Sex-dependent grades of haematopoietic modulation in patients with major depressive episodes are associated with suicide attempts

ARTICLE IN PRESS JID: NEUPSY [m6+; June 26, 2020;5:25 ] Eu opean Neu opsychopha macology (2020) 000, 1–14 www.else ie .com/loca e/eu oneu o Sex-dependen g ades o haema opoie ic modula ion in pa ien s wi h majo dep essi e episodes a e associa ed wi h suicide a emp s Pa icia Ma ínez-Bo ía a , b , 1 , Angela Velasco a , c , d , 1 , Vale ia Rolle a , Luis Jiménez-T e ino a , c , d , e , Lo ena De la Fuen e-Tomás a , c , d , Ángel Be na do a , , Tama a A ias a , g , Ma ía del Ca men Muñoz-Tu illas a , g , Le icia Ga cía-Al a ez a , d , Le icia González-Blanco a , c , d , e , Julia Rod íguez-Re uel a a , c , e , Ma ia Paz Ga cia-Po illa a , c , d , e , Philippe Cou e h , i , Julio Bobes a , c , d , e , Lau a Gu ié ez a , b , ∗, Pila Alejand a Sáiz a , c , d , e , ∗ a Ins i u o de In es igación Sani a ia del P incipado de As u ias (ISPA), O iedo, Spain b Depa men o Medicine, Uni e sidad de O iedo, Spain c Depa men o Psychia y, Uni e sidad de O iedo, Spain d Biomedical Resea ch Ne wo king Cen e in Men al Heal h (CIBERSAM), O iedo, Spain e Se icio de Salud del P incipado de As u ias (SESPA), O iedo, Spain Hospi al Uni e si a io Cen al de As u ias, Labo a o io de Diagnós ico Clínico Hema ología, O iedo, Spain g Cen o Comuni a io de Sang e y Tejidos de As u ias, O iedo, Spain h Depa men o Eme gency Psychia y & Pos -Acu e Ca e, Lapey onie Hospi al, CHU Mon pellie – Inse m U1061, Uni e si y o Mon pellie , Mon pellie , F ance i Fonda ion FondaMen al, C é eil, F ance Recei ed 19 Decembe 2019; ecei ed in e ised o m 8 May 2020; accep ed 9 June 2020 A ailable online xxx ∗Co esponding au ho s a : Ins i u o de In es igación Sani a ia del P incipado de As u ias (ISPA) and Uni e sidad de O iedo, O iedo, Spain. E-mail add esses: [email p o ec ed] (L. Gu ié ez), [email p o ec ed] (P.A. Sáiz). 1 These au ho s con ibu ed equally o his wo k. h ps://doi.o g/10.1016/j.eu oneu o.2020.06.006 0924-977X/ ©2020 The Au ho (s). Published by Else ie B.V. This is an open access a icle unde he CC BY-NC-ND license. ( h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/ ) Please ci e his a icle as: P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al., Sex-dependen g ades o haema opoie ic modula ion in pa ien s wi h majo dep essi e episodes a e associa ed wi h suicide a emp s, Eu opean Neu opsychopha macology, h ps://doi.o g/10.1016/j. eu oneu o.2020.06.006 2 P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al. ARTICLE IN PRESS JID: NEUPSY [m6+; June 26, 2020;5:25 ] KEYWORDS Majo dep essi e episode; Haema opoiesis; Suicide; Inflamma ion; Sex; LTE Abs ac Suicide is he leading cause o non-na u al dea h wo ldwide, and majo dep essi e diso de (MDD) is he mood diso de wi h he highes p e alence among indi iduals wi h suicidal be- ha iou (SB). The ole o inflamma ion and immunomodula ion in mood diso de s has aised in e es in ecen yea s, as inflamma ion bioma ke s ha e been epo ed o be inc eased in mood diso de pa ien s, sugges ing a ole o inflamma ion in hei pa hogenesis. The influence o inflamma ion on he haema opoie ic p oduc ion is well known; howe e , a comp ehensi e s udy o he haema opoie ic p oduc ion in pa ien s wi h majo dep essi e episodes (MDE) is lacking. We examined global haema opoie ic pa ame e s om comple e blood coun s (CBC) o pa ien s wi h MDE, in sea ch o p ognos ic pa e ns. MDE pa ien s p esen ed di e ences in se e al CBC pa ame e s, di e ences ha we e clea ly p onounced and/o significan in concu - ence wi h suicide a emp s (SA). Red and whi e blood cell lineage pa ame e s we e a ec ed, sugges ing gene al haema opoie ic modula ion o imbalance. We obse ed dis inc haema o- logical pa ame e changes in women e sus men, wi h men p esen ing milde al e a ions han women. In e es ingly, we ound ha he Lis o Th ea ening Expe iences (LTE) sco e, bu no he Childhood T auma Ques ionnai e (CTQ), was associa ed wi h he haema opoie ic al e a ions obse ed exclusi ely in women and, mo e impo an ly, se ed as a pa ame e o s a i y e- male MDE pa ien s based on concu ence o non-concu ence wi h SA. In conclusion, g ades o haema opoie ic modula ion in MDE pa ien s a e associa ed wi h absence o p esence o SA. Haema opoie ic mani es a ions di e be ween men and women and, in he la e , a e ma kedly influenced by la e, and no ea ly, auma ic e en s. ©2020 The Au ho (s). Published by Else ie B.V. This is an open access a icle unde he CC BY-NC-ND license. ( h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/ ) 1. In oduc