Lianne M. Tomfohr

Depressed mood and flow-mediated dilation: a systematic review and meta-analysis.

Objective: This systematic and quantitative review evaluates the literature on associations between depressed mood and flow-mediated dilation (FMD), a measure of endothelial function, in adults. Methods: Published English-language articles (through December 2010) were identified from literature searches, assessed for data extraction, and evaluated for quality. Results: The literature includes cross-sectional (n = 9) and retrospective examinations (n = 3) of how FMD correlates with clinical or subclinical depression in healthy adults and cardiovascular patients (total N across 12 studies = 1491). FMD was assessed using a variety of methodologies. Samples were predominately older white and Asian subjects with higher socioeconomic status. In eight of the 12 articles selected for this review, at least one significant inverse association was noted between depressed mood and FMD, with primarily moderate effect sizes. The overall meta-analysis (random-effects model) revealed a combined effect size of correlation coefficient r = 0.19 (95% confidence interval = 0.08-0.29, p = .001). Significant combined effects were found for subgroups of studies that a) received better quality ratings (r = 0.29), b) examined patients with cardiovascular disease or with cardiovascular disease risk factors/comorbidity (r = 0.29), c) used maximum vasodilation to quantify FMD (r = 0.27), and d) assessed samples that had a mean age of 55 years and older (r = 0.15). Conclusions: Diverse studies support the inverse correlation between depressed mood and endothelial function, as measured by FMD. This literature would be strengthened by prospective studies, increased methodological consistency in FMD testing, and broader sampling (e.g., African Americans, younger age, lower socioeconomic status).BDI = Beck Depression Inventory; CVD = cardiovascular disease; FMD = flow-mediated dilation; MDD = major depressive disorder; SES = socioeconomic status

Racial differences in sleep architecture: the role of ethnic discrimination.

African Americans have been consistently shown to have less deep (slow wave sleep; SWS) and more light (Stages 1 and 2) sleep than Caucasian Americans. This paper explored whether discrimination, a stressor that uniquely impacts certain ethnic groups, contributes to differences in sleep architecture. The sleep of 164 African and Caucasian Americans was examined with laboratory based polysomnography (PSG). Experiences of perceived discrimination (The Scale of Ethnic Experience) and sociodemographic factors were also assessed. After adjusting for age, body mass index (BMI), socioeconomic status (SES) and smoking status, African Americans slept approximately 4.5% more total sleep time (TST) in Stage 2 sleep and 4.7% less TST in SWS than Caucasian Americans (ps<.05). Perceived discrimination was a partial mediator of ethnic differences in sleep architecture. Individuals who reported experiencing more discrimination slept more time in Stage 2 and less time in SWS (ps<.05). Results suggest that the impact of stress related to ethnic group membership plays a part in explaining differences in sleep architecture.

Symptoms of depression and impaired endothelial function in healthy adolescent women

Depression is related to increased morbidity and mortality from coronary heart disease (CHD), but the underlying mechanisms are unclear. One possibility is that depressive symptoms influence CHD pathogenesis by fostering endothelial dysfunction. To evaluate this possibility, we studied one hundred and two adolescent women with no known or suspected major health problems. Depressive symptoms were assessed using the Beck Depression Inventory (BDI) and endothelial function with a non-invasive beat-to-beat plethysmographic recording of the finger arterial pulse-wave amplitude (PWA) before and after occlusion of the brachial artery. Regression analysis revealed a significant inverse relationship between depressive symptoms and endothelial function. This persisted after controlling for age, ethnicity, health practices and waist circumference. Depression explained 4–6% of the variance in endothelial function above and beyond the effects of covariates. Most patients in our sample had subclinical depressive symptoms, suggesting that even mild affective difficulties are capable of negatively influencing endothelial function in otherwise healthy youngsters.

Everyday Discrimination and Nocturnal Blood Pressure Dipping in Black and White Americans

