3. Depression
Grief is the normal response to
bereavement
Major depression is a common
and sometimes fatal mood
disorder
Sadness decreases over time Feelings of sadness worsen
4. Cytokine
Cytokines communicate with cells to trigger the protective defenses of the
immune system.
Pro-inflammatory Cytokines
• Small nonstructural proteins that are released during infection, immune
responses, inflammation and trauma
5. Reason for studying Cytokines
Can’t we just use anti-depressants?
• Although these drugs have greatly improved since their arrival, they
appear to have hit a plateau (30% TRD)
• Past decade, inflammation has been revisited as factor of mood
disorders
• patients with increased inflammatory cytokines before treatment
have been reported to be less responsive to antidepressant
treatment
• Understanding the mechanisms by which
inflammation effects brain function to induce mood
disorders may lead to new forms of treatment
7. Theories on Physiologic Pathways
Potential mechanisms
• Inflammatory cytokines are increased during depression and are
produced in the gut, in adipose tissue.
• Once produced, the cytokines can access the brain and activate local
central nervous system inflammatory networks to produce alterations
in neurotransmitter function, leading to further behavioral alterations.
8. Theories on Physiologic Pathways
Pre-clinical evidence suggests that increased cytokines induce mood
symptoms by
– decreasing serotonin levels
– activating the hypothalamic-pituitary-adrenal (HPA) axis to induce
high levels of glucocorticoid neuron cell death
– activating microglial cells to cause pathological synaptic pruning
and induce structural brain changes depression
9. Potential Support
In the treatment of hepatitis C, IFN is
commonly used to boost the immune
system to clear the viral infection
• High doses 50% , 90%
Aspirin significantly improved
depressive behaviors in
fluoxetine treatment
Resistant depressive
rats
10. Objectives
• Likelihood of developing MDD after experiencing traumatic event based on
specified factors.
• Further investigate the idea of a pertinent subtype of immune-based depression.
• Test validity of the findings that claim pro-inflammatory cytokines are related to
depression
• Identify threshold that precedes MDD relative to baseline measurements.
• If depression and cytokine are linked, determine effectiveness of anti-
inflammatory treatment
Address
• Do people who develop MDD have increased cytokine activity, while those who
share depressive symptoms during bereavement have a reduction in cytokine
activity over time?
11. Hypothesis
1. Pro-inflammatory cytokines can be used as a valid
predictor for the onset of major depression in relatives
of homicide victims
2. Aspirin may be an effective additional treatment for
those experiencing immune-based depression
12. Warrant for the Study
• Potential confounders are relatively unaccounted
• Further research, especially longitudinal studies of cytokine
activity as a valid biomarker is needed to produce definitive
results
• Research involves studies on animals
• Human studies typically compare pre-diagnosed patients with
healthy patients.
– Or patients with chronic diseases who are induced with cytokines as
treatment
13. Participating Organizations
Collaboration with research-based institutions
• University of Michigan Ann-arbor
– Ann Arbor, Michigan
• Johns Hopkins University
– Baltimore, Maryland
• UC Berkeley
– Berkeley, California
14. Materials and Methods
Recruitment
Location
• Close proximity to participating institutions
• Near and in cities with high homicide rates
Advertising (in-person and online)
• Grief share programs
• Primary care offices
• Hospitals
• County assistance offices (financial assistance)
• Court houses
• Law offices
• Police stations
• Churches
• Mortuary and cemetery offices
• Victims advocacy agencies (NOVA & NOPMC)
15. Materials and Methods
Homicide: unexpected reckless or intentional
taking of another human life by an individual
• 13-55 (Male and Female)
• RHVs must meet criteria
• Multiple nuclear family members
• Recruitment of 1 year
• Reimbursement
16. Materials and Methods
Screening Process
overt inflammation screen (evaluation of medical history)
– To exclude patients who have health disorder known to cause obvious
inflammation
• cardiovascular disease
• Cancer
• Patients with pre-existing depression will also be excluded from the study
– The Beck’s Depression Inventory-II (>30)
• Liver disease
• Autoimmune disease
• Immunodeficiency virus
17. Materials and Methods
Baseline Assessments
• Blood Analysis for cytokine activity
• Depression Severity & Diagnosis
– BDI-II & Psychiatric Assessment
Other Initial Assessments
• Health Questionnaire (Potential Confounders)
– BMI (Obesity = BMI> 30)
– Medication use
– Sleeping habits
– Family history of depression
– Lifestyle factors (smoking, alcohol consumption, diet, exercise)
18. Materials and Methods
Blood Analysis
• collect, date, and label blood samples (6 mL collection tubes)
• Centrifuge for 15min at 3300 rpm w/ Nanopure water
• Place plasma supernatant in 2 mL centrifuge tubes Eppendorf mini
centrifuge 10 min at 2.8 rpm
• Plasma cryotubes stored at -150° C
• Once samples thaw slowly to room temp undergrad RAs determine
cytokine levels using Instant ELISA kit (eBioscience®)
• Follow recommendations for biomarkers
• Final reading using SpectraMax Plus plate reader
TNFR1, IL-6, CRP, TNFRa, IFN
19. The Beck Depression Inventory (BDI-II)
1-10_______considered normal
11-16______Mild mod disturbance
17-20______Borderline clinical
dep.
