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Université de Paris, AP-HP, Hôpital Hôtel-Dieu, DMU Psychiatrie et Addictologie, Service de Psychiatrie de l’adulte, INSERM, Institut de Psychiatrie et Neurosciences de Paris, UMR_S1266, Paris, France
Université de Paris, INSERM, U970, Paris Cardiovascular Research Center, Paris, FranceSchool for Cardiovascular Diseases Maastricht and Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
Depression is common in older individuals and is associated with high disability and mortality. A major problem is treatment resistance: >50% of older patients do not respond to current antidepressants. Therefore, new effective interventions for prevention and treatment of depression in older individuals need to be developed, which requires a better understanding of the mechanisms underlying depression. The pathophysiology of depression is multifactorial and complex. Microvascular dysfunction may be an early and targetable mechanism in the development of depression, notably depression that initiates in late life (late-onset depression). Late-onset depression commonly co-occurs with other diseases or syndromes that may share a microvascular origin, including apathy, cognitive impairment, dementia, and stroke. Together, these disabilities may all be part of one large phenotype resulting from global cerebral microvascular dysfunction. In this review, we discuss the pathophysiology of microvascular dysfunction–related late-onset depression, summarize recent epidemiological evidence on the association between cerebral microvascular dysfunction and depression, and indicate potential drivers of cerebral microvascular dysfunction. We also propose the hypothesis that depression may be a manifestation of a larger phenotype of cerebral microvascular dysfunction, highlight potential therapeutic targets and interventions, and give directions for future research.
Depression is a large contributor to global disability in older individuals. Major depression occurs in 2% of adults aged 65 years or older, and its prevalence rises with increasing age. In addition, 10% to 15% of older adults have clinically significant depressive symptoms, even in the absence of major depression (
). Given the aging society, better understanding of the underlying mechanisms of depression in older individuals is required so that more effective prevention and treatment strategies can be developed.
The pathophysiology of late-life depression is multifactorial and complex. Patients with late-life depression are a heterogeneous group, including individuals with late-onset depression, in whom the initial depressive episode occurs after age 60 years, and individuals with early-onset depression who already had a first depressive episode earlier in life (
). Several years ago, it was postulated that cerebrovascular damage may contribute to depression via disruption of brain regions involved in mood regulation (
). This mechanism may be particularly relevant in older individuals without a history of depression (i.e., late-onset depression). Subsequent studies have identified evidence for this vascular depression hypothesis (
) and suggest that vascular depression may be a specific subtype of depression (Table 1). However, these studies mostly focused on late stages of cerebrovascular disease when irreversible brain damage was already evident. For effective interventions, it is crucial to identify mechanisms that can be targeted in an early stage of the disease before irreversible damage occurs.
Table 1Selected Key Terms and Definitions
Terms
Definition and Comments
Depression Heterogeneity
Depression is a highly heterogeneous syndrome driven by varying genetic and neurophysiological mechanisms, which give rise to varying symptom profiles, clinical trajectories, and treatment outcomes. This heterogeneity may be more apparent in late-life depression, because aging-related changes across multiple organ systems may contribute to depression (
) suggested the following criteria for vascular depression: 1) evidence of vascular pathology in elderly subjects with or without cognitive impairment, 2) absence of previous depressive episodes preceding obvious cerebrovascular disease, 3) presence of cerebrovascular risk factors, 4) coincidence of depression with cerebrovascular risk factors, 5) clinical symptoms characteristic of vascular depression (executive dysfunction, decrease in processing speed, and lethargy), and 6) neuroimaging data confirming cerebrovascular disease. However, these diagnostic criteria for vascular depression are, until now, not widely accepted, and vascular depression has not been included in formal psychiatric manuals.
Cerebral Microvascular Function and Dysfunction
Core functions of the cerebral microcirculation, defined as cerebral vessels with a diameter <150 μm (arterioles, capillaries, and venules), are to 1) optimize the delivery of nutrients and removal of waste products in response to variations in neuronal activity, 2) maintain the cerebral interstitial milieu for proper cell function, and 3) decrease and stabilize pulsatile hydrostatic pressure at the level of capillaries (
). Cerebral microvascular dysfunction is defined as an impairment in any of these functions.