ion Suicide is he leading cause o non-na u al dea h wo ld- wide and he second leading cause o mo ali y in indi id- uals aged 15–29 yea s (Wo ld Heal h O ganiza ion, 2018 ), psychia ic diso de s and subs ance abuse being he ac- knowledged isk ac o s. Majo dep essi e diso de (MDD) is he mos p e alen mood diso de in indi iduals wi h sui- cidal beha iou (SB), dep ession i sel being associa ed wi h a 20- old inc ease in suicide mo ali y a e ( Osby e al., 2001 ). S esso s in childhood and adul hood ha e been as- socia ed wi h suicide a emp s (SA), and he e is ongoing deba e whe he ea ly e en s ha e a s onge associa ion wi h SB in compa ison wi h la e o ecen e en s ( Liu e al., 2017 ; Ludwig and Dwi edi, 2018 ). Impo an ly, indi iduals who ha e a emp ed suicide a e a highe isk o u u e a emp s, and a la ge p opo ion o hem expe ience sel - inflic ed inju ies o long- e m disabili y, equi ing medical a en ion and ollow-up. I is he e o e o in e es o heal h sys ems o de elop and ely on mo e p ecise pe sonalised algo i hms and bioma ke s o be e p edic and p e en SA ( Ba igon and Baca-Ga cia, 2018 ). In his di ec ion, e o s ha e been made o iden i y di e en no el bioma ke s using high- h oughpu echnologies (GWAS, me abolomics), high- ligh ing he impo ance o ans e sal o mul idisciplina y app oaches o unde s and mood diso de s. The ole o inflamma ion and immunomodula ion in di - e en condi ions o pa hologies, including mood diso de s, has aised in e es ecen ly ( Pa ian e, 2017 ). Inflamma ion- ela ed bioma ke s, such as he neu ophil- o-lymphocy e a io (NLR) ( Ekinci and Ekinci, 2017 ; I ko ic e al., 2016 ; Velasco e al., 2020 ) and C- eac i e p o ein (CRP) ( Cou e e al., 2015 ; Gibbs e al., 2016 ), ha e been epo ed o be inc eased in mood diso de pa ien s, sugges ing a ole o inflamma ion in hei pa hogenesis and a po en ial use o hese bioma ke s as p edic o s o SB. Mo e ecen ly, NLR and mean pla ele olume (MPV) ha e been ela ed o he se e - i y o SA ( O um e al., 2018 ). Inflamma o y and in ec ious diseases, including alle gy, as hma, and oxoplasmosis, ha e been associa ed wi h SB ( Pos olache e al., 2008 ; Zhang e al., 2012 ). Fu he mo e, an associa ion has been es ab- lished be ween SA, inflamma ion, and inc eased isk o mo - bidi y and mo ali y om na u al (ca diome abolic) causes ( Be gen e al., 2012 ). In e es ingly, pa ien s ea ed wi h p o-inflamma o y cy okines demons a ed inc eased isk o suicidal idea ion o SA ( F agoso e al., 2010 ). A comp ehensi e model ocusing on he influence o he immune sys em in he pa hophysiology o SB has been p oposed ( Cou e e al., 2016 ), whe e childhood abuse, sleep dis u bance, in ec ions, and o he s esso s induce a ch onic inflamma o y s a e causing dys egula ion o he hypo halamic-pi ui a y-ad enal axis, inc easing co isol le - els and indolamine 2,3-dioxygenase ac i a ion, which e- sul s in inc eased N-me hyl-D-aspa a e (NMDA) agonis and dec eased se o onin le els. All hese mechanisms may lead o psychological ulne abili y and SB. Howe e , he cause- consequence ela ionship be ween psychia ic diso de s, SB, and sys emic inflamma ion esponse and eedback is s ill la gely unknown. Please ci e his a icle as: P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al., Sex-dependen g ades o haema opoie ic modula ion in pa ien s wi h majo dep essi e episodes a e associa ed wi h suicide a emp s, Eu opean Neu opsychopha macology, h ps://doi.o g/10.1016/j. eu oneu o.2020.06.006 3 ARTICLE IN PRESS JID: NEUPSY [m6+; June 26, 2020;5:25 ] Haema opoiesis occu s in an in e -lineage equilib ium, whe e p oduc ion o he di e en haema opoie ic cell ypes ha ci cula e in he blood is igh ly egula ed, as hey need o be cons an ly eplenished due o hei sho li espan. A comple e blood coun (CBC) es measu es a numbe o a i- ables ela ed o he di e en ci cula ing blood cell- ypes, and is a bona fide po ai o an indi idual’s heal h s a- us. Hence, comple e blood coun (CBC) a iables ollow a gi en co ela ion in heal hy indi iduals. When haema opoi- e ic dis ess, imbalance, o modula ion occu s, hose co - ela ions a e dis up ed, because he haema opoie ic ou - pu shi s depending on he unde lying physiological de- mand. I is well known ha in esponse o ex e nal cues (e.g. cy okines du ing inflamma ion), he s eady s a e ou - pu o he di e en ypes o blood cells shi s, usually o- wa ds p oducing highe numbe s o inna e immune cells (e.g. basophils, neu ophils, e c.), a he expense o e y- h opoiesis, megaka yopoiesis, and lymphopoiesis ( Zhao and Bal imo e, 2015 ). Fo example, anaemia o inflamma ion occu s when he body eels a need o