21-30______Moderate depression
31-40______Severe depression
>40________Extreme depression
Depression Severity Assessment
• Used alongside psychiatric
assessments to determine
diagnosis
20. SPSS
All statistical analysis using Statistical Package for Social Sciences
– Continuous data
– Correlational
– Categorical data
– Cross-sectional analysis
– Onset of depression between variables
21. Relative of Homicide Victim Questionnaire
(as best described)
Evaluation of closeness to victim
• How were you informed of the homicide?
• Age of victim
• Biological or non-biological.
• Age difference
• Ability to understand event
• Cause of Death (may or may not be known at time of interview)
• Knowledge of Gang affiliation
• Known criminal offenses (violent and non-violent crimes)
• Instant death or prolonged death
22. • Severity of crime
– Alcohol related car crash, shot, stabbed, rape-involved murder,
torture, dismemberment, abandoned
• Witness
• Relationship of the RHV to the murder victim
• Last time RHV had contact with victim
• Level of regret in relationship between victim
• Closure
– Suspect arrested or convicted
– If arrested, status of trial
Coping Systems section
• Religiosity
• Support systems available
• primary coping mechanisms
– (asked every six months)
23. Materials and Methods
Demographic Questionnaire
• Age
• Gender
• Ethnicity
• Education
• Current marital status
• Professional or Employment
Status
• Household income
• Best describes occupation
Personality Questionnaire (1-5)
(Resilience and SAS)
• Am a bad loser
• Not easily affected by my
emotions
• Can stand criticism
• Believe that events in my life are
determined only by me
• Can handle opposition
• Respond well to change
24. Timeline
• Once a participant has given consent for study, initial overt inflammation
screening will be given and assessments will begin
1st year
Every month Health Assessment, ELISA test, BDI (12 times)
Psychiatric Evaluation/ Diagnosis (6 times)
Relative Homicide Victim Questionnaire
Personality assessment
Demographic Questionnaire
2nd year
Health Assessment, ELISA test, BDI (12 times)
Psychiatric Evaluation/ Diagnosis (6 times)
25. Timeline
3rd year
Health Assessment, ELISA test, BDI (12 times)
Psychiatric Evaluation/ Diagnosis (6 times)
Next 3 months (Experiment) New baseline
Health Assessment, ELISA test, BDI (3 times)
Psychiatric Evaluation/ Diagnosis (3 times)
Fluoxetine
Aspirin
33. Works cited
Al-Hakeim, H. Al-Rammahi, D., & Al-Dujaili, A. (2015). IL-6, IL-18, sIL-2R, and TNFa proinflammatory markers in depression and schizophrenia patients who
are free of overt inflammation. Journal of Affective Disorders, 106-114.
Charles, L. R., Capuron, L., & Andrew, H. M. (2006). Evolutionary imperatives for the depression-inflammation link. Trends in Immunology, 27(1), 24-31
Felger, J., & Lotrich, F. (2013). Inflammatory cytokines in depression: Neurobiological mechanisms and therapeutic implications. Neuroscience, 199-229
Jo, W., Zhang, Y., Emrich, H. ,& Dietrich, D. (2015). Glia in the cytokine-mediated onset of depression: Fine tuining the immune response. Frontiers in
Cellulare Neuroscience, 9,
Kelber, O., Okpanyi, S. , Abdel-Aziz, H., & Khayyal, M. (2014). Brain, joint, gut: inflammation as link between depression, rheumatism and irritable bowel
syndrome. Planta Medica, 80(16), 1361.