Blood-Brain Barrier
A tightly linked monolayer of endothelial cells, together with a basement membrane, astrocyte end feet, and mural cells (pericytes in capillaries and vascular smooth muscle cells in arterioles). The blood-brain barrier separates the circulating blood and brain compartments and strictly regulates blood-to-brain and brain-to-blood transport of solutes to maintain the highly controlled internal milieu of the central nervous system (
). Upon an increase in neuronal activity, astrocytes signal to endothelial cells the paracrine release of vasoactive agents. These signals engage smooth muscle cells and, possibly, pericytes to induce vasodilatation, reduce cerebrovascular resistance, and increase local cerebral blood flow (
Ratio of cerebrospinal fluid albumin to serum albumin level. Albumin originate solely from the systemic circulation and cannot cross an intact blood-brain barrier. An increase in the albumin quotient can, thus, be used as an indirect measure of blood-brain permeability.
Cerebrovascular Reactivity
Change in flow in response to increased neuronal activity (i.e., neurovascular coupling) or a metabolic or vasodilatory stimulus, e.g., increase in partial pressure of carbon dioxide (
Cerebrovascular reactivity measurement in cerebral small vessel disease: Rationale and reproducibility of a protocol for MRI acquisition and image processing.
). This response reflects the ability of the cerebrovasculature, notably, arterioles and capillaries, to dilate in response to increased neuronal metabolic demand and is endothelium-dependent (
We propose that microvascular dysfunction is an early and targetable mechanism in the development of late-onset depression. Late-life depression commonly co-occurs with other syndromes or diseases that may share a microvascular origin, including apathy, cognitive impairment, dementia, and stroke. Together, these disabilities may all be part of one large phenotype resulting from global cerebral microvascular dysfunction.
In this review, we discuss the functions of the cerebral microvasculature and how microvascular dysfunction may contribute to the development of late-onset depression. Cerebral microvascular dysfunction is the overlying construct that includes (or can be defined by) blood-brain barrier leakage, impaired cerebral autoregulation, impaired neurovascular coupling, and disturbed capillary flow patterns (
) (Table 1). We review emerging evidence that cerebral microvascular dysfunction and damage are present in older individuals with depression and are associated with apathy, cognitive dysfunction, and stroke in these individuals. We will also indicate which factors may contribute to cerebral microvascular dysfunction in depression, highlight potential interventions, and give directions for future research.
In discussing these issues, we rely to an important extent on data obtained in humans, because currently, no experimental model exists that approximates the complex underlying mechanisms and heterogeneous manifestations of late-onset depression in patients. However, experimental studies are crucial to understand the individual causative pathways by which impairment of the different functions of the microvasculature can contribute to depressive symptoms. For example, recent basic studies have provided important insights into the role of stress susceptibility and blood-brain barrier leakage in the development of depressive symptoms. These studies suggest that maintenance of blood-brain barrier integrity could represent an approach to develop therapeutic strategies to treat depression. This has been discussed in recent reviews (
). The cerebral microcirculation represents the site of resistance to flow and the surface of exchanges. It is the major component of the blood-brain barrier and has a crucial role in the regulation of cerebral perfusion via control of neurovascular coupling and cerebral autoregulation (Table 1) (
Contribution of Microvascular Dysfunction to Depression
The mechanistic pathways by which microvascular dysfunction may contribute to depression are shown in Figures 1 and 2. Microvascular dysfunction includes increased blood-brain permeability and impaired blood perfusion regulation, with disturbed neurovascular coupling and cerebral autoregulation (
). These impairments can each lead to focal brain injury, which may damage neuronal circuits involved in mood regulation and contribute to clinical depressive symptoms and negatively influence the effect of antidepressants (
Figure 1Detrimental effects of cerebral microvascular dysfunction on the brain. Microvascular dysfunction may include increased blood-brain permeability (A) and impaired blood perfusion regulation, with disturbed neurovascular coupling (B) and impaired cerebral autoregulation (C) (
). Increased blood-brain permeability (A) leads to leakage of inflammatory proteins and cells and other plasma constituents into the perivascular space (
). Neurovascular coupling (B) involves a complex interaction between various cells (i.e., neuronal cells, astrocytes, endothelial cells, pericytes, and smooth muscle cells) and various mediators (