inc ease whi e blood cell (WBC) p oduc ion in esponse o in ec ion, a he ex- pense o ed blood cell (RBC) p oduc ion; in his case, he anaemia is caused by a ise in IL-6 and hepcidin le els, wi h subsequen inhibi ion o i on abso p ion, ul ima ely esul - ing in hampe ed e y h opoiesis ( Neme h and Ganz, 2014 ). In a ansgenic mouse model o anaemia o ch onic disease, cha ac e ised by enhanced CD27-media ed co-s imula ion and a s ong inc ease in he p oduc ion o IFN- γ-p oducing e ec o T cells, p og essi e anaemia is due o inhibi ion o e y h opoiesis h ough he IRF-1-dependen ac i a ion o PU.1 ansc ip ion ac o in haema opoie ic p ecu so s ( Lib eg s e al., 2011 ). This exemplifies how his balance is sel - egula ed h ough ansc ip ional ep og amming o haema opoie ic p ecu so s. Con a iwise, ecu en in ec- ions a e ypical o ch onic anaemia pa ien s, as, in hese cases, he necessi y o inc ease RBC p oduc ion nega i ely influences he commi men and di e en ia ion o lymphoid p ecu so s ( Jonke e al., 2017 ). I has been epo ed ha inflamma ion influences haema opoiesis a he haema opoi- e ic s em cell le el ( King and Goodell, 2011 ). Hence, i is plausible ha he sub-clinical inflamma ion ( Köhle e al., 2017 ) epo ed in pa ien s wi h MDE may be accompanied by o he al e a ions in he haema opoie ic p oduc ion, which, we hypo hesise, will mani es a di e en le els depending on SA co-occu ence, sex, and ea ly o la e s esso s. In he p esen s udy, we examine global haema opoie ic pa ame e s om CBCs o MDE pa ien s, wi h o wi hou SA, and e alua e po en ial haema opoie ic imbalance based on SA co-occu ence, sex, and ea ly o la e s esso s, wi h he objec i e o defining clinical pa e ns ha would con ibu e o a be e p ognosis and SB managemen in hese pa ien s. 2. Expe imen al p ocedu es 2.1. S udy sample We pe o med a c oss-sec ional s udy, including 172 Caucasian pa - icipan s aged ≥18 yea s ec ui ed in he a ea o O iedo, Spain, om Ap il 2016 o Sep embe 2018. All pa icipan s ga e in o med consen . The s udy was conduc ed acco ding o he Decla a ion o Helsinki ( Wo ld Medical Associa ion, 2013 ). The coho consis ed o 79 pa ien s ec ui ed a he Men- al Heal h Se ices o O iedo, diagnosed wi h MDE acco ding o he Diagnos ic and S a is ical Manual o Men al Diso de s (DSM- 5) ( Ame ican Psychia ic Associa ion, 2013 ). The exclusion c i e- ia we e como bid psychia ic diagnoses, acu e in ec ion, ac i e o ch onic inflamma o y o au oimmune diseases, smoking ≥20 ciga e es/day, obesi y (BMI > 30 kg/m 2 ), cu en ea men wi h an i-inflamma o y o immunosupp essan d ugs, acu e co ona y synd ome, his o y o ch onic enal, hepa ic, o ce eb o ascula dis- ease, and epo ed haema ological diso de s. Ou con ol popula ion consis ed o 93 heal hy ac i e blood dono s app o ed by he egional blood bank (Cen o Comuni a io de Sang e y Tejidos de As u ias, CCSTA). 2.2. Clinical assessmen Pa ien s we e assessed by well- ained in e iewe s using an ad hoc p o ocol o sociodemog aphic and clinical da a. Psychome - ic e alua ion included he Spanish e sions o di e en scales and ques ionnai es. We employed he Hamil on Dep ession Ra ing Scale (HDRS) ( Bobes e al., 2003 ) o de e mine se e i y o dep ession; he Childhood T auma Ques ionnai e–Sho Fo m (CTQ-SF) ( He nandez e al., 2013 ), a sel - epo ques ionnai e, o de ec ea ly li e s es- so s (emo ional, physical and sexual abuse, and emo ional and physical neglec ); he Lis o Th ea ening Expe iences (LTE) o de- ec wel e s ess ul li e e en s in he six mon hs p io o he e al- ua ion ( Mo ico e al., 2013 ), and he Medical Damage Scale (MDS) ( Beck e al., 1975 ) o sco e medical damage due o SA, anging om 0 (none) o 8 (dead). SA was defined as a “sel -ini ia ed sequence o beha iou s by an indi idual who, a he ime o ini ia ion, expec ed ha he se o ac ions would lead o his o he own dea h” ( Ame ican Psychia ic Associa ion, 2013 ). Fo e e y pa ien , se en days p io o assessmen , mean daily an idep essan doses we e calcula ed and s anda dised o fluoxe- ine equi alen s ( Hayasaka e al., 2015 ). 2.3. CBC analysis Fas ing blood samples we e collec ed in he mo ning in EDTA ubes. CBCs we e pe o med he same day using a Sysmex XN-10/XN-20 haema ology analyse . 