Introduction: Depression is a pervasive mood disorder significantly impacting mental health and quality of life, with global prevalence ranging from 3.2% to 4.7%. Nesfatin-1, a hypothalamus-derived anorexigenic peptide, is implicated in stress and emotional regulation via its effects on the hypothalamic-pituitary-adrenal (HPA) axis. This study investigates the relationship between plasma nesfatin-1 levels and the severity of major depressive disorder (MDD) in a sample population. Methods: A case-control study was conducted at Mahatma Gandhi Memorial Government Hospital, Tiruchirappalli, Tamil Nadu, India, involving 89 participants. Depression severity was assessed using the PHQ-9 scale, with scores ≥5 classified as cases and <4 as controls. Plasma nesfatin-1 levels were quantified using ELISA. Statistical analyses included ANOVA, Student’s *t*-test, Post-Hoc Bonferroni test, and ROC curve analysis for sensitivity and specificity. Results: A significant positive correlation was observed between PHQ-9 scores and plasma nesfatin-1 levels (*p*<0.001). Mean nesfatin-1 levels progressively increased across depression severity groups: normal (5.63 ng/mL), mild (11.38 ng/mL), moderate (21.97 ng/mL), moderately severe (27.85 ng/mL), and severe (36.46 ng/mL). ROC analysis demonstrated an area under the curve (AUC) of 0.92, indicating high diagnostic accuracy of nesfatin-1 for depression severity, with a sensitivity of ~80% and specificity of ~76-85% at a cutoff of ~15-16 ng/mL. Gender had no significant impact on nesfatin-1 levels or PHQ-9 scores. Conclusion: Elevated plasma nesfatin-1 levels are associated with higher depression severity, underscoring its potential utility as a biomarker for MDD diagnosis and stratification. Further multicentric studies are recommended to validate these findings.
Depression is a mood disorder that weakens an individual's mental health, leading to the cause of disability in taking the right decisions during life events, resulting in more chance of suicidal thoughts affecting more than 120 million people globally.1 3-8% of adolescents were affected by depressive disorders worldwide2. Depression is an unstable condition with a low mood and a discouraged stage that interferes with the person's behaviors, feelings, and cognition3. The present diagnostic strategies for appraising depression depend on the patient's behavior, interviews and symptoms, and the unreliability mounts up to 30% as a consequence.
In India Depression was the third leading cause of disability in the year 2014.4 Global prevalence of depression varies from 3.2% to 4.7%. WHO-World Mental Health Survey stated that prevalence of depression was 0.8% to 9.6% across countries.5 In India prevalence ranges from 0.5 to 78 per 1000 population, that is one third of the patients seeking treatment from health care facilities.
The hypothalamic–pituitary–adrenal (HPA) axis is activated by nesfatin-1 and the HPA hyperactivity triggers depressive episodes. Water avoidance stress induced in animals is associated with acute depression and increased plasma nesfatin-1 levels.6
Hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis was closely associated with triggering of depressive mental state during a stressful life event. The recent findings showed that the elevated corticosterone levels in blood were associated with hyperactivity of the HPA axis in the animal model.
Nesfatin-1 is an anorexigenic peptide hormone, which is produced by the hypothalamus. It plays a crucial role in energy consumption, glucose balance, and nutrition. Recent findings reported that nesfatin-1 also participates in the regulation of emotional status in addition to stress and anxiety7.
An elevated plasma nesfatin-1 level and mRNA expression of nesfatin-1was found in the acute stress induced rat model. An interesting note is that nesfatin - 1 stimulates the hyperactivity of the HPA axis leads to depressive episodes.3 Increased anxiety was observed in the intracerebroventricularly injected Nesfatin -1 rodents model8. HPA axis hyperactivity was observed in the intraperitoneally injected nesfatin-1 in rats.
The present study is to investigate the plasma nesfatin-1 level in depressive patients attending Mahathma gandhi memorial government hospital Tiruchirappalli, Tamil Nadu, India. The aim of the present study is to detect the level of nesfatin-1 and the relationship between plasma nesfatin-1 concentration and the severity of the major depressive disorder (MDD).