). Dysfunction of each of these components may contribute to disturbed neurovascular coupling. For instance, both endothelial and neuronal dysfunction may lead to lower release of endothelial- or neuronal-derived nitric oxide, leading to impaired vasodilatation (
). Cerebral autoregulation (C) is the ability of the cerebrovasculature to maintain a constant level of global brain perfusion despite varying arterial blood pressure (
). With impaired autoregulation, the normal autoregulation curve that expresses the relationship between cerebral blood flow and mean blood pressure (black curve) in panel (C) may become more linear and steeper, and perfusion may become pressure-dependent (red curve) in panel (C) (
Figure 2Mechanistic pathway by which cerebral microvascular dysfunction may contribute to late-onset depression. Microvascular dysfunction–related increased blood-brain permeability leads to leakage of proteins and other plasma constituents into the perivascular space. This may directly damage neurons and is related to inflammatory and immune responses (
). Cerebral microvascular dysfunction also includes impaired blood flow regulation with impaired cerebral autoregulation and neurovascular coupling and disturbed capillary flow patterns (
). This can result in perfusion deficits, reduced oxygen extraction, and hypoxia. Hypoxia leads to activation of hypoxia-inducible transcription factors, which, in turn, triggers inflammation and expression of matrix metalloproteinases and proangiogenic factors (
). Matrix metalloproteinases damage endothelial tight junctions, contributing to increased blood-brain barrier permeability. Proangiogenetic factors, including vascular endothelial growth factor, also increase the permeability of the blood-brain barrier and stimulate angiogenesis. Angiogenesis is associated with formation of capillaries that are leaky and poorly perfused and that lack pericyte support (
). Via these mechanisms, microvascular dysfunction can lead to local ischemia and hemorrhage and focal brain injury, ultimately leading to disturbed affective and cognitive processing and depression. BBB, blood-brain barrier.
Evidence of Cerebral Microvascular Dysfunction in Depression
A summary of studies in adults on the association between cerebral microvascular function and structure and depression is shown in Table 2, and these studies are discussed in the sections below. Most studies found an association between microvascular dysfunction and depression, although not all results are consistent. Most studies had a case-control design and included relatively small (N < 100) clinical samples of individuals with a current depressive episode.
Table 2Altered Cerebral Microvascular Function and Structure in Individuals With Incident or Prevalent Depression as Compared With Individuals Without Depression: Summary of Findings in Humans
Studies evaluated major depressive disorder according to DSM criteria (24–27,35–42,47–49,53,60–62,64,65), or presence of depressive symptoms based on questionnaires (35,40,44,46,52,53,59). The sample sizes of studies (N) were <50 (26,38,41,42,49,60,61,64,65), 50–100 (24,25,36,37,39,44,62), 100–500 (27,46–48,59), or >500 (35,40,52,53). Study designs included case-control (25–27,36–39,41,42,44,48,49,59–62,64,65) and cross-sectional (24,40) or longitudinal (35,46,52,53) cohorts. Population sources were clinical sample-based (25–27,36–39,41,42,44,46–49,60–62,64,65) and population-based (24,35,40,52,53,59). Studies included older adults (>60 years or older) only (24,35,38,40,42,47–49,53,59–62,64) or also included younger individuals (25–27,36,37,39,41,44,46,52). Of the studies investigating older individuals only, some excluded individuals with a depressive disorder before late life (38,47,48,62,65), whereas others did not (24,35,40,42,49,52,53,59–61,64).
Manifestation of Altered Cerebral Microvascular Function and Structure
Technique(s)
Findings in Individuals With Depression as Compared to Those Without
Increased Blood-Brain Barrier Permeability
Qalb; neuropathology
Increased blood-brain barrier permeability in cross-sectional studies (
Cerebrospinal fluid analysis in affective and schizophrenic spectrum disorders: Identification of subgroups with immune responses and blood-CSF barrier dysfunction.
Brain energy metabolism and blood-brain barrier permeability in depressive patients: Analyses of creatine, creatinine, urate, and albumin in CSF and blood.
), lower cerebral blood flow velocity, an indirect measure of blood flow, was associated with incident depression. No prospective data available on direct measures of cerebral blood flow. Cross-sectional studies (
) found that cerebral small vessel disease features increase the risk of depression. Results are stronger for features in frontal and subcortical regions. Neuropathology studies (
Cerebrospinal fluid analysis in affective and schizophrenic spectrum disorders: Identification of subgroups with immune responses and blood-CSF barrier dysfunction.