2.4. S a is ical analysis Desc ip i e pa ame e s we e shown as mean and s anda d de ia- ion. In addi ion, no mal dis ibu ion was assessed by he Shapi o– Wilk es . A Chi-squa e es was used o compa ison o ca ego ical a iables, whe eas an unpai ed Mann–Whi ney U es o a K uskal– Wallis es we e used o compa e con inuous a iables among wo o mo e g oups, espec i ely. False disco e y a e (FDR) co ec- ion was applied o accoun o mul iple compa isons. Co ela ion analyses we e pe o med by Spea man co ela ion, ollowed by FDR co ec ion. S a is ical significance was conside ed p (o q alue in he case o FDR co ec ion) < 0.05. All da a we e analysed using R e sion 3.6 (R Co e Team, 2019 ), and figu es we e p oduced using he ggplo 2 package ( Wickham, 2009 ). P incipal componen anal- ysis (PCA) was pe o med a e scale- o-in e al no malisa ion o a iable alues using Pe seus So wa e e sion 1.5.2.6. Please ci e his a icle as: P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al., Sex-dependen g ades o haema opoie ic modula ion in pa ien s wi h majo dep essi e episodes a e associa ed wi h suicide a emp s, Eu opean Neu opsychopha macology, h ps://doi.o g/10.1016/j. eu oneu o.2020.06.006 4 P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al. ARTICLE IN PRESS JID: NEUPSY [m6+; June 26, 2020;5:25 ] 3. Resul s 3.1. Pa ien coho : socio-demog aphics and psychia ic e alua ion The s udy popula ion consis ed o 79 MDE pa ien s [mean age (SD): 52.28 (10.56) yea s; emales: 46 (58.2%)], mos wi h MDD [ n = 71 (89.9%)]. MDE pa ien s we e s a ified in o wo majo g oups based on his o y o SA (MDE SA) [ n = 48 (60.8%)] o absence o SA (MDE noSA) [ n = 31 (39.2%)]. The con ol g oup consis ed o 93 heal hy ac i e blood dono s [mean age (SD): 48.22 (11.44) yea s; emales: 40 (43.0%)]. No significan di e ences be ween pa ien g oups we e iden ified wi h ega d o sociodemog aphic cha ac e - is ics o sex. Age di e ed conside ably be ween pa ien and con ol g oups, al hough pos -hoc pai wise analysis (Dun- can) e ealed significan di e ences only in he MDE noSA g oup compa ed wi h he con ol g oup ( Table 1 and Supple- men a y Table 1). 3.2. CBC o MDE pa ien s: g ades o haema opoie ic modula ion associa ed wi h SA The CBCs o all pa ien s we e wi hin no mal ange o all a iables analysed, including WBC and di e en ial coun (neu ophils, lymphocy es, monocy es, eosinophils, and basophils), RBC coun , mean co puscula olume (MCV), ed cell dis ibu ion wid h (RDW), haema oc i (HCT), and haemoglobin- ela ed a iables (haemoglobin (Hb), mean co puscula haemoglobin (MCH), mean co pus- cula haemoglobin concen a ion (MCHC)), and pla ele s and mean pla ele olume (PLT, MPV). F om hese da a, he neu ophil- o-lymphocy e (NLR), monocy e- o-lymphocy e (MLR), and pla ele - o-lymphocy e (PLR) a ios we e calcu- la ed ( Table 2 and Supplemen a y Table 1). P incipal componen analysis (PCA) was pe o med on he CBC a iables as p esen ed in Supplemen a y Table 1 ( aking in o conside a ion only he WBC di e en ial coun s and no he pe cen ages) in o de o isualise he clus e ing o he pa ien s in he di e en g oups and he con ols. This anal- ysis e ealed ha while he clus e s o MDE pa ien s wi h- ou SA (MDE noSA) and he con ols o e lapped o a la ge ex en , he clus e o MDE pa ien s wi h SA (MDE SA) p e- sen ed only a pa ial o e lap wi h he clus e o con ols, wi h a numbe o MDE SA pa ien s loca ed e y dis an om he nucleus (o cen e) o he con ol clus e ( Fig. 1 ). O no e, he MDE SA pa ien s who clea ly sepa a ed om he con ol clus e nucleus we e emales. This da a sugges s di - e en ial clus e ing o MDE pa ien s, in concu ence wi h o wi hou SA, based on hei CBC measu emen s. To iden i y he a iables esponsible o his di e en ial clus e ing, we nex compa ed po en ial haema ological di - e ences in blood samples be ween he wo majo subg oups o MDE pa ien s (SA and noSA) and con ols. Desc ip i e analysis e ealed significan changes in RBC lineage- ela ed pa ame e s, e.g. RBC coun ( educed), MCV (inc eased), RDW ( educed), MCH (inc eased), and MCHC ( educed), wi h no Hb o HCT changes, sugges ing signs o s ess e y h o- poiesis in MDE pa ien s. The e we e no significan changes in WBC coun s; howe e , he e was a significan educ ion in monocy es and an inc ease in eosinophils and basophils, sug- ges i e o sys emic inflamma ion. Pla ele - ela ed pa ame- e s showed a endency owa d h ombocy osis (no signi - ican ) wi h a significan educ ion in MPV in MDE pa ien s e sus con ols. The di e ence in hese a iables was sig- nifican and/o g ea e in MDE pa ien s in concu ence wi h SA, suppo ing he PCA esul s. Fu he mo e, a endency o- wa d inc eased NLR and significan ly educed MLR we e ob- se ed in MDE SA pa ien s ( Tables 2 and 3 and Fig. 2 ). 