It was Case control study done at Mahathma gandhi memorial government hospital Tiruchirappalli, Tamil Nadu, India. Purposive sampling techniques was used and all individuals (89 attending OPD) were selected as the sample size of study. Informed and Written Consent obtained. Administration of PHQ-9 Scale - questionnaire were issued to all the individuals (89). PHQ-9 score < 4 were included as control and PHQ-9 score > 5 were included as cases. Ethical clearance was taken from IEC of hospital.
Inclusion Criteria-
Exclusion Criteria-
METHODOLOGY
Under aseptic precautions, totally 5 ml of blood was collected from study group and controls by vene puncture. 2.5 ml of blood was collected in anti-coagulant tube (EDTA tube). 2.5 ml blood in serum separating tube and centrifuged at 3000 g for 15 minutes. Serum were separated from the cells and used for measuring serum glucose, urea, creatinine, total cholesterol, TSH, fT4, T3. Plasma was separated from blood in the EDTA tube by centrifuging at 3000g for 15minutes .Plasma nesfatin-1 level was done in all the samples using ELISA technique. Plasma collected using EDTA as an anticoagulant. Samples centrifuged for 15 min at 3000×g at 2-8℃ within 30 mins of collection. Supernatant collected to carry out the assay.
STATISTICAL ANALYSIS
SPSS Package - Statistical products and service solutions were used for statistical analysis. Student‘t’ test - used to compare biochemical parameters of controls and cases with depression. p value <0.05 – Statistical significance level & p value <0.001 – High statistical significance level. One-way ANOVA used to separate observed variance data. Post-Hoc Bonferroni test shows the difference in mean nesfatin-1 levels between various classifications of groups. ROC curve analysis to determine sensitivity and specificity of serum nesfatin-1 levels.
Table 1: Age and Gender wise segregation of depressive patients based on the PHQ-9 scores (n=89)
Sr. No |
Particulars |
Frequency |
Percentage of depressive status |
1. |
Below 30yrs |
9 |
10.1 |
2. |
31 to 40yrs |
34 |
38.2 |
3. |
41 to 50yrs |
22 |
24.7 |
4. |
51yrs & above |
24 |
27.0 |
Total |
89 |
100.0 |
The study population was composed of 89 depressive patients consisting of 40 males, and 49 females. The study population was segregated age wise into four groups and measured the depressive status based on the Patient Health Questionnaire (PHQ-9). A higher frequency of depressive patients was observed between the age ranges of 31 to 40. A lower depressive status was observed in ages below 30 years, which is shown in Table 1. The frequency of depressive status was higher in females compared to males.
Table 2: Gender wise comparison of PHQ-9 scores (n=89)
Gender |
N |
Mean PHQ-9 score |
Std. Deviation |
Student ‘t’ test |
Male |
40 |
14.08 |
5.507 |
0.946 |
Female |
49 |
14 |
4.852 |
Based on the PHQ-9 score, there was no statistically significant difference (p=0.946) between males and females in terms of PHQ-9 scores, shown in Table.
Table 3: Gender wise comparison of Nesfatin - 1 (n=89)
Gender |
N |
Mean Nesfatin-1 level (ng/ml) |
Std. Deviation |
Student ‘t’ test |
Male |
40 |
23.130 |
10.7865 |
0.988 |
Female |
49 |
23.166 |
11.1927 |
There was no statistically significant difference (p=0.988) observed between males and females in terms of Nesfatin-1 level, which is shown in table 3. This evidence suggests that Nesfatin -1 was not associated with the sex of people.