Rosenblat, J., Cha, D., Mansur, R., & Mcintyre, R. (2014). Inflamed moods: A review of interactions between inflammation and mood disorders. Progress in
Neuro-Psychopharmacology and Biological Psychiatry, 23-34
Sayers, J. (2001). The world health report 2001; mental health: New understanding, new hope. (books & electronic media). Bulletin of the World Health
Organization, 79(11), 1085
Wang, Y., Yang, F., Liu, Y., Gao, F., & Jiang, W. (2011). Acetylsalicylic acid as an augmentation agent in fluoxetine treatment resistant depressive rats.
Neuroscience Letters, 74-79
Editor's Notes
Depression vs. Grief
Cytokine
Cytokine Theories & Research
Materials and Methods
Research Design Diagram
Budget
Major depression is a common and sometimes fatal disorder [20]. It is estimated that by 2020 major depression will be the second most disabling condition in the world
Grief vs. Depression
Grief is the normal response to bereavement
Natural for patients to experience:
Sadness, guilt, disbelief, confusion, or thoughts of joining deceased
Hope and self-esteem
Major Depression (MD)
When feelings of sadness worsen, rather than improve
significant impairment in functioning, psychotic experiences unrelated to the deceased
or feelings of worthlessness, and inability to feel pleasure
May have thoughts of suicide
By 2020 MD will be the second leading cause of
Disability.
This association is in support of a bidirectional interaction between inflammation and mood disorders. Moreover, the bidirectional link between inflammation and mood disorders suggests that inflammation may induce mood symptoms and vice versa creating a potential positive feedback loop. (inflammed mood)
In summary, inflammation appears to have a strong association with mood disorders. Moreover, the relationship appears to be bi-directional in that both clinical and pre-clinical evidence shows that inflammation can induce mood symptoms and vice versa. (inflammed mood)
entry through leaky regions in the blood-brain barrier, such as the circumventricular organs; (ii) binding to cytokine-specific transport molecules expressed on brain endothelium and (iii) activation of vagal afferent fibers which transmit cytokine signals to specific brain nucl
Reasons for studying Cytokines?
Can’t we just use anti-depressants?
Although these drugs have greatly improved since their arrival, they appear to have hit a plateau
Past decade, inflammation has been revisited as factor of mood disorders
An understanding of the mechanisms by which
inflammation effects brain function to induce mood
disorders may lead to new forms of treatment
Once produced, the cytokines can access the brain and activate local central nervous system inflammatory networks to produce alterations in neurotransmitter function, leading to further behavioral alterations
Synaptic pruning – neuron connections are deleted
Sereonin- neurotrasmitter helps relay messages from one area of the brain to another, reserachers believe seretonin imbalance influences mood in a way that leads to depression
Rosenblat, J., Cha, D., Mansur, R., & Mcintyre, R. (n.d..). Inflamed moods: A review of interactions between inflammation and mood disorders. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 23-34
These cytokines have been shown to have an effect on central serotonin levels, the hypothalamic–pituitary– adrenal (HPA) axis, microglial activation and brain structure. (inflammed mood)
In the treatment of hepatitis C, IFN is commonly used to boost the immune system to clear the viral infection (Liang and Ghany, 2013).
The power of IFN-a to induce psychic misery in patients taking it for hepatitis C virus infection or cancer is not subtle.
High doses of IFN 50% of patients without depression will meet criteria for MDD within 3 months
90% or more will endorse at least two significant depressive symptoms
Inferon-alpha is a type of cytokine that interferes with virus replication by protecting cells from virus infections.
They activate macrophages and increase host defenses
Fluoxetine inhibits uptake of seritonin in the brain
Likelihood of developing MDD after experiencing traumatic event based on specified factors.
Further investigate the idea of a pertinent subtype of immune-based depression.
Test validity of the findings that claim pro-inflammatory cytokines are related to depression
Identify threshold that precedes MDD relative to baseline measurements.
If depression and cytokine are linked, determine efficacy of anti-inflammatory treatment, such as aspirin
Address
Do people who develop MDD have increased cytokine activity, while those who share depressive symptoms during bereavement have a reduction in cytokine activity over time?
However, many patients receive proinflammatory cytokines as treatment, and thus these individuals may give us further insight on the relationships within human models.
Longitudinal studies should also be conducted to further investigate the role of proinflammatory cytokines in depressed and healthy patients.
Potential confounders are relatively unaccounted
Further research, especially longitudinal studies of cytokine activity as a valid biomarker is needed to produce definitive results
Much research involves studies on animals
Human studies typically compare pre-diagnosed patients with healthy patients.