3.3. Dis up ion o haema opoie ic equilib ium in MDE pa ien s We nex e alua ed he haema ological equilib ium o CBC a iables by s udying hei co ela ions in MDE pa ien s e - sus con ols, wi h he hypo hesis ha he iden ified di - e ences and di e en ial clus e ing obse ed in he PCA analysis could be explained by he loss o canonical o ap- pea ance o de no o co ela ions, suppo ing he no ion o haema opoie ic dis ess o p oduc ion imbalance. In ac , he significan co ela ions iden ified in he con- ol g oup, and hus, he no mal equilib ium o haema opoi- e ic p oduc ion, we e g adually dis up ed in MDE pa ien s, wi h inc easing se e i y associa ed wi h concu ence o SA ( Fig. 3 ). In e es ingly, we obse ed new significan co ela- ions o haema opoie ic a iables ha would indica e an im- balance o haema opoiesis no p esen in he con ol g oup. This imbalance would sugges an incipien shi a ou - ing WBC lineage a he expense o RBC lineage p oduc ion ( Fig. 3 ). 3.4. Sex and haema opoie ic modula ion in MDE I is well known ha some haema ological pa ame e s om a CBC depend on age and sex ( Cheng e al., 2004 ; Qiao e al., 2014 ); he e o e we pe o med mul iple eg ession analyses, which allowed us o iden i y he haema ological pa ame e s dependen on o influenced by hese a iables in ou coho o pa ien s and con ols ( Table 2 ). As is al eady known, emales p esen ed sligh ly educed RBC coun , Hb, HCT, and MCH compa ed wi h males. Con a iwise, emales displayed significan ly highe pla ele numbe s. This also ex- plains he di e en ial clus e ing o male and emale indi- iduals in he PCA ( Fig. 1 ). Addi ionally, we obse ed age- ela ed di e ences ha , al hough small, we e s ill signifi- can ; i.e. he RDW % was highe in olde indi iduals while he opposi e was ue o lymphocy e coun s ( Table 2 ). I was he e o e impo an o s udy whe he he haema opoie ic imbalance obse ed in ou coho was main- ained when he sexes we e s udied sepa a ely and whe he i would impac males and emales equally. The e o e, we nex pe o med he same compa a i e analysis a e s a i- fica ion o ou coho based on sex. O no e, he di e ence obse ed in age in he global popula ion (MDE noSA s con- ols) disappea ed in women a e s a i ying ou coho , bu pe sis ed in men (da a no shown). We obse ed inc eased SA-associa ed haema opoie ic im- balance bo h in men and women; howe e , bo h sexes p e- sen ed pa icula i ies and sepa a e haema opoie ic modu- la ion p ofiles. While emales expe ienced he mos e i- Please ci e his a icle as: P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al., Sex-dependen g ades o haema opoie ic modula ion in pa ien s wi h majo dep essi e episodes a e associa ed wi h suicide a emp s, Eu opean Neu opsychopha macology, h ps://doi.o g/10.1016/j. eu oneu o.2020.06.006 5 ARTICLE IN PRESS JID: NEUPSY [m6+; June 26, 2020;5:25 ] Table 1 Sociodemog aphic and clinical da a. SD: S anda d de ia ion; HDRS: Hamil on Dep ession Ra ing Scale; MDE: Majo Dep essi e Episode; SA: Suicide a emp ; noSA: No suicide a emp ; MDS: Medical Damage Sco e; LTE: Lis o Th ea ening Expe- iences; CTQ: Childhood T auma Ques ionnai e; SSRI: Selec i e Se o onin Reup ake Inhibi o ; SNRI: Se o onin and No epineph ine Reup ake Inhibi o ; NDRI: No epineph ine Dopamine Reup ake Inhibi o ; 1 S a is ically di e en (Pos -hoc Duncan es ). MDE MDE SA MDE noSA Heal hy con ols MDE MDE + Con ols n = 79 n = 48 n = 31 n = 93 X 2 ∗/ T es ( p ) X 2 ∗/ANOVA ( p ) Sex [ n (%)] Males 33 (41.8%) 18 (37.5%) 15 (48.4%) 53 (57.0%) 0.918 ∗(0.338) 4.849 ∗(0.089) Females 46 (58.2%) 30 (62.5%) 16 (51.6%) 40 (43.0%) 1.414 (0.162) 3.810 (0.024) Age [Mean (SD)] 52.28 (10.56) 50.94 (9.71) 54.35 (11.61) 1 48.22 (11.44) 1 Diagnosis [ n (%)] Majo Dep essi e Diso de 71 (89.9%) 43 (89.6%) 28 (90.3%) 0.011 ∗(0.915) Bipola Diso de 8 (10.1%) 5 (10.4%) 3 (9.7%) HDRS [Mean (SD)] 21.15 (4.21) 21.04 (4.56) 21.32 (3.67) 0.288 (0.774) Numbe o SA [Mean (SD)] –2.58 (2.53) –– Age o 1s SA [Mean (SD)] – 39.71 (13.64) –– MDS [Mean (SD)] – 3.17(1.45) –– LTE [Mean (SD)] 2.99 (2.44) 3.25 (2.99) 2.58 (1.12) −1.193 (0.237) CTQ To al Sco e [Mean (SD)] 51.09 (17.90) 53.94 (19.93) 46.77 (13.45) −1.894 (0.062) CTQ Physical Abuse [Mean (SD)] 6.64 (3.39) 7.13 (4.07) 5.90 (1.78) −1.817 (0.074) CTQ Sexual Abuse [Mean (SD)] 6.82 (4.34) 7.32 (4.81) 6.06 (3.42) −1.344 (0.183) CTQ Emo ional Abuse [Mean (SD)] 8.88 (4.62) 9.45 (4.86) 8.03 (4.16) −1.331 (0.187) CTQ Physical Neglec [Mean (SD)] 8.41 (3.83) 8.85 (3.71) 7.74 (3.98) −1.256 (0.213) CTQ Emo ional Neglec [Mean (SD)] 11.03 (5.40) 11.64 (5.48) 10.10 (5.21) −1.239 (0.219) Pha macological T ea men [ n (%)] 74 (93.7%) 46 (95.8%) 28 (90.3%) 0.965 ∗(0.326) An idep essan equi alen o fluoxe ine 40 mg/day [Mean (SD)] 45.21 (19.08) 45.74 (20.71) 44.36 (16.41) −0.316 (0.766) SSRI [ n (%)] 26 (32.9%) 17 (35.4%) 9 (29.0%) 0.348 ∗(0.555) SNRI [ n (%)] 36 (45.6%) 21 (43.6%) 15 (48.4%) 0.163 ∗(0.686) NDRI [ n (%)] 7 (8.9%) 4 (8.3%) 3 (9.7%) 0.042 ∗(0.837) O he s [ n (%)] 36 (45.6%) 23 (47.9%) 13 (41.9%) 0.272 ∗(0.602) Mood S abilise s [ n (%)] 10 (12.7%) 7 (14.6%) 3 (9.7%) 0.410 ∗(0.522) An ipsycho ics [ n (%)] 32 (40.5%) 23 (47.9%) 9 (29.0%) 2.787 ∗(0.095) Benzodiazepines [ n (%)] 67 (84.8%) 43 (89.6%) 24 (77.4%) 2.163 ∗(0.141) O he s [ n (%)] 12 (15.18%) 6 (12.5%) 6 (19.4%) 0.687 ∗(0.407) Tobacco consump ion [ n (%)] Yes 36 (45.6%) 20 (41.7%) 16 (51.6%) 0.751 ∗(0.386) No 43 (54.4%) 28 (58.3%) 15 (48.4%) No. o ciga e es/day [Mean (SD)] 15.19 (9.56) 13.35 (5.76) 17.50 (12.70) 1.307 (0.200) den changes, hese we e no always significan ly al e ed in males ( Table 3 ). Rega ding RBC lineage, a significan in- c ease in RBC coun wi h no change in RDW was obse ed in MDE emales; howe e , in males, he MCV and RDW changes we e significan only in concu ence wi h SA ( Fig. 4 ). RDW is a ec ed by age, as ou analysis showed ( Table 2 ), bu since age was di e en in he MDE noSA g oup and he sig- nifican di e ence was de ec ed in he MDE SA g oup, we conside ou esul s alid. These da a sugges ha emales wi h MDE a e mo e p one o expe ience haema ological im- balance, a ec ing bo h he RBC and WBC lineages, while men p esen o e all milde al e a ions. 3.5. CTQ and LTE sco es and haema opoie ic modula ion in MDE Fu he analyses we e conduc ed o e alua e he associa- ions be ween s esso s du ing childhood and adul hood, as assessed using CTQ and LTE sco es, espec i ely, and he Please ci e his a icle as: P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al., Sex-dependen g ades o haema opoie ic modula ion in pa ien s wi h majo dep essi e episodes a e associa ed wi h suicide a emp s, Eu opean Neu opsychopha macology, h ps://doi.o g/10.1016/j. eu oneu o.2020.06.006 6 P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al. ARTICLE IN PRESS JID: NEUPSY [m6+; June 26, 2020;5:25 ] Table 2 Comple e blood pa ame e s in he pa ien and con ol g oups. Va iables a e summa ised as mean (s anda d de ia ion). Di e ences be ween he MDE SA and MDE noSA g oups and he heal hy con ols we e assessed by one-way K uskal–Wallis es . Va iables wi h significan di e ences ( p < 0.05) a e highligh ed in bold. MDE: Majo Dep essi e Episode; SA: Suicide a emp ; noSA: No suicide a emp ; WBC: whi e blood cell coun ; RBC: ed blood cell coun ; MCV: mean co puscula olume; MCH: mean co puscula haemoglobin; MCHC: mean co puscula haemoglobin concen a ion; RDW: ed cell dis ibu ion wid h; MPV: mean pla ele olume; NLR: neu ophil- o-lymphocy e a io; PLR: pla ele - o-lymphocy e a io; MLR: monocy e- o-lymphocy e a io. MDE MDE SA MDE noSA Heal hy con ols One-way K uskal–Wallis Sex adjus ed Age adjus ed N = 79 N = 48 N = 31 N = 93 p p p WBC (10 3 / μL) 7.47 (2.25) 7.82 (2.38) 6.93 (1.94) 7.11 (1.66) 0.205 1 1 RBC (10 6 / μL) 4.73 (0.46) 4.69 (0.43) 4.79 (0.49) 4.90 (0.38) 0.017 < 0.001 1 Haemoglobin (g/dL) 14.31 (1.54) 14.17 (1.60) 14.51 (1.44) 14.56 (1.11) 0.460 < 0.001 1 Haema oc i (%) 42.49 (4.03) 42.25 (4.12) 42.86 (3.93) 42.34 (2.79) 0.945 < 0.001 1 MCV ( L) 89.76 (5.22) 89.87(6.35) 89.59 (2.75) 86.52 (3.94) < 0.001 1 1 MCH (pg) 31.83 (9.84) 32.80 (12.54) 30.33 (1.29) 29.73 (1.50) 0.006 < 0.001 1 MCHC (g/dL) 33.73 (1.29) 33.65 (1.45) 33.85 (1.00) 34.37 (1.00) 0.003 1 1 RDW (%) 13.39 (1.24) 13.41 (1.41) 13.36 (0.96) 13.70 (1.01) 0.022 1 < 0.001 Neu ophils (10 3 / μL) 4.23 (1.84) 4.54 (2.02) 3.74 (1.39) 3.95 (1.29) 0.109 1 1 Lymphocy es (10 3 / μL) 2.38 (0.84) 2.41 (0.87) 2.35 (0.81) 2.31 (0.78) 0.835 1 < 0.001 Monocy es (10 3 / μL) 0.56 (0.17) 0.57 (0.16) 0.55 (0.19) 0.64 (0.18) 0.012 1 1 Eosinophils (10 3 / μL) 0.24 (0.15) 0.25 (0.15) 0.21 (0.14) 0.19 (0.12) 0.043 1 1 Basophils (10 3 / μL) 0.05 (0.02) 0.06 (0.02) 0.05 (0.02) 0.03 (0.01) < 0.001 1 1 Pla ele s (10 3 / μL) 252.16 (68.97) 260.08 (80.56) 239.90 (44.09) 244.25 (60.63) 0.540 < 0.001 1 MPV ( L) 10.83 (0.80) 10.80 (0.81) 10.89 (0.78) 11.29 (0.94) 0.008 1 1 NLR 1.97 (1.35) 2.17 (1.66) 1.68 (0.57) 1.87 (0.80) 0.510 1 1 PLR 117.26 (53.49) 122.39 (64.51) 109.30 (28.50) 117.99 (54.77) 0.952 1 1 MLR 0.26 (0.11) 0.26 (0.12) 0.25 (0.08) 0.30 (0.13) 0.017 1 1 Fig. 1 P incipal componen analysis (PCA) o haema ological pa ame e s in MDE pa ien s and heal hy con ols shows dis inc clus e ing o samples depending on co-occu ence o SA. PCA o haema ological pa ame e s pe o med on MDE pa ien s (MDE noSA, MDE SA, and con ols) is depic ed. Please ci e his a icle as: P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al., Sex-dependen g ades o haema opoie ic modula ion in pa ien s wi h majo dep essi e episodes a e associa