Table 4: Depression in subjects with chronic diseases (n=89)
Chronic Disease |
Depression Grading (PHQ-9 score) |
Count |
Column N % |
CKD |
Moderate depression (10 to 14) |
2 |
16.7% |
Moderately severe depression (15 to 19) |
9 |
75.0% |
|
Severe depression (20 to 27) |
1 |
8.3% |
|
Diabetes |
Moderate depression (10 to 14) |
11 |
52.4% |
Moderately severe depression (15 to 19) |
10 |
47.6% |
|
Severe depression (20 to 27) |
0 |
0.0% |
|
Low Back Ache |
Moderate depression (10 to 14) |
2 |
33.3% |
Moderately severe depression (15 to 19) |
4 |
66.7% |
|
Thyroid Disorders |
Moderate depression (10 to 14) |
9 |
69.2% |
Moderately severe depression (15 to 19) |
4 |
30.8% |
In patients with chronic kidney disease 75% - Moderately severe depression, 16.7% - Moderate depression, and 8.3% - Severe depression was observed. In Diabetic patients 52.4% - Moderate depression and 47.6% - Moderately severe depression was observed. In patients with LBA 66.7% - Moderately severe depression and 33% - Moderate depression was observed. In Patients with Thyroid Disorders 69.2% -Moderate depression and 30.8% - Moderately severe depression was observed. This evidence suggested that all the subjects who had chronic diseases suffered from predominantly either moderately severe or severe depression. 22 patients were normal.
Table 5: Association between Depression and plasma Nesfatin-1 levels among the study subjects (n=89)
Depression (PHQ-9 score) |
N |
Mean Nesfatin-1 level |
Std. Deviation |
|
Normal (<4) |
3 |
5.630 |
0.8017 |
|
Mild depression (5 to 9) |
18 |
11.381 |
6.7978 |
|
Moderate depression (10 to 14) |
24 |
21.970 |
7.8692 |
|
Moderately severe depression (15 to 19) |
34 |
27.845 |
8.2911 |
|
Severe depression (20 to 27) |
10 |
36.459 |
3.3848 |
The results of the Analysis of Variance showed that the PHQ-9 scores were positively correlated with plasma Nesfatin-1. As depression level increases there is also a corresponding rise in mean Nesfatin-1 levels and this difference in mean Nesfatin-1 levels between the groups is statistically significant (p<0.001) in the ANOVA test, which is shown in Table
Table 6: Post-Hoc test for comparing serum Nesfatin-1 levels between Depression groups (n=89)
Between groups comparison (PHQ-9 scores) |
Mean Nesfatin-1 difference |
p value |
Normal vs Mild Depression |
-5.75 |
0.723 |
Normal vs Moderate Depression |
-16.34 |
0.005 |
Normal vs Moderately severe Depression |
-22.21 |
<0.001 |
Normal vs Severe Depression |
-30.83 |
<0.001 |
Mild vs Moderate Depression |
-10.59 |
<0.001 |
Mild vs Moderately severe Depression |
-16.46 |
<0.001 |
Mild vs Severe Depression |
-25.07 |
<0.001 |
Moderate vs Moderately severe Depression |
-5.87 |
0.030 |
Moderate vs Severe Depression |
-14.49 |
<0.001 |
Moderately severe vs Severe Depression |
-8.61 |
0.014 |
Post-Hoc Bonferroni test shows that the difference in mean Nesfatin-1 levels between various classified groups of depression is statistically significant (p<0.001) except for the difference between normal subjects and subjects with mild depression (p=0.723), which is shown in Table. This evidence clearly indicates that plasma Nesfatin-1 levels were strongly associated with the severity status of depression.
Figure 1: ROC curve analysis to determine sensitivity and specificity of serum Nesfatin 1 levels for diagnosing Moderate to severe depression (PHQ score>10)
The ROC curve analysis is a tool, which shows the trade-off between sensitivity (or TPR) and specificity (1 – FPR). The statistically significant area under the curve of ~92% indicates that 92% of the time a randomly selected subject with depression will have elevated levels of Nesfatin- 1 when compared to the subject without depression. The cut-off levels of mean Nesfatin -1 levels show that levels between ~15 to ~16 ng/ml will have sensitivity in the range of ~80% and specificity in the range between ~76 to 85%.
