Domain specific self-efficacy mediates the impact of pain catastrophizing on pain and disability in overweight and obese osteoarthritis patients

This study examined whether self-efficacy mediated the relationship between pain catastrophizing and pain and disability. Participants were 192 individuals diagnosed with osteoarthritis (OA) of the knees who were overweight or obese. Multiple mediator analyses were conducted to simultaneously test self-efficacy for pain control, physical function, and emotional symptoms as mediators while controlling for demographic and medical status variables. Higher pain catastrophizing was associated with lower self-efficacy in all 3 domains (Ps < .05). Self-efficacy for pain control fully mediated the relationship between pain catastrophizing and pain (beta = .08, Sobel test Z = 1.97, P < .05). The relationship between pain catastrophizing and physical disability was fully mediated by self-efficacy for physical function (beta = .06, Sobel test Z = 1.95, P = .05). Self-efficacy for emotional symptoms partially mediated the relationship between pain catastrophizing and psychological disability (beta = .12, Sobel test Z = 2.92, P < .05). These results indicate that higher pain catastrophizing contributed to greater pain and disability via lower domain-specific self-efficacy. Efforts to reduce pain and improve functioning in OA patients should consider addressing pain catastrophizing and domain specific self-efficacy. Pain catastrophizing may be addressed through cognitive therapy techniques and self-efficacy may be enhanced through practice of relevant skills and personal accomplishments.

PERSPECTIVE

This study found that higher pain catastrophizing contributed to greater pain and disability via domain specific self-efficacy. These results suggest that treatment efforts to reduce pain and improve functioning in OA patients who are overweight or obese should consider addressing both pain catastrophizing and self-efficacy.

Coping and quality of life in patients awaiting lung transplantation

OBJECTIVE

Patients with end-stage lung disease (ESLD) experience significant decrements in quality of life (QOL). Although coping strategies are related to QOL in patients with ESLD, the extent to which specific native lung disease moderates this relationship is unknown.

METHODS

We investigated the relationship between coping, native lung disease, and QOL among 187 patients awaiting lung transplantation, including 139 patients with chronic obstructive pulmonary disease (COPD) and 48 with cystic fibrosis (CF). Participants completed a psychosocial battery assessing psychological QOL, physical QOL, and coping strategies.

RESULTS

For both COPD and CF patients, higher levels of Active Coping (P< .0001) and lower levels of Disengagement (P< .0001) were associated with better psychological QOL. For physical QOL, we observed a Native Disease x Coping interaction (P=.01) such that Active Coping was associated with better physical QOL in patients with COPD but not in patients with CF.

CONCLUSIONS

The relationship between coping and QOL may vary as a function of native lung disease. Patients' native disease may need to be considered in order to develop effective interventions to help patients cope successfully with ESLD.

Depression and five year survival following acute myocardial infarction: a prospective study

Depression has been shown to be a risk factor for mortality during the 12 months following an acute myocardial infarction (MI), but few studies have examined whether it is associated with increased risk over longer periods. Most of the existing studies utilized depression questionnaires rather than diagnostic interviews, the gold standard for clinical depression diagnosis. The purpose of this study was to determine whether interview-diagnosed clinical depression affects survival for at least 5 years after an acute MI. Vital status was determined for 163 patients with major depression, 195 with minor depression or dysthymia, and 408 nondepressed patients, during a median follow-up period of 60 months after an acute MI. Survival analysis was used to model time from the index MI to death. There were 106 deaths during the follow-up. After adjusting for other risk factors for mortality, patients with either major or minor depression (HR=1.76; 95% CI: 1.19 to 2.60), major depression alone (HR=1.87; 95% CI: 1.17 to 2.98), or minor depression alone (HR=1.67; 95% CI: 1.06 to 2.64) were at higher risk for all-cause mortality compared to the nondepressed patients. Depression is an independent risk factor for death 5 years after an acute MI. Even minor depression is associated with an increased risk. Although it is not known whether treating depression can improve survival, patients with depression should be recognized as being at increased risk long after their acute MI.

Understanding prognostic benefits of exercise and antidepressant therapy for persons with depression and heart disease: the UPBEAT study--rationale, design, and methodological issues

BACKGROUND

Depression is relatively common in patients with coronary heart disease (CHD) and is associated with worse prognosis. Recently there has been interest in evaluating the impact of treating depression on clinical outcomes. Anti-depressant medications have been shown to be safe and efficacious for many patients; exercise also may be effective for treating depression and may also improve cardiopulmonary functioning. However, methodological limitations of previous studies have raised questions about the value of exercise, and no study has compared the effects of exercise with standard anti-depressant medication in depressed cardiac patients.