ed wi h suicide a emp s, Eu opean Neu opsychopha macology, h ps://doi.o g/10.1016/j. eu oneu o.2020.06.006 7 ARTICLE IN PRESS JID: NEUPSY [m6+; June 26, 2020;5:25 ] Table 3 Di e ences be ween pa ien g oups, s a ified by se e i y o MDE (SA/noSA) and sex, and heal hy con ols we e e alu- a ed by he Mann–Whi ney U es , and he False Disco e y Ra e (FDR, q alue) is indica ed. Va iables wi h significan di e ences a e highligh ed in bold. Ra ios show he ela ionship be ween he means o each pa ien g oup and he heal hy con ols o each haema ological pa ame e . MDE: Majo Dep essi e Episode; SA: Suicide a emp ; noSA: No suicide a emp ; WBC: whi e blood cell coun ; RBC: ed blood cell coun ; MCV: mean co puscula olume; MCH: mean co puscula haemoglobin; MCHC: mean co puscula haemoglobin concen a ion; RDW: ed blood cell dis ibu ion wid h; MPV: mean pla ele olume; NLR; neu ophil- o-lymphocy e a io; PLR: pla ele - o-lymphocy e a io; MLR: monocy e- o-lymphocy e a io. Global Male Female MDE SA MDE noSA MDE SA MDE noSA MDE SA MDE noSA q Ra io q Ra io q Ra io q Ra io q Ra io q Ra io WBC (10 3 / μL) 0.236 0.722 0.687 0.811 0.726 0.134 0.85 RBC (10 6 / μL) 0.02 0.96 0.218 0.638 0.811 0.190 0.309 Haemoglobin (g/dL) 0.342 0.676 0.856 0.914 0.797 0.630 Haema oc i (%) 0.884 0.947 0.687 0.811 0.698 0.576 MCV ( L) < 0.001 1.04 < 0.001 1.04 0.04 1.03 0.153 0.005 1.04 0.003 1.04 MCH (pg) 0.02 1.10 0.125 0.056 0.365 0.182 0.409 MCHC (g/dL) 0.02 0.98 0.077 0.130 0.811 0.190 0.02 0.98 RDW (%) 0.02 0.98 0.218 0.04 0.96 0.351 0.660 0.630 Neu ophils (10 3 / μL) 0.193 0.558 0.587 0.811 0.726 0.128 Lymphocy es (10 3 / μL) 0.656 0.947 0.995 0.811 0.732 0.521 Monocy es (10 3 / μL) 0.03 0.88 0.089 0.587 0.860 0.153 0.031 0.71 Eosinophils (10 3 / μL) 0.03 1.34 0.558 0.242 0.365 0.190 0.978 Basophils (10 3 / μL) < 0.001 2.05 < 0.001 1.81 0.001 1.87 0.009 1.88 < 0.001 2.27 0.031 1.78 Pla ele s (10 3 / μL) 0.386 0.993 0.812 0.994 0.726 0.921 MPV ( L) 0.020 0.96 0.111 0.242 0.145 0.153 0.693 NLR 0.545 0.676 0.812 0.811 0.855 0.309 PLR 0.998 0.917 0.964 0.811 0.883 0.921 MLR 0.02 0.88 0.218 0.638 0.990 0.112 0.128 haema opoie ic modula ion obse ed in MDE pa ien s, wi h o wi hou s a ifica ion based on sex. Fi s , we s udied he dis ibu ion o CTQ and LTE sco es in ou pa ien coho . Al hough he e was a endency owa ds a p og essi e inc ease in hose sco es om lowe in MDE noSA pa ien s o highe in MDE SA pa ien s, he e we e no significan changes in CTQ no LTE sco es (da a no shown). In o de o analyse he associa ion o CTQ and LTE sco es wi h he haema opoie ic imbalance obse ed in MDE pa ien subg oups, we gene a ed new a io a iables calcula ed as “haema opoie ic pa ame e alue s CTQ o LTE sco e” pe pa ien ( Table 4 ) in he global MDE coho and a e s a ifi- ca ion based on sex. This analysis showed ha LTE (and no CTQ) was associa ed wi h he haema ological al e a ions obse ed in emales only, and ha he a ios calcula ed wi h all he RBC lineage pa ame e s and hose calcula ed wi h lymphocy es and monocy es as pa o he WBC di e en ial clea ly sepa a ed SA om noSA in emales ( Fig. 5 ). These esul s sugges ha emales a e mo e suscep ible o de el- oping signs o haema opoie ic dis ess, ha his imbalance is mo e se e e in concu ence wi h SA, and ha he co ela- ion o all RBC lineage pa ame e s and some o he WBC pa- ame e s wi h he LTE sco e clea ly sepa a es SA om noSA in emale pa ien s wi h MDE. 4. Discussion We examined global haema ological pa ame e s om CBCs o MDE pa ien s, wi h o wi hou SA, and e alua ed po en ial haema opoie ic modula ion, imbalance o dis ess due o co-occu ence o SA, and how sex and ea ly o la e s esso s may influence po en ial haema opoie ic modula ion mani- es a ions in MDE pa ien s. We sugges ha he haema opoie ic imbalance obse ed in hese pa ien s goes beyond he inflamma o y s a us p e i- ously epo ed by o he s ( Cou e e al., 2016 , 2015 ; Ekinci and Ekinci, 2017 ; Gibbs e al., 2016 ; Glaus e al., 2018a , b ; I ko ic e al., 2016 ; Kayhan e al., 2017 ; Liu e al., 2012 ; Mazza e al., 2019 ; Mille and Raison, 2016 ; O um e al., 2018 ). Haema opoie ic imbalance, modula ion, o dis ess e e s o he physiological esponse o he haema opoi- e ic sys em o a ce ain s imulus, which causes loss o he haema opoie ic p oduc ion equilib ium. This loss o equilib- ium may no a ec single a iables (as he no mal anges o some o hem a e conside ably wide), and hence, CBCs as such may be wi hin he no mal ange. Howe e , since he haema opoie ic p oduc ion is so igh ly egula ed, co ela- ions amongs a iables s a o be los e en when shi s o a iables a e s ill p esen wi hin he no mal