According to the present study using the PHQ-9 score, no statistically significant difference (p=0.946) was observed in sex (males and females). Similarly, no statistically significant difference (p=0.988) was observed between males and females in terms of Nesfatin-1 level. This finding indicates that Nesfatin 1 was not associated with sex difference. This was substantiated in the study conducted by Min-Min Xiao et al., 20183, that the differences in plasma Nesfatin-1 and cortisol between the moderately severe depressive disorder (MSDD) groups and healthy control groups were not influenced by age and sex differences.
PHQ-9 scores are closely associated with multiple vital signs of disease and clinical measures, that point to reduced physical status. When a person with a high PHQ-9 score of depression seeks much attention from a clinician, contextual awareness is critically important to provide an effective clinical intervention (Robert M Califf, P.Murali duraiswamy et al.2022)9,10.
Depression is a mental disorder that can affect both diseased and healthy individuals. Nevertheless, diseased individuals suffered more than healthy individuals from depressive disorder. Chronic disease conditions like chronic kidney disease, low backache, diabetes, and thyroid were observed among depressive patients. Our present findings indicate that those with chronic diseases suffered predominantly from either moderately severe or severe depression based on the PHQ-9.
Nesfatin-1 is a novel satiety molecule closely associated with various mental disorders, including anxiety, obsessive-compulsive disorder, panic disorder, and depression (YerlikayaAydemir, et al., 2021)11,12,. Our results of the Analysis of Variance showed that the PHQ- 9 scores were positively correlated with plasma Nesfatin-113. As depression level increases there is also a corresponding rise in mean Nesfatin-1 levels and this difference in mean Nesfatin-1 levels between the groups is statistically significant (p<0.001) in the ANOVA test.
Furthermore, we observed that the plasma nesfatin-1 level gradually increased from mild depression to severe depression. These findings suggested that plasma nesfatin-1 is closely associated with depression severity status13
In our study ROC curve analysis shows the statistically significant area under the curve of ~92% indicating that 92% of the time a randomly selected subject with depression will have elevated levels of Nesfatin-1 when compared to the subject without depression. The cut-off levels of mean Nesfatin-1 levels show that levels between ~15 to ~16 ng/ml will have a sensitivity of ~80% and specificity between ~76 to 85%. The results of the ROC curve analysis showed that the AUC for nesfatin-1 was 0.919 and the 95% Confidence Interval for AUC was 0.861 to 0.978 separating depressive patients from healthy individuals.
In a study by Min-Min Xiao et al., 20183, multivariate logistic regression analysis states nesfatin-1 can be used as an independent indicator for severe depression in depressive patients and ROC curve analysis with a sensitivity of 82.4% and a specificity of 91.3% by plasma nesfatin-1(cut-off value = 20.25 ng/mL). Min-Min Xiao et al., 2018 reported that the plasma nesfatin-1 level may act as a suitable biomarker to identify severe depression in Chinese patients.3
Similar findings were reported by Ya-Yun Xu et al., 201811, in which the ROC analysis disseminate an AUC of 0.985 with 97.1% specificity and 94.3% sensitivity of plasma nesfatin-1. Therefore, the plasma nesfatin-1level may be considered as a notable biomarker to identify depressive patients with severe, moderately severe, moderate, and mild depression13.
The limitation of this study should also be acknowledged. All subjects were collected from a single center located in Tiruchirappalli, Tamil Nadu. Also, the sample size was small and individual factors, such as food habits and sedentary lifestyles, have not been taken into consideration during the study.
In conclusion, our research findings suggest that plasma nesfatin-1 levels are closely associated with depressive severity status based on the PHQ-9. The PHQ-9 scores were positively correlated with plasma Nesfatin-1. As depression level increases, there is a corresponding rise in plasma Nesfatin-1 levels. Based on the findings, we suggested that the plasma nesfatin-1level may be considered a notable biomarker to identify depressive patients with severe, moderate-severe, moderate, and mild depression.
People with depression can find it difficult to take the first step in seeking support. The good news is that just like a physical illness depression is treatable and effective treatments are available. The sooner the person with depression seeks to support, the sooner they recover.
Conflict of Interest- None declared
Source of Funding- None