypotension, particularly imipramine. Oral monoamine–oxidase inhibitors, less frequently skin patch formulations, have been associated with orthostatic hypotension or, conversely, with hypertensive crisis due to ingestion of tyramine-containing food (i.e., cheese reaction). Lastly, a hypertensive crisis may complicate antidepressant treatment as a part of the serotonin syndrome, also including neuromuscular, cognitive, and autonomic dysfunctions. Clinicians treating depressive patients should carefully consider their blood pressure status and cardiovascular comorbidities because of the effects of antidepressant drugs on blood pressure profiles and potential interactions with antihypertensive treatments.

Endothelial dysfunction in neuroprogressive disorders-causes and suggested treatments

BACKGROUND

Potential routes whereby systemic inflammation, oxidative stress and mitochondrial dysfunction may drive the development of endothelial dysfunction and atherosclerosis, even in an environment of low cholesterol, are examined.

MAIN TEXT

Key molecular players involved in the regulation of endothelial cell function are described, including PECAM-1, VE-cadherin, VEGFRs, SFK, Rho GEF TRIO, RAC-1, ITAM, SHP-2, MAPK/ERK, STAT-3, NF-κB, PI3K/AKT, eNOS, nitric oxide, miRNAs, KLF-4 and KLF-2. The key roles of platelet activation, xanthene oxidase and myeloperoxidase in the genesis of endothelial cell dysfunction and activation are detailed. The following roles of circulating reactive oxygen species (ROS), reactive nitrogen species and pro-inflammatory cytokines in the development of endothelial cell dysfunction are then described: paracrine signalling by circulating hydrogen peroxide, inhibition of eNOS and increased levels of mitochondrial ROS, including compromised mitochondrial dynamics, loss of calcium ion homeostasis and inactivation of SIRT-1-mediated signalling pathways. Next, loss of cellular redox homeostasis is considered, including further aspects of the roles of hydrogen peroxide signalling, the pathological consequences of elevated NF-κB, compromised S-nitrosylation and the development of hypernitrosylation and increased transcription of atherogenic miRNAs. These molecular aspects are then applied to neuroprogressive disorders by considering the following potential generators of endothelial dysfunction and activation in major depressive disorder, bipolar disorder and schizophrenia: NF-κB; platelet activation; atherogenic miRs; myeloperoxidase; xanthene oxidase and uric acid; and inflammation, oxidative stress, nitrosative stress and mitochondrial dysfunction.

CONCLUSIONS

Finally, on the basis of the above molecular mechanisms, details are given of potential treatment options for mitigating endothelial cell dysfunction and activation in neuroprogressive disorders.

Photoplethysmographic Waveform Analysis for Autonomic Reactivity Assessment in Depression

OBJECTIVE

In the present study, a photoplethysmographic (PPG) waveform analysis for assessing differences in autonomic reactivity to mental stress between patients with Major Depressive Disorder (MDD) and healthy control (HC) subjects is presented.

METHODS

PPG recordings of 40 MDD and 40 HC subjects were acquired at basal conditions, during the execution of cognitive tasks, and at the post-task relaxation period. PPG pulses are decomposed into three waves (a main wave and two reflected waves) using a pulse decomposition analysis. Pulse waveform characteristics such as the time delay between the position of the main wave and reflected waves, the percentage of amplitude loss in the reflected waves, and the heart rate (HR) are calculated among others. The intra-subject difference of a feature value between two conditions is used as an index of autonomic reactivity.

RESULTS

Statistically significant individual differences from stress to recovery were found for HR and the percentage of amplitude loss in the second reflected wave ( A₁₃) in both HC and MDD group. However, autonomic reactivity indices related to  A₁₃ reached higher values in HC than in MDD subjects (Cohen's [Formula: see text]), implying that the stress response in depressed patients is reduced. A statistically significant ( ) negative correlation ( r=-0.5) between depression severity scores and A₁₃ was found.

CONCLUSION

A decreased autonomic reactivity is associated with higher degree of depression.

SIGNIFICANCE

Stress response quantification by dynamic changes in PPG waveform morphology can be an aid for the diagnosis and monitoring of depression.

A systematic review of ultrasound imaging and therapy in mental disorders

BACKGROUND

Increasing evidence suggests that ultrasound (US) imaging may provide biomarkers and therapeutic options in mental disorders. We systematically reviewed the literature to provide a global overview of the possibilities of US for psychiatry.

METHODS

Original English language articles published between January 2000 and September 2019 were identified through databases searching and analyzed to summarize existing evidence according to PRISMA methodology.

RESULTS

A total of 81 articles were included. Various US techniques and markers have been used in mental disorders, including Transcranial Doppler and Intima-Media Thickness. Most of the studies have focused on characterizing the pathophysiology of mental disorders, especially vascular physiology. Studies on therapeutic applications are still scarce.

DISCUSSION

US imaging has proved to be useful in characterizing vascular impairment and structural and functional brain changes in mental disorders. Preliminary findings also suggest potential interests for therapeutic applications. Growing evidence suggests that US imaging could provide a non-invasive, portable and low-cost tool for pathophysiological characterization, prognostic assessment and therapeutic applications in mental disorders.

Impact of Mood on Endothelial Function and Arterial Stiffness in Bipolar Disorder

Background

Previous research in bipolar disorder demonstrates greater than expected vascular dysfunction later in the course of illness, proportionate to the cumulative burden of mood symptoms. However, little is known about the effect of acute mood states on vascular function. Here we examine the relation between vascular function and mood state in individuals with bipolar disorder.

Method

This prospective study followed 40 individuals with bipolar disorder for up to 6 months. Participants were assessed for mood state and vascular function at baseline, 2 weeks, and 6 months. Mood state was determined using clinician-administered Montgomery-Åsberg Depression Rating Scale and Young Mania Rating Scale. Vascular function was assessed by flow-mediated dilation (FMD) of the brachial artery, forearm vascular resistance (FVR), and arterial stiffness.

Results

Participants had a mean age of 30.1 years and 75% were male. Primary outcome measures FMD and nitroglycerine-mediated dilation were not found to have statistically significant associations with depressive or manic symptoms. In unadjusted models, higher manic symptoms were significantly associated with increased FVR nitroprusside-mediated dilation and diastolic blood pressure. In adjusted models, higher depressive symptoms were significantly associated with increases in augmentation index adjusted for heart rate of 75 bpm, and higher manic symptoms remained associated with increases in diastolic blood pressure.

Conclusion

FMD may have limited sensitivity as a biomarker for measuring short-term effects of mood state. Longer-term prospective studies are needed to clarify the temporal relation between chronic mood symptoms and vascular function in bipolar disorder.