Objective: To investigate whether an association exists between experiences of everyday discrimination and blood pressure (BP) dipping in a biracial sample of black and white adults. Attenuated nocturnal BP dipping is closely linked to cardiovascular morbidity and mortality. Self-reported experiences of everyday discrimination have also been associated with negative cardiovascular health outcomes. Methods: Seventy-eight hypertensive and normotensive women and men (n = 30 black and 48 white) reported on their experiences of everyday discrimination (Everyday Discrimination Scale) and underwent two separate 24-hour ambulatory BP monitoring (ABPM) sessions approximately 1 week apart. Results: Correlation analysis revealed that higher endorsement of everyday discrimination was significantly associated with less diastolic BP (DBP) and systolic BP (SBP) dipping (p < .05). Subsequent hierarchical regression analyses indicated that everyday discrimination explained 8% to 11% of the variance in SBP and DBP dipping above and beyond other demographic and life-style-related factors, including race, age, 24-hour BP, body mass index, and current socioeconomic status. The relationship between discrimination and dipping was significantly stronger on the second night of monitoring. Finally, analyses revealed that everyday discrimination mediated the relationship between race and BP dipping. Conclusions: These findings suggest that experiences of everyday discrimination are associated with less nocturnal SBP and DBP dipping above and beyond the effect of known covariates. The use of multiple ABPM sessions may facilitate the detection of relationships between psychological variables and BP dipping. BP = blood pressure; ABPM = ambulatory blood pressure monitoring; DBP = diastolic blood pressure; SBP = systolic blood pressure; BMI = body mass index; SES = socioeconomic status.

Is obstructive sleep apnea associated with cortisol levels? A systematic review of the research evidence

The pathophysiology of obstructive sleep apnea (OSA) has been associated with dysregulation of the hypothalamic pituitary adrenal (HPA) axis; however a relationship between OSA and altered cortisol levels has not been conclusively established. We conducted a systematic review using the PRISMA Guidelines based on comprehensive database searches for 1) studies of OSA patients compared to controls in whom cortisol was measured and 2) studies of OSA patients treated with continuous positive airway pressure (CPAP) in whom cortisol was measured pre and post treatment. Five electronic databases were searched along with the reference lists of retrieved studies. The primary outcomes were 1) differences in cortisol between OSA and control subjects and 2) differences in cortisol pre-post CPAP treatment. Sampling methodology, sample timing and exclusion criteria were evaluated. Fifteen studies met the inclusion criteria. Heterogeneity of studies precluded statistical pooling. One study identified differences in cortisol between OSA patients and controls. Two studies showed statistically significant differences in cortisol levels pre-post CPAP. The majority of studies were limited by assessment of cortisol at a single time point. The available studies do not provide clear evidence that OSA is associated with alterations in cortisol levels or that treatment with CPAP changes cortisol levels. Methodological concerns such as infrequent sampling, failure to match comparison groups on demographic factors known to impact cortisol levels (age, body mass index; BMI), and inconsistent control of variables known to influence HPA function may have limited the results.

Multiwave associations between depressive symptoms and endothelial function in adolescent and young adult females.

Objective: Depression has been linked to endothelial dysfunction, and some research suggests that past depressive episodes are associated with a lasting, negative impact on the endothelium. However, investigations in this area have been predominantly cross-sectional, raising questions about the direction of these associations. Using a multiwave design, we sought to extend previous research in this area by examining whether depressive symptoms have a lasting negative influence on endothelial function. Methods: A total of 135 adolescent and young adult females with no known or suspected major health problems were followed for 2½ years. Endothelial function was assessed at three time points throughout the study. The Beck Depression Inventory was administered, and information about health practices was collected every 6 months. Results: Self-reported depressive symptoms covaried with endothelial functioning on a within-person basis (&bgr; = −0.23, p <.05). As a participants depression symptoms rose beyond her typical level, her endothelial function declined commensurately. This association persisted after controlling for health practices and adiposity. There was no evidence that depressive symptoms predicted endothelial function at later time points or interacted with time to predict the trajectories of endothelial function over the follow-up period. Conclusions: Depressive symptoms were concurrently associated with endothelial function in this cohort of healthy adolescent girls and young women. On visits when participants endorsed depressive symptoms that were higher than their mean level of depression, they tended to have worse endothelial function. We did not observe a lasting negative effect of depression on endothelial function.BDI = Beck Depression Inventory; PWA = pulse-wave amplitude.

Childhood Socioeconomic Status and Race Are Associated With Adult Sleep

Race and current socioeconomic status (SES) are associated with sleep. Parental education, a commonly studied component of childhood SES, is predictive of adult health outcomes; yet, its impact on adult sleep remains unclear. In this study, the sleep of 128 Black and White adults was investigated. Participants with lower childhood SES (assessed via parental education) spent more time in Stage 2 sleep and less time in slow-wave sleep (SWS) than those with higher childhood SES. In addition, women from low childhood SES backgrounds took longer to fall asleep than women from high SES backgrounds. Black participants spent less time in SWS than their White counterparts, and an Age × Race interaction was detected in the prediction of subjective sleep quality. Results were not mediated via current SES or health practices.