Brain energy metabolism and blood-brain barrier permeability in depressive patients: Analyses of creatine, creatinine, urate, and albumin in CSF and blood.
Cerebrospinal fluid analysis in affective and schizophrenic spectrum disorders: Identification of subgroups with immune responses and blood-CSF barrier dysfunction.
Brain energy metabolism and blood-brain barrier permeability in depressive patients: Analyses of creatine, creatinine, urate, and albumin in CSF and blood.
Cerebrospinal fluid analysis in affective and schizophrenic spectrum disorders: Identification of subgroups with immune responses and blood-CSF barrier dysfunction.
Brain energy metabolism and blood-brain barrier permeability in depressive patients: Analyses of creatine, creatinine, urate, and albumin in CSF and blood.
Cerebrospinal fluid analysis in affective and schizophrenic spectrum disorders: Identification of subgroups with immune responses and blood-CSF barrier dysfunction.
Brain energy metabolism and blood-brain barrier permeability in depressive patients: Analyses of creatine, creatinine, urate, and albumin in CSF and blood.
Cerebrospinal fluid analysis in affective and schizophrenic spectrum disorders: Identification of subgroups with immune responses and blood-CSF barrier dysfunction.
Brain energy metabolism and blood-brain barrier permeability in depressive patients: Analyses of creatine, creatinine, urate, and albumin in CSF and blood.
Evidence for the presence of increased blood-brain barrier permeability in depression in humans comes mostly from biochemical studies that assessed the ratio of cerebrospinal fluid albumin to serum albumin level, which is known as the albumin quotient (for explanation of albumin quotient, see Table 1). One case-control study (
) found a higher albumin quotient among older patients with depression than among older individuals without depression. Other studies among patients with depression found a higher albumin quotient in a subset of these patients than previously reported reference values in the general population (
Cerebrospinal fluid analysis in affective and schizophrenic spectrum disorders: Identification of subgroups with immune responses and blood-CSF barrier dysfunction.
Brain energy metabolism and blood-brain barrier permeability in depressive patients: Analyses of creatine, creatinine, urate, and albumin in CSF and blood.
). Additionally, postmortem studies have found evidence of structural alterations of the blood-brain barrier in depression. This includes an increased endothelial expression of intercellular adhesion molecule-1 (
Vascular and extravascular immunoreactivity for intercellular adhesion molecule 1 in the orbitofrontal cortex of subjects with major depression: Age-dependent changes.
). The prefrontal cortex and nucleus accumbens are crucial regions within the brain’s reward circuitry, and their function is impaired in individuals with major depression (
). Reduced expression of claudin-5 has also been found in an animal model of depression, and this was related to greater blood-brain permeability in this model (
Cerebrovascular Reactivity, Cerebral Autoregulation, and Resting Cerebral Blood Flow
Microvascular dysfunction may manifest as disrupted cerebrovascular reactivity (for explanation of cerebrovascular reactivity, see Table 1). One prospective, population-based study showed that lower cerebrovascular reactivity was associated with higher risk of depression in older individuals (
), found lower cerebrovascular reactivity in individuals with depression than in individuals without depression. However, most of these studies measured cerebrovascular reactivity at the level of a large artery with use of Doppler ultrasound, and only some studies (
) measured cerebrovascular reactivity at the tissue level with use of magnetic resonance imaging or single-photon emission computed tomography. The interpretation of vasoreactivity measured in a large artery is difficult because it may reflect the function not only of arterioles and capillaries but also of larger cerebral arteries (
Microvascular dysfunction might also contribute to altered cerebral autoregulation (for explanation of cerebral autoregulation, see Table 1). However, data on cerebral autoregulation in depression are scarce. Altered cerebral autoregulation was identified in a recent small cross-sectional study (
Altered resting cerebral blood flow or blood flow velocity may be another manifestation of cerebral microvascular dysfunction. However, the interpretation of resting cerebral blood flow is complex, because reduced resting cerebral blood flow might be a cause of tissue damage or a consequence (i.e., reflect loss of viable tissue), or both. Lower cerebral blood flow velocity assessed at the level of large cerebral arteries with Doppler ultrasound, which may be related to lower global cerebral perfusion (
Relationship between cerebral blood flow estimated by transcranial Doppler ultrasound and single-photon emission computed tomography in elderly people with dementia.