PURPOSE

UPBEAT is a randomized clinical trial (RCT) funded by NHLBI to evaluate the effects of sertraline or exercise compared to placebo on depression and biomarkers of cardiovascular risk in patients with CHD and elevated depressive symptoms.

METHODS

The UPBEAT study includes 200 stable CHD patients with scores on the Beck Depression Inventory (BDI) > or =9 randomized to 4 months of treatment with aerobic exercise, sertraline, or placebo. The primary outcomes include depressive symptoms determined by clinical ratings on the Hamilton Rating Scale for Depression (HAM-D) and measures of heart rate variability (HRV), baroreflex control (BRC), vascular function (i.e., flow-mediated dilation (FMD)), and measures of inflammation and platelet aggregation.

RESULTS

This article reviews the rationale and design of UPBEAT and addresses several key methodologic issues that were carefully considered in the development of this protocol: the use of a placebo control condition in depressed cardiac patients, study design, and selection of intermediate endpoints or biomarkers of cardiovascular risk.

LIMITATIONS

This study is not powered to assess treatment group differences in CHD morbidity and mortality. Intermediate endpoints are not equivalent to 'hard' clinical events and further studies are needed to determine the clinical significance of these biomarkers.

CONCLUSIONS

The UPBEAT study is designed to assess the efficacy of exercise in treating depression in cardiac patients and evaluates the impact of treating depression on important biomarkers of cardiovascular risk.

Laboratory-based blood pressure recovery is a predictor of ambulatory blood pressure

The recovery phase of the stress response is an individual difference characteristic that may predict cardiovascular risk. The purpose of this study was to examine whether laboratory-based blood pressure (BP) recovery predicts ambulatory BP (ABP). One hundred and eighty-two participants underwent a standard laboratory stress protocol, involving a 20-min baseline rest period, and four stressors presented in a counterbalanced order, each followed by a 10-min recovery period. Participants also wore an ABP monitor for 24h during a typical workday. Hierarchical regression analyses showed that BP recovery accounted for significant additional variance for daytime SBP (p<0.001), nighttime SBP (p<0.001), daytime DBP (p<0.001), and nighttime DBP (p<0.001), after controlling for baseline and reactivity BP. Results suggest that persistence of the BP response following stress may be a more salient characteristic of the stress response in understanding its potential impact on longer term cardiovascular regulation.

Effects of exercise and weight loss on depressive symptoms among men and women with hypertension

OBJECTIVE

This study aimed to investigate changes in depressive symptoms in hypertensive individuals participating in an exercise and weight loss intervention.

METHODS

This study involved 133 sedentary men and women with high blood pressure (BP; 130-180 mmHg systolic BP and/or 85-110 mmHg diastolic BP) who participated in a 6-month intervention consisting of three groups: aerobic exercise, aerobic exercise and weight loss, and a waiting list control.

RESULTS

Participants in both treatment groups demonstrated significant improvements in aerobic capacity and lower BP compared with participants in the control group. Participants in the active treatment groups who had mild to moderate depressive symptoms at baseline also exhibited greater reductions in depressive symptoms compared with participants in the control group.

CONCLUSION

Results from the present study suggest that exercise, alone or combined with weight management, may reduce self-reported depressive symptoms among patients with hypertension.

Effects of extreme hemodilution during cardiac surgery on cognitive function in the elderly

BACKGROUND

Strategies for neuroprotection including hypothermia and hemodilution have been routinely practiced since the inception of cardiopulmonary bypass. Yet postoperative neurocognitive deficits that diminish the quality of life of cardiac surgery patients are frequent. Because there is uncertainty regarding the impact of hemodilution on perioperative organ function, the authors hypothesized that extreme hemodilution during cardiac surgery would increase the frequency and severity of postoperative neurocognitive deficits.

METHODS

Patients undergoing coronary artery bypass grafting surgery were randomly assigned to either moderate hemodilution (hematocrit on cardiopulmonary bypass >or=27%) or profound hemodilution (hematocrit on cardiopulmonary bypass of 15-18%). Cognitive function was measured preoperatively and 6 weeks postoperatively. The effect of hemodilution on postoperative cognition was tested using multivariable modeling accounting for age, years of education, and baseline levels of cognition.

