Leaky Gut Biomarkers as Predictors of Depression and Suicidal Risk: A Systematic Review and Meta-Analysis

Abstract

Background: The gut-brain axis (GBA) has been demonstrated to be involved in normal neurodevelopment, with its dysfunction potentially contributing to the onset of mental disorders. In this systematic review and meta-analysis, we aimed to examine the relationship between levels of specific biomarkers of intestinal permeability or inflammation and scores of depressive symptoms or suicidality. Methods: All studies investigating the link between depressive symptoms and/or suicidality and biomarkers associated with intestinal permeability or inflammation were included. Studies providing data for comparisons between two groups-depressive or suicidal patients vs. healthy controls, or suicidal vs. non-suicidal patients-were included in the meta-analysis. Studies examining the correlation between depressive symptoms and biomarker levels were also included into the review. Data were independently extracted and reviewed by multiple observers. A random-effects model was employed for the analysis, and Hedge's g was pooled for the effect size. Heterogeneity was assessed using the I² index. Results: Twenty-two studies provided data for inclusion in the meta-analysis, while nineteen studies investigated the correlation between depressive symptoms and biomarker levels. For depressive symptoms, when compared to the controls, patients showed significantly increased levels of intestinal fatty acid-binding protein (I-FABP) (ES = 0.36; 95% CI = 0.11 to 0.61; p = 0.004; I² = 71.61%), zonulin (ES = 0.69; 95% CI = 0.02 to 1.36; p = 0.044; I² = 92.12%), antibodies against bacterial endotoxins (ES = 0.75; 95% CI = 0.54 to 0.98; p < 0.001; I² = 0.00%), and sCD14 (ES = 0.11; 95% CI = 0.01 to 0.21; p = 0.038; I² = 10.28%). No significant differences were found between the patients and controls in levels of LPS-binding protein (LBP) and alpha-1 antitrypsin (A-1-AT). For suicidality, four studies were identified for quantitative analysis, three of which focused on I-FABP. No significant differences in I-FABP levels were observed between suicidal patients and the controls (ES = 0.24; 95% CI = -0.30 to 0.79; p = 0.378; I² = 86.44%). Studies investigating the correlation between depressive symptoms and levels of intestinal permeability and inflammation biomarkers did not provide conclusive results. Conclusions: A significant difference was observed between patients with depressive symptoms and controls for biomarkers of intestinal permeability (zonulin, which regulates tight junctions), inflammatory response to bacterial endotoxins (antibodies to endotoxins and sCD14-a soluble form of the CD14 protein that modulates inflammation triggered by lipopolysaccharides), and acute intestinal epithelial damage (I-FABP, released upon enterocyte injury). Studies investigating suicidality and related biomarkers were limited in number and scope, preventing definitive conclusions. Overall, these findings suggest that biomarkers of gut permeability represent a promising area for further investigation in both psychiatric and forensic pathology. They may have practical applications, such as supporting diagnostic and therapeutic decision-making in clinical settings and providing pathologists with additional information to help determine the manner of death in forensic investigations.

Keywords: biomarkers; depressive symptoms; dysbiosis; forensic medicine; gut–brain axis; inflammation; intestinal permeability; suicidality.

Figure 1

Summary of systematic review performed according to the preferred reporting items for systematic reviews and meta-analysis guidelines.

Figure 2

Forest plots of the meta-analysis on overall levels of circulating biomarkers in depressive patients vs. controls. Compared to the null value, values to the left indicate higher levels in controls, and values to the right indicate higher levels in patients.

Figure 3

Forest plot of the meta-analysis on overall levels of circulating I-FABP in suicidal patients vs. controls. Compared to the null value, values to the left indicate higher levels in controls, and values to the right indicate higher levels in patients.

Figure 4

Forest plot of the meta-analysis on levels of circulating I-FABP in depressive patients vs. controls according to a moderator analysis for depressive symptom severity. Compared to the null value, values to the left indicate higher levels in controls, and values to the right indicate higher levels in patients.