). In addition, cross-sectional studies in older individuals with depression have found altered global (measured at the level of large arteries) or regional (at the tissue level) cerebral perfusion, independent of cerebral atrophy (
). In one study, regional cerebral perfusion was altered to a greater extent in individuals with late-onset depression (defined in that study as the first onset of the episode after the age of 60 years), compared with individuals with early-onset depression and individuals without any depression, and altered cerebral perfusion was associated with worse cognitive performance in these individuals (
The retina offers a unique opportunity to study microvascular changes in the brain because it allows direct and reproducible visualization of a microvascular bed that shares anatomical and physiological similarities with the cerebral microvasculature (
), both population based, evaluated the association between measures of the retinal microvasculature and incident depressive symptoms, but they had inconsistent findings. One study found that a reduced flicker light–induced retinal arteriolar dilatation response, indicating worse microvascular function, was associated with a higher incidence of depressive symptoms (
). Another study evaluated the association between retinal arteriolar and venular diameters and incident depression but did not find a statistically significant association (
Cerebral microvascular dysfunction can also manifest itself as features of cerebral small vessel disease, which include white matter hyperintensities and lacunes of presumed vascular origin, cerebral microbleeds, perivascular spaces, total cerebral atrophy, and microinfarcts (
). These features are indirect or late-stage markers of small vessel abnormalities because they reflect brain parenchymal damage potentially related to various small vessel changes. Recent meta-analyses (
) have consistently shown that cerebral small vessel disease features are associated with a higher risk of depression. Strongest associations were found for features located in regions involved in mood regulation, i.e., frontal and subcortical brain regions, compared with features in other brain regions (
) on the presence of cerebral small vessel disease in depression have been inconsistent. The results of these studies are, however, difficult to compare because of differences in patient populations, brain regions of interest, and the definitions used of cerebral small vessel disease features.
Contribution of Microvascular Dysfunction to Apathy, Cognitive Dysfunction, and Stroke in Depression
Depression, apathy, cognitive dysfunction, and stroke commonly occur together. Apathy, or diminished motivation, is a common symptom in late-life depression but may also exist independently of depression (
). In addition, late-life depression and apathy increase the risk of decline in any and multiple cognitive domains but most commonly in executive function and processing speed (
Increasing data suggest that the link between late-life depression, apathy, cognitive dysfunction, and stroke can be explained, at least in part, by microvascular dysfunction as a shared underlying mechanism. These disabilities may therefore be manifestations of a larger phenotype of global cerebral microvascular dysfunction. For example, the clustering of depression and executive dysfunction, also described as the depression-executive dysfunction syndrome (
). Recent longitudinal data showed that only individuals with depressive symptoms that increased in late life and no other trajectories of depressive symptoms across the life course had higher white matter hyperintensity volumes (
) in individuals without depression. In addition, presence and progression of cerebral small vessel disease over time, notably, increase in white matter hyperintensity volume and incident lacunar infarcts, have been associated with a higher risk of dementia (
). Microvascular dysfunction has also been reported to be associated with an increased risk of stroke, notably lacunar ischemic stroke and deep hemorrhagic stroke (
IST-3 collaborative group Association between brain imaging signs, early and late outcomes, and response to intravenous alteplase after acute ischaemic stroke in the third International Stroke Trial (IST-3): Secondary analysis of a randomised controlled trial.