RESULTS

After randomization of 108 patients, the trial was terminated by the Data Safety and Monitoring Board due to the significant occurrence of adverse events, which primarily involved pulmonary complications in the moderate hemodilution group. Multivariable analysis revealed an interaction between hemodilution and age wherein older patients in the profound hemodilution group experienced greater neurocognitive decline (P = 0.03).

CONCLUSIONS

In this prospective, randomized study of hemodilution during cardiac surgery with cardiopulmonary bypass in adults, the authors report an early termination of the study because of an increase in adverse events. They also observed greater neurocognitive impairment among older patients receiving extreme hemodilution.

Arthritis self-efficacy and self-efficacy for resisting eating: relationships to pain, disability, and eating behavior in overweight and obese individuals with osteoarthritic knee pain

This study examined arthritis self-efficacy and self-efficacy for resisting eating as predictors of pain, disability, and eating behaviors in overweight or obese patients with osteoarthritis (OA) of the knee. Patients (N=174) with a body mass index between 25 and 42 completed measures of arthritis-related self-efficacy, weight-related self-efficacy, pain, physical disability, psychological disability, overeating, and demographic and medical information. Hierarchical linear regression analyses were conducted to examine whether arthritis self-efficacy (efficacy for pain control, physical function, and other symptoms) and self-efficacy for resisting eating accounted for significant variance in pain, disability, and eating behaviors after controlling for demographic and medical characteristics. Analyses also tested whether the contributions of self-efficacy were domain specific. Results showed that self-efficacy for pain accounted for 14% (p=.01) of the variance in pain, compared to only 3% accounted for by self-efficacy for physical function and other symptoms. Self-efficacy for physical function accounted for 10% (p=.001) of the variance in physical disability, while self-efficacy for pain and other symptoms accounted for 3%. Self-efficacy for other (emotional) symptoms and resisting eating accounted for 21% (p<.05) of the variance in psychological disability, while self-efficacy for pain control and physical function were not significant predictors. Self-efficacy for resisting eating accounted for 28% (p=.001) of the variance in eating behaviors. Findings indicate that self-efficacy is important in understanding pain and behavioral adjustment in overweight or obese OA patients. Moreover, the contributions of self-efficacy were domain specific. Interventions targeting both arthritis self-efficacy and self-efficacy for resisting eating may be helpful in this population.

Social support and prognosis in patients at increased psychosocial risk recovering from myocardial infarction

OBJECTIVE

To compare the impact of network support and different types of perceived functional support on all-cause mortality or nonfatal reinfarction for patients with a recent acute myocardial infarction (AMI).

DESIGN

Participants were recruited from the Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial; 2,481 AMI patients with depression or low social support were randomized to a cognitive-behavioral intervention or to a usual care control group. Data collection for certain measures of social support was limited: 2,466 participants completed the ENRICHD Social Support Inventory; 2,457 completed the Perceived Social Support Scale; 1,296 completed the Social Network Questionnaire; and 707 completed the Interpersonal Support and Evaluation List, Tangible Support subscale. Patients also completed the Beck Depression Inventory and were followed for up to 4.5 years.

MAIN OUTCOME MEASURE

Time to death or nonfatal reinfarction.

RESULTS

Over the follow-up period, 599 patients (24%) died or had a nonfatal AMI. Survival models controlling age, sex, race, socioeconomic status, smoking, antidepressant use, and a composite measure of increased risk revealed that higher levels of perceived social support were associated with improved outcome for patients without elevated depression but not for patients with high levels of depression. Neither perceived tangible support nor network support were associated with more frequent adverse events.

CONCLUSION

AMI patients should be assessed for multiple dimensions of perceived functional support and depression to identify those at increased psychosocial risk who may benefit from treatment.

Spirituality, religion, and clinical outcomes in patients recovering from an acute myocardial infarction

OBJECTIVE

To assess the prospective relationship between spiritual experiences and health in a sample of patients surviving an acute myocardial infarction (AMI) with depression or low social support.

METHODS

A subset of 503 patients participating in the enhancing recovery in coronary heart disease (ENRICHD) trial completed a Daily Spiritual Experiences (DSE) questionnaire within 28 days from the time of their AMI. The questionnaire assessed three spirituality variables-worship service/church attendance, prayer/meditation, and total DSE score. Patients also completed the Beck Depression Inventory to assess depressive symptoms and the ENRICHD Social Support Inventory to determine perceived social support. The sample was subsequently followed prospectively every 6 months for an average of 18 months to assess all-cause mortality and recurrent AMI.