ange, bu de- ia e om he alues and co ela ions measu ed in a gi en indi idual unde heal hy condi ions. A simple cold, which is ansi o y, will induce such dis ess. Fu he mo e, s udy- ing a gi en a iable, like he ed blood cell coun , in a ce ain pa ien coho , such as he one as we p esen in his manusc ip , may show a skewed dis ibu ion owa ds a minimum h eshold -s ill wi hin he no mal ange-, while in heal hy dono s, he dis ibu ion is e enly dispe sed wi hin he op and bo om limi s. While i is impo an o ac- Please ci e his a icle as: P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al., Sex-dependen g ades o haema opoie ic modula ion in pa ien s wi h majo dep essi e episodes a e associa ed wi h suicide a emp s, Eu opean Neu opsychopha macology, h ps://doi.o g/10.1016/j. eu oneu o.2020.06.006 8 P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al. ARTICLE IN PRESS JID: NEUPSY [m6+; June 26, 2020;5:25 ] Fig. 2 Haema ological pa ame e s a e a ec ed in MDE pa ien s and changes a e mo e p onounced in co-occu ence wi h SA. (a) Box plo s o selec ed haema ological pa ame e s om he CBCs o MDE pa ien s (SA and noSA) and heal hy con ols. Top ow depic s some pa ame e s o he RBC lineage. Middle ow depic s some pa ame e s o he WBC lineage di e en ial. Lowe ow depic s he mean pla ele olume. (b) Box plo s o calcula ed a ios. RBC, ed blood cell; MCV, mean co puscula olume; MCHC, mean co puscula haemoglobin concen a ion; MPV, mean pla ele olume; NLR, neu ophil-lymphocy e a io; and MLR, monocy e- lymphocy e a io. ∗p < 0.05 and ∗∗∗ p < 0.001. NS: no significan . knowledge ha CBCs o all pa ien s we e wi hin he no - mal ange, we obse ed clea signs o s ess e y h opoiesis ( educed RBC and RDW wi h inc eased MCV) accompany- ing inflamma ion (dec eased monocy es and inc eased ba- sophils and eosinophils). The endency owa d inc eased pla ele coun s, al hough no significan , along wi h e- duced MPV, a e sugges i e o eac i e h ombocy osis and pla ele esicula ion, which is no mally p esen in acu e phase esponse o sys emic inflamma ion. All hese changes we e mo e p onounced o significan in MDE pa ien s in co- occu ence wi h SA. Fu he mo e, he equilib ium o he haema opoie ic p oduc ion, as exemplified by haema olog- ical a iable co ela ion ma ixes, showed a disappea ance o many co ela ions and he appea ance o de no o co e- la ions in MDE pa ien s e sus con ols. These da a, aken oge he , sugges inc easing g ades o haema opoie ic mod- ula ion/dis ess in MDE pa ien s (associa ed wi h SA), in- dica i e o inflamma ion (as p e iously epo ed), bu also Please ci e his a icle as: P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al., Sex-dependen g ades o haema opoie ic modula ion in pa ien s wi h majo dep essi e episodes a e associa ed wi h suicide a emp s, Eu opean Neu opsychopha macology, h ps://doi.o g/10.1016/j. eu oneu o.2020.06.006 9 ARTICLE IN PRESS JID: NEUPSY [m6+; June 26, 2020;5:25 ] Fig. 3 Co ela ion o haema ological pa ame e s is dis u bed in MDE pa ien s. Co ela ion ma ixes o haema ological pa ame e s in MDE pa ien s (noSA and SA) and heal hy con ols a e depic ed. Significan co ela ions a e shown by di e en sized ci cles, indica ing he s eng h o he slope. Di ec co ela ions a e colou ed blue, while nega i e co ela ions a e colou ed ed. No e ha many co ela ions iden ified in he heal hy con ol g oup disappea in MDE pa ien s. De no o co ela ions a e amed in a ed-line squa e. (Fo in e p e a ion o he e e ences o colou in his figu e legend, he eade is e e ed o he web e sion o his a icle.) indica i e o unde lying o onse o s ess e y h opoiesis. Changes in haema ological pa ame e s in mood diso de s ha e been p e iously epo ed, including he appea ance o specific co ela ions as we epo in his s udy ( Wysokinski and Szczepocka, 2016 , 2018 ). In some epo s, he enden- cies obse ed a e he opposi e (inc eased RDW s dec eased RDW as we obse ed) ( Demi can e al., 2016 ). He e ogene- i y among s udy coho s (p obably due o sociodemog aphic and en i onmen al ac o s) and sample size may condi ion his disc epancy, sepa a ing inflamma ion-associa ed e y- h oid s ess due o i on deficiency (o malabso p ion) om o he ypes o dyse y h opoiesis. Fu he mo e, he a iables a ec ed by sex (i.e. RBC, HB, HCT, MCH, and PLT) o by age (RDW and lymphocy e coun ) sugges ha co ec ion o Please ci e his a icle as: P. Ma ínez-Bo ía, A. Velasco and V. Rolle e al., Sex-dependen g ades o haema opoie ic modula ion in pa ien s wi h majo dep essi e episodes a e associa ed wi h suicide a emp s, Eu opean Neu opsychopha macology, h ps://doi.o g/10.1016/j. eu oneu o.2020.06.006