Drivers of Microvascular Dysfunction in Depression: Aging, Psychological Stress, Arterial Stiffness and Hypertension, and Type 2 Diabetes and the Metabolic Syndrome
Aging
Aging of the vasculature is an important contributor to cerebral microvascular dysfunction. Aging has been associated with increased blood-brain barrier permeability, lower cerebrovascular reactivity, altered cerebral autoregulation, and reduced cerebral microvascular perfusion (
Chronic stress is major risk factor for depression. For example, the association between objective stress-related environmental risk factors (e.g., neighborhood quality) and increased risk of depressive symptoms in adulthood is well established (
)]. Emerging experimental data suggest that chronic stress also has detrimental effects on the microvasculature, mediated via inflammatory mechanisms, which may contribute to the development of depression (
). Chronic stress mobilizes the innate immune system and stimulates enhanced proliferation and release of inflammatory monocytes and neutrophils into the bloodstream (
). Animal studies have shown that this stress-induced inflammation can alter blood vessel morphology in the brain with discontinuous tight junctions, leading to greater blood-brain permeability (
). Greater blood-brain permeability was associated with depression-like behaviors in these models. For example, in a study of mice undergoing social defeat, a mouse model of chronic stress, it was shown that expression of the tight-junction protein claudin-5 in the blood-brain barrier was reduced in stress-susceptible animals (
). This promoted the passage of interleukin 6 across the blood-brain barrier and induced depressive-like behaviors in these animals. Furthermore, other studies showed that anti-inflammatory therapy was able to reduce stress-induced increases in blood-brain barrier permeability and lower depressive symptoms (
). Stiffening of large arteries impairs their cushioning function and increases blood pressure and flow pulsatility (Figure 3). This increased pulsatile load may transmit distally into the cerebral circulation and thereby contribute to cerebral microvascular damage (
). The microvasculature of the brain is particularly vulnerable because it is characterized by high flow and low impedance, allowing the pulsatile load to penetrate deeply into its microvascular bed (
) showed that greater stiffness of the carotid artery is associated with a higher risk of depressive symptoms. In addition, cross-sectional data from another large study (
Associations between arterial stiffness, depressive symptoms and cerebral small vessel disease: Cross-sectional findings from the AGES-Reykjavik Study.
) showed that the association between greater arterial stiffness and presence of depressive symptoms was in part explained, or mediated, by features of cerebral small vessel disease. In addition, some studies (
), have shown that hypertension is associated with a higher risk of depression in older individuals.
Figure 3Presumed pathway by which arterial stiffness contributes to cerebral microvascular dysfunction and late-onset depression. Stiffening of large arteries impairs their cushioning function and increases pressure and flow pulsatility. This increased load may cause direct microvascular damage and may induce a microvascular remodeling response (
). However, this protective response may ultimately become unfavorable, leading to impaired vasoreactivity and hypoperfusion. In addition, arterial stiffening may cause excessive blood pressure fluctuations that may further sensitize organs to the harmful effects of impaired microvascular vasoreactivity (
Arterial stiffening may also contribute to substantial fluctuations in blood pressure, including orthostatic hypotension and exercise-induced hypertension (
). Greater blood pressure fluctuations may further sensitize the brain to the harmful effects of impaired microvascular-related cerebral autoregulation and vasoreactivity, with cerebral hypoperfusion during hypotension and overexposure to high pulsatility at high pressure (Figure 3). In accordance, studies have shown that orthostatic hypotension (
) are associated with higher risk of depressive symptoms.
Type 2 Diabetes and Metabolic Syndrome
Type 2 diabetes and late-life depression commonly co-occur; individuals with type 2 diabetes have a doubled risk for depression as compared with individuals without type 2 diabetes. Furthermore, individuals with depression have a 1.5 times higher risk of type 2 diabetes (
). The mechanisms underlying the relationship between type 2 diabetes and late-life depression are likely multifactorial and may include psychosocial factors, e.g., diabetes burden and distress, and biological factors, including central insulin resistance (
). Some evidence also suggests that depression in diabetes may be associated with microvascular dysfunction. One cross-sectional study found that individuals with type 2 diabetes and depression had wider retinal arterioles than individuals with type 2 diabetes but without depression (
), consistent with an association between depression and early microvascular changes in diabetes. Moreover, a recent, population-based large study found that individuals with type 2 diabetes had greater increase in depressive symptoms over time, and cerebral small vessel disease partly explained this association (
). Importantly, cerebral microvascular blood flow may be increased in early type 2 diabetes, possibly to compensate for reduced oxygen extraction efficacy related to subtle, or early, microvascular dysfunction, whereas in more advanced stages of the disease, blood flow may be reduced (
). Because of this high flow state in early diabetes, the increased pulsatile load associated with arterial stiffening may penetrate more deeply into the cerebral microvascular bed and contribute to cerebral damage (
). This suggests that individuals with type 2 diabetes may be more vulnerable for the detrimental effects of arterial stiffening on the brain, but this requires further study.
Potential Therapeutic Targets and Interventions
Vascular-related depression is associated with poor response to current antidepressant treatments (
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