RESULTS

Of the 503 participants who completed the DSE questionnaire at the time of index AMI, 61 (12%) participants either died or sustained a recurrent MI during the follow-up period. After adjustment for gender, education level, ethnicity, and a composite medical prognosis risk score derived specifically for the ENRICHD trial, we observed no relationship between death or nonfatal AMI and total spirituality as measured by the DSE (p = .446), worship service attendance (p = .120), or frequency of prayer/meditation (p = .679).

CONCLUSION

We found little evidence that self-reported spirituality, frequency of church attendance, or frequency of prayer is associated with cardiac morbidity or all-cause mortality post AMI in patients with depression and/or low perceived support.

Age moderates the short-term effects of transdermal 17beta-estradiol on endothelium-dependent vascular function in postmenopausal women

OBJECTIVE

We evaluated age and coronary heart disease (CHD) as potential moderators of the effects of 17beta-estradiol on vascular endothelial function in postmenopausal women.

METHODS AND RESULTS

In a double-blind crossover design, 100 postmenopausal women aged 50 to 80 years were randomized to each of 3 transdermal patches, releasing 17beta-estradiol (0.05 mg/d), 17beta-estradiol (0.05 mg/d) + norethindrone acetate (NETA, 0.14 mg/d), and placebo. Flow-mediated dilation (FMD) and response to 400 microg sublingual glyceryl trinitrate (GTN-D) were assessed approximately 18 hours after patch placement. Age, but not CHD, moderated the FMD response to treatment (P=0.01). For women in their fifties, the estradiol patch was associated with improved FMD (7.69+/-4.79%) compared with placebo (4.81+/-5.97%, P<0.05), but the estradiol+norethindrone patch response (5.81+/-4.85%) was not significantly different from placebo. Women in their sixties and seventies showed no alterations in FMD response to either active patch. GTN-D response declined with advancing age (P<0.01), with women in their seventies exhibiting blunted GTN-D response compared with younger women.

CONCLUSIONS

The cardiovascular benefits of natural estrogen supplementation on vascular endothelial function may be dependent on postmenopausal age, with improved vascular function evident only in the early postmenopausal years. Short-term FMD response to estradiol might help stratify individual differences in risks versus benefits of HRT.

Genetic Variants in P-Selectin and C-Reactive Protein Influence Susceptibility to Cognitive Decline After Cardiac Surgery

OBJECTIVES

We hypothesized that candidate gene polymorphisms in biologic pathways regulating inflammation, cell matrix adhesion/interaction, coagulation-thrombosis, lipid metabolism, and vascular reactivity are associated with postoperative cognitive deficit (POCD).

BACKGROUND

Cognitive decline is a common complication of coronary artery bypass graft (CABG) surgery and is associated with a reduced quality of life.

METHODS

In a prospective cohort study of 513 patients (86% European American) undergoing CABG surgery with cardiopulmonary bypass, a panel of 37 single-nucleotide polymorphisms (SNPs) was genotyped by mass spectrometry. Association between these SNPs and cognitive deficit at 6 weeks after surgery was tested using multiple logistic regression accounting for age, level of education, baseline cognition, and population structure. Permutation analysis was used to account for multiple testing.

RESULTS

We found that minor alleles of the CRP 1059G/C SNP (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.16 to 0.78; p = 0.013) and the SELP 1087G/A SNP (OR 0.51, 95% CI 0.30 to 0.85; p = 0.011) were associated with a reduction in cognitive deficit in European Americans (n = 443). The absolute risk reduction in the observed incidence of POCD was 20.6% for carriers of the CRP 1059C allele and 15.2% for carriers of the SELP 1087A allele. Perioperative serum C-reactive protein (CRP) and degree of platelet activation were also significantly lower in patients with a copy of the minor alleles, providing biologic support for the observed allelic association.

CONCLUSIONS

The results suggest a contribution of P-selectin and CRP genes in modulating susceptibility to cognitive decline after cardiac surgery, with potential implications for identifying populations at risk who might benefit from targeted perioperative antiinflammatory strategies.

Relationship of Depression to Death or Hospitalization in Patients With Heart Failure

BACKGROUND

Depression is widely recognized as a risk factor in patients with coronary heart disease. However, patients with heart failure (HF) have been less frequently studied, and the effect of depression on prognosis, independent of disease severity, is uncertain.