Or patients with chronic diseases who are induced with cytokines as treatment
Strong research-based institutions in related fields: biomedical and behavioral neuroscience
Use of research facilities
Undergraduates will be employed to reduce cost
Institutions are not located in one state for better generalization
Based on 2013 Uniform Crime Report statistics released by FBI
University of Michigan ann-arbor
#1 Detroit – 316 (murders & non-negligent manslaughters)
John Hopkins University
#5 Baltimore – 233 (Murders and non-negligent manslaughters)
UC Berkeley
#8 - 90 (Murders and non-negligent manslaughters)
Recruitment
Location
Close proximity to participating institutions
Near and in cities with high homicide rates
Advertising (in-person and online)
Grief share programs
Primary care offices
Hospitals
County assistance offices (financial assistance)
Court houses
Law offices
Police stations
Churches
Mortuary and cemetery offices
Victims advocacy agencies
National Organization for Victim Assistance
National Organization of Parents of Murdered Children
Homicide: unexpected reckless or intentional taking of another human life by an individual
13-55 (Male and Female)
RHVs must meet criteria
Eligible 1 month after incident
Experienced a homicide of nuclear family member (biological and non-biological) within one month
Lived thirteen years with victim
Multiple nuclear family members
Recruitment (1st year only until n=300)
RHV asked to schedule follow-up appointment month from first visit
Complete 3 questionnaires outside of facility
RHV Questionnaire, personality test, demographic
Only 5 cytokines believed to be associated with depression were chosen to meet budget
May affect depression by activating HPA axis increase in cortisol
Hyperactivity of the HPA axis in depressed patients has been consistent finding in biological psychiatry. (Barden, 2004) (Primary Caregivers)
Continuous data: Anova Test
Correlational: Pearson-product
Categorical data: Descriptive Analysis (ANOVA test)
Demographic variables
Cross-sectional analysis: Multiple linear regression
Onset of depression between variables
Hazard Ratios (time-to-event analysis) and 95% Confidence Intervals
Relative of Homicide Victim Questionnaire
Evaluation of closeness to victim
Time spent (weekly)
How often did they see them
What activities did you do with victim enjoy most
How were you informed of the homicide?
Telephone, through media,
Age of victim
Biological or non-biological.
Age difference
Ability to understand event
Cause of Death (may or may not be known at time of interview)
Knowledge of Gang affiliation
Criminal offenses (violent and non-violent crimes)
Instant death or prolonged death
Severity of crime
drunk car crash 1, shot, stabbed, rape-involved murder, torture, dismemberment, abandoned)
Witness
Relationship of the RHV to the murder victim.
Last time RHV had contact with victim
Level of regret in relationship between victim
Closure
Suspect arrested or convicted
If arrested, status of trial
Coping Systems section
Religiosity
Support systems available
primary coping mechanisms/ methods
(asked every six months patients are)
Why 3 years?
Physicians and grief counselors recognize that the duration is more commonly 1-2 years.
4 year timeline for entire study
Each participant is studied for 3 years
Recruitment will stop after first year. (n = 200)
In a retrospective analysis, depression severity and proinflammatory cytokine levels will be compared across patients according to the relative contiguity from the event.
Drink a full glass of water with each dose
Adults and children 12 years and over, take 1 or 2 tablets every 4 hours, or 3 every six hours.
Children under 12, consult with doctor.
MDDs already using treatment will be split up
ASA, 45 mg/kg or 22.5 mg/kg and fluoxetine (mg/kg)
Acetyl-Salicylic Acid ASA, one of medicine's oldest agents, is a non- steroidal anti-inflammatory drug (NSAID) that irreversibly inhibits COX-1 and COX-2 thereby decreasing prostaglandin and thromboxane levels and thus decreasing TNF-α and IL-6 (Vane and Botting, 2003).
the evidence of ASA as an effective therapeutic option for MDD and BP has yet to be established, however, observational studies are promising and further investigation is currently underway. (inflammed moods
further research is most definitely needed. Ongoing clinical trials of various anti-inflammatory agents will hopefully yield more definitive results. As well, in testing these agents, clinical trials may be expedited as side-effect profiles of most anti-inflammatory agents are already well established.
Everyone who is diagnosed with MDD is admitted for experiment. Effectiveness of therapy will be based on individual baseline severity assessed at the beginning of three month period.
non-steroidal
Randomly assign
How to make a blind study.
