Elsevier

Journal of Affective Disorders

Volume 323, 15 February 2023, Pages 101-107
Journal of Affective Disorders

Research paper
Associations of systemic inflammation and social support with suicidal ideation in patients with acute coronary syndrome and stroke

https://doi.org/10.1016/j.jad.2022.11.055Get rights and content

Highlights

  • Effects of serum hsCRP and social support (SS) on suicidal ideation (SI) in ACS and stroke patients were evaluated.

  • Individual associations of hsCRP and SS levels with SI were inconsistent between the diseases.

  • Significant modifying effects of SS on the associations between hsCRP and SI were found in both diseases.

  • Associations of hsCRP and SI were only significant in the higher group but not in the lower SS group.

  • Clinical predictions of suicidality could be improved by evaluating serum hsCRP and SS levels.

Abstract

Background

This study aimed to investigate associations of serum high-sensitivity C-reactive protein (hsCRP) and social support (SS) levels with suicidal ideation (SI), and to evaluate potential modifying effects of SS on the associations between serum hsCRP levels and SI in two longitudinal cohorts with cardio-/cerebrovascular diseases.

Methods

1152 acute coronary syndrome (ACS) and 423 stroke patients were recruited at baseline within 2 weeks of disease onset, and evaluated for: i) serum hsCRP levels; ii) SS by the Social Support Scale and Social Undermining Scale; iii) SI by the “suicidal thoughts” item of the Montgomery–Åsberg Depression Rating Scale; and iv) covariates including socio-demographics, depression, vascular risk factors, and index disease severity. At 12-month follow-up, SI was re-evaluated. Logistic regression models were used to adjust for potential covariates.

Results

In the ACS cohort, higher serum hsCRP and lower SS levels were significantly associated with SI at baseline; and only lower SS levels were significantly associated with SI at follow-up. In the stroke cohort, lower SS levels were significantly associated with SI at baseline; but no other association was found. Associations of serum hsCRP levels with SI at both baseline and follow-up were only significant at higher SS levels with significant interaction terms in both cohorts.

Limitations

This study evaluated SI, but not suicide attempts or death; it also used a single-center design.

Conclusions

By considering SS evaluations with routine serum hsCRP levels in cardio-/cerebrovascular disease, clinical prediction of SI both at acute and chronic phases of the diseases might be improved.

Introduction

Acute coronary syndrome (ACS) and stroke are major circulatory diseases and leading causes of disability (Virani et al., 2020) with psychiatric sequelae including depression and anxiety (Smith et al., 2015; Chun et al., 2018). In turn, comorbid psychiatric problems have negative effects on course and prognosis in circulatory diseases (Kim et al., 2018a; Lee et al., 2021). Suicidal behaviours are also common and known to be associated with poor outcomes of these diseases (Kim et al., 2018b; Vyas et al., 2021). Suicidal ideation is a prerequisite for more severe suicidal behaviour including non-fatal and fatal suicidal attempt, and could be a treatment target if it was adequately detected (Kim et al., 2016). Identifying potential determinants of suicidal ideation would be an important first step.

The roles of immune and inflammatory dysfunction have long been investigated as markers of suicidal behaviour in various psychiatric disorders (Black and Miller, 2015) and high-sensitivity C-reactive protein (hsCRP), as a well-documented clinical marker of general inflammation, has been received particular attention. Most studies have been conducted in patients with depressive disorder, but the results have been controversial. Some studies have found that peripheral hsCRP levels are significantly higher in depressed patients with suicidal behaviours than in those without (Ventorp et al., 2015; Ekinci and Ekinci, 2017; Oh et al., 2019), although others have found no such differences (Karlović et al., 2012; Chang et al., 2017; Peng et al., 2018). In a meta-analysis, blood hsCRP levels were significantly increased in psychiatric patients with suicidality versus healthy controls but did not distinguish psychiatric patients with or without suicidality (Black and Miller, 2015). Inflammatory biomarkers, and hsCRP in particular, have also been associated with incident myocardial infarction and stroke (Ridker et al., 1997); however, inflammatory hypotheses for suicidal behaviours have rarely been investigated in these patients with cardio-/cerebrovascular diseases.

Social support reflects the perception that individuals are cared about and held in positive regard by those in their support networks. Previous studies have repeatedly reported that social support is associated with a reduced risk of suicidal behaviours, both directly associated with reduced incidence (Chioqueta and Stiles, 2007; Kleiman and Liu, 2013) and buffering the impact of risk factors including life stresses (Yang and Clum, 1994; Meadows et al., 2005). In cardio-/cerebrovascular diseases, associations of social support have been investigated with depression (Kim et al., 2017) but rarely with suicidal behaviours (Kishi et al., 1996).

Based on the existing evidence, we hypothesised that social support might modify the associations of higher hsCRP levels with increased risk of suicidal behaviours in patients with cardio-/cerebrovascular diseases, a question that had not been previously investigated to our knowledge. Using data from two prospective Korean cohorts with ACS and stroke, we investigated associations of serum hsCRP and social support levels measured at acute phase of diseases with suicidal ideation evaluated both at acute and chronic phases, then evaluated potential modifying effects of social support on the associations between serum hsCRP levels and suicidal ideation.

Section snippets

Study outline

This analysis was carried out as a component of two larger parent studies, which were set up to investigate mental disorders in ACS and stroke survivors using naturalistic prospective designs. The study designs were similar between the studies and have been published (Kim et al., 2013; Kim et al., 2014). In brief, participants with recent ACS and ischemic stroke were recruited within the Department of Cardiology and Neurology of Chonnam National University Hospital, Gwangju, South Korea.

Recruitment

The recruitment process and prevalence rates of suicidal ideation at baseline and at follow-up points are summarized in Fig. 1. Overall, 1152 ACS and 423 acute stroke patients, who met the eligibility criteria, comprised the baseline samples. Mean (SD) age/number (%) male were 58.6 (11.3)/824 (71.5) for ACS patients and 64.5 (10.1)/229 (57.7) for stroke patients, respectively. The follow-up samples in turn comprised 828 (72 %) ACS and 222 (68 %) stroke patients, successfully re-evaluated 1 year

Discussion

In this longitudinal study of two independent cohorts with cardio-/cerebrovascular diseases, individual associations of serum hsCRP and social support levels with suicidal ideation were rather inconsistent between the patient groups and between the evaluation points. However, similar findings were apparent in both cohorts for modifying effects between social support and serum hsCRP levels on suicidal ideation: associations of serum hsCRP levels and suicidal ideation both at baseline and at

Funding

The study was funded by a grant of National Research Foundation of Korea Grant [NRF-2020M3E5D9080733] and [NRF-2020R1A2C2003472] to Jae-Min Kim. Robert Stewart is part-funded by: i) the National Institute for Health Research (NIHR) Biomedical Research Centre at the South London and Maudsley NHS Foundation Trust and King's College London; ii) the National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King's College Hospital NHS

CRediT authorship contribution statement

Jae-Min Kim: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Writing – original draft, Writing – review & editing. Ju-Wan Kim: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Writing – review & editing. Ye-Jin Kim: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Writing – review & editing. Hee-Ju Kang: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Writing – review &

Conflict of interest

Jae-Min Kim declares research support in the last 5 years from Janssen and Lundbeck. Robert Stewart declares research support in the last 5 years from Janssen, GSK and Takeda. Sung-Wan Kim declares research support in the last 5 years from Janssen, Boehringer Ingelheim, Allergan and Otsuka. All other authors report no biomedical financial interests or potential conflicts of interest.

Acknowledgements

None.

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