METHODS

Two hundred four outpatients having a diagnosis of HF, with a ventricular ejection fraction of 40% or less, underwent baseline assessments including evaluation of depressive symptoms using the Beck Depression Inventory and of HF severity determined by plasma N-terminal pro-B-type natriuretic peptide. Cox proportional hazards regression analyses were used to examine the effects of depressive symptoms on a combined primary end point of death and hospitalizations because of cardiovascular disease (hereafter referred to as cardiovascular hospitalization) during a median follow-up of 3 years.

RESULTS

Symptoms of depression (Beck Depression Inventory score) were associated with risk of death or cardiovascular hospitalization (P<.001) after controlling for established risk factors including HF disease severity, ejection fraction, HF etiology, age, and medications. Clinically significant symptoms of depression (Beck Depression Inventory score >/=10) were associated with a hazard ratio of 1.56 (95% confidence interval, 1.07-2.29) for the combined end point of death or cardiovascular hospitalization. Contrary to our expectation, antidepressant medication use was associated with increased likelihood of death or cardiovascular hospitalization (hazard ratio, 1.75; 95% confidence interval,1.14-2.68, P =.01) after controlling for severity of depressive symptoms and for established risk factors.

CONCLUSIONS

Symptoms of depression were associated with an adverse prognosis in patients with HF after controlling for HF severity. The unexpected association of antidepressant medications with worse clinical outcome suggests that patients with HF requiring an antidepressant medication may need to be monitored more closely.

Heart failure and a controlled trial investigating outcomes of exercise training (HF-ACTION): design and rationale

BACKGROUND

Although there are limited clinical data to support the use of exercise training as a means to reduce mortality and morbidity in patients with heart failure, current guidelines state that exercise is beneficial.

TRIAL DESIGN

The objective of this trial is to determine whether exercise training reduces all-cause mortality or all-cause hospitalization for patients with left ventricular systolic dysfunction and heart failure symptoms. After undergoing baseline assessments to determine whether they can safely exercise, patients are randomized to either usual care or exercise training. Patients in the exercise training arm attend 36 supervised facility-based exercise training sessions. Exercise modalities are cycling or walking. After completing 18 sessions, patients initiate home-based exercise and then transition to solely home-based exercise after completing all 36 sessions. Patients return for facility-based training every 3 months to reinforce their exercise training program. Patients are followed for up to 4 years. Physiologic, quality-of-life, and economic end points that characterize the effect of exercise training in this patient population will be measured at baseline and at intervals throughout the trial. Blood samples will be collected to examine biomarkers such as brain natriuretic peptide, tumor necrosis factor, and C-reactive protein.

CONCLUSIONS

Because of its relatively low cost, high availability, and ease of use, exercise training is an intervention that could be accessible to most patients with heart failure. The HF-ACTION trial is designed to definitively assess the effect of exercise training on the clinically relevant end points of mortality, hospitalization, and quality of life in patients with heart failure.

Donepezil for cognitive decline following coronary artery bypass surgery: a pilot randomized controlled trial

OBJECTIVE

To study the effect of donepezil in treating patients with cognitive decline following coronary artery bypass graft (CABG) surgery.

METHODS

Forty-four patients, with at least a 0.5 SD decline at 1 year post-CABG on at least one cognitive domain compared to their pre-CABG baseline score, were randomized to treatment with donepezil (titrated to 10 mg daily) or placebo in a 12-week double-blind, single center, randomized study. A composite cognitive change score served as the primary outcome. Secondary outcome measures included tests of memory, attention, psychomotor speed, and executive function.

RESULTS

The composite cognitive outcome did not show significant treatment effects. Secondary measures varied in their sensitivity to donepezil effects with the largest effects seen on the Wechsler Visual Memory Scale-Delayed and Immediate recall tests. More than twice (52% vs. 22%) as many donepezil-treated patients showed a significant improvement compared with placebo patients on Delayed recall. Tests with weak effect sizes and minimal trends favoring donepezil were the Boston Naming and Digit Symbol. However, most of the other instruments (e.g., Digit Span, Trails B, and Controlled Word Association) showed no treatment benefits. More donepezil-treated than placebo-treated patients experienced diarrhea, but other adverse effects and safety measures did not differ between groups.

CONCLUSION

In the post-CABG mild cognitive decline setting, donepezil did not improve composite cognitive performance but improved some aspects of memory. Donepezil was well tolerated and had no significant effects on EKG parameters. Because of limitations such as small sample size and multiplicity of tests, these findings are preliminary but add to our knowledge of cholinergic effects in vascular mild cognitive decline.