Trajectories of Sleep Quality and Associations with Mood during the Perinatal Period

OBJECTIVE The aim of this study was to investigate trajectories of sleep quality and associations with mood in the perinatal period. Although it is commonly accepted that subjective sleep quality declines during pregnancy and the transition to parenthood, some women may follow qualitatively distinct trajectories. DESIGN, SETTING, AND PARTICIPANTS Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI). Data were collected from 293 women at four time points: during early pregnancy, at Time 1 (T1; < 22 w gestational age [GA]; late pregnancy, at Time 2 (T2; 32 w GA); during the postnatal period at Time 3 (T3; 3 mo postpartum); and Time 4 (T4; 6 mo postpartum). A group-based semiparametric mixture model was used to estimate patterns of sleep quality throughout the perinatal period. RESULTS Four trajectory groups were identified, including patterns defined by high sleep quality throughout (21.5%), mild decrease in sleep quality (59.5%), significant decrease in sleep quality (12.3%) and a group with poor sleep quality throughout (6.7%). Women who had the worst sleep quality at Time 1 and those who experienced significant increases in sleep problems throughout pregnancy were also the groups who reported the highest levels of anxiety and depressive symptoms in early pregnancy and the lowest levels of social support. After controlling for covariates, the groups with worst subjective sleep quality during pregnancy were also the most likely to experience high symptoms of depression in the postpartum period. CONCLUSIONS Most of the women in our sample reported mild sleep disturbances through the perinatal period. A subgroup of women reported a significant decline in sleep quality from early to late pregnancy and another reported poor subjective sleep quality throughout pregnancy; these groups had the greatest risk of experiencing high symptoms of depression in the postpartum period.

Psychometric characteristics of the Pittsburgh Sleep Quality Index in English speaking non-Hispanic whites and English and Spanish speaking Hispanics of Mexican descent.

STUDY OBJECTIVES The current study investigated the factor structure of the Pittsburgh Sleep Quality Index (PSQI) among English speaking non-Hispanic whites (NHW) and English and Spanish speaking Hispanics of Mexican descent (HMD). DESIGN The PSQI was administered during a telephone interview. In order to test the factor structure of the PSQI structure across ethnic/language groups, multiple group confirmatory analysis with covariates (MIMIC) was employed. The 1- and 3-factor versions of the PSQI previously reported in the literature were examined. SETTING San Diego County. PARTICIPANTS Community-dwelling English speaking, NHW (n = 1,698) and English (n = 654) and Spanish (n = 792) speaking HMD. MEASUREMENT AND RESULTS A single-factor scoring model fit across language/ethnic groups; however, a 3-factor model provided a better than the 1-factor model in all language/ethnic groups. The subscale sleep medications loaded poorly and was removed from all models. CONCLUSION Across groups, a 3-factor model of the PSQI more reliably assessed sleep quality than a single-factor global score. Results indicate that the 3-factor structure of the PSQI was uniform across English speaking NHW and English and Spanish speaking HMD.

Continuous positive airway pressure for treatment of obstructive sleep apnea in stroke survivors: what do we really know?

Obstructive sleep apnea (OSA) has serious cardiovascular consequences and increases the risk of stroke.1,2 OSA is common in patients with stroke3,4 and is associated with impaired quality of life, reduced cognitive function, and excessive fatigue,5–7 conditions that are common in stroke victims and that may delay poststroke recovery.8–10 It is possible that treating OSA could improve clinical recovery in patients with stroke. Continuous positive airway pressure (CPAP) is the “gold standard” treatment for OSA; however, there have been few studies of CPAP use in patients poststroke, and the ability for CPAP to definitively improve outcomes has yet to be established in this population. Part of the motivation for this review stems from our experience with a clinical trial that closed due to futility.1 As a “postmortem” on the trial’s closure, we scrutinized the literature, summarizing outcome data in the area and considering recruitment experience in similar trials. Finally, we comment on possible study design characteristics that might make future trials more successful. ### Number of Studies A PubMed search up to November 2011 using the terms stroke OR transient ischemic attack AND apnea AND continuous positive airway pressure revealed 17 published studies (online-only Data Supplement Table I). Studies were heterogeneous with regard to timing of treatment onset, follow-up assessment timing, and outcomes studied, making a meta-analysis inappropriate; therefore, we conducted a systematic qualitative review of the literature. Nine studies were observational,11–19 3 of which examined the same cohort of patients over time.16–18 Six studies randomized patients to CPAP versus treatment as usual (TAU),20–26 and one study randomized patients to CPAP or sham CPAP.27 On average, studies followed a small number of patients: observational studies included a median of 22 patients who …