Ventricular ectopy: impact of self-reported stress after myocardial infarction

BACKGROUND

Although psychologic stress has been implicated in the pathogenesis of ventricular arrhythmias, the relationship between self-reported stress and ventricular ectopy has not been evaluated under naturalistic conditions in acute post-myocardial infarction (MI) patients, a group at elevated risk for arrhythmias.

MATERIALS AND METHODS

Diary-reported stress was measured during 24-hour Holter monitoring in 80 patients (52 men and 28 women) approximately 12 weeks after their MI. In addition, state and trait anxiety were measured using the Spielberger State and Trait Anxiety Inventory, which was administered at the beginning of the 24-hour Holter monitoring session. The relationships between diary-reported stress, anxiety, and ventricular ectopy were evaluated.

RESULTS

Mean diary-reported stress was associated with total ventricular ectopy (beta = .29, P = .01). State anxiety was also associated with 24-hour ectopy (beta = .24, P = .04); however, trait anxiety was not significantly associated with ectopy. Temporal analyses of the relationship between stress and ectopy showed that diary-reported stress was associated with an increase in the number of ventricular premature beats occurring in the following hour (beta = .74, P < .0001).

CONCLUSIONS

These findings extend existing evidence linking psychologic factors to ventricular arrhythmias by demonstrating that psychologic stress predicts increased arrhythmic activity during routine daily activities in post-MI patients.

Cerebrovascular risk factors, vascular disease, and neuropsychological outcomes in adults with major depression

OBJECTIVE

To investigate the relationship of cerebrovascular risk factors (CVRFs), endothelial function, carotid artery intima medial thickness (IMT), and neuropsychological performance in a sample of 198 middle-aged and older individuals with major depressive disorder (MDD). Neuropsychological deficits are common among adults with MDD, particularly among those with CVRFs and potentially persons with subclinical vascular disease.

METHODS

CVRFs were indexed by the Framingham Stroke Risk Profile (FSRP) and serum cholesterol levels obtained by medical history and physical examination. Patients completed a neuropsychological test battery including measures of executive functioning, working memory, and verbal recall. Vascular function was indexed by carotid artery IMT and brachial artery flow mediated dilation (FMD). Hierarchical multiple regression analyses were used to investigate the association between CVRFs, vascular disease, and neurocognitive performance.

RESULTS

Greater FSRP scores were associated with poorer executive functioning (b = -0.86; p = .041) and working memory (b = -0.90; p = .024). Lower high-density lipoprotein levels also were associated with poorer executive functioning (b = 1.03; p = .035). Higher IMT (b = -0.83; p = .028) and lower FMD (b = 1.29; p = .032) were associated with poorer executive functioning after controlling for CVRFs. Lower FMD was also associated with poorer working memory (b = 1.58; p = .015).

CONCLUSIONS

Greater CVRFs were associated with poorer neuropsychological performance. Vascular dysfunction also was associated with neuropsychological decrements independent of traditional CVRFs.

Exercise and pharmacotherapy in the treatment of major depressive disorder

OBJECTIVE

To assess whether patients receiving aerobic exercise training performed either at home or in a supervised group setting achieve reductions in depression comparable to standard antidepressant medication (sertraline) and greater reductions in depression compared to placebo controls.

METHODS

Between October 2000 and November 2005, we performed a prospective, randomized controlled trial (SMILE study) with allocation concealment and blinded outcome assessment in a tertiary care teaching hospital. A total of 202 adults (153 women; 49 men) diagnosed with major depression were assigned randomly to one of four conditions: supervised exercise in a group setting; home-based exercise; antidepressant medication (sertraline, 50-200 mg daily); or placebo pill for 16 weeks. Patients underwent the structured clinical interview for depression and completed the Hamilton Depression Rating Scale (HAM-D).

RESULTS

After 4 months of treatment, 41% of the participants achieved remission, defined as no longer meeting the criteria for major depressive disorder (MDD) and a HAM-D score of <8. Patients receiving active treatments tended to have higher remission rates than the placebo controls: supervised exercise = 45%; home-based exercise = 40%; medication = 47%; placebo = 31% (p = .057). All treatment groups had lower HAM-D scores after treatment; scores for the active treatment groups were not significantly different from the placebo group (p = .23).

CONCLUSIONS

The efficacy of exercise in patients seems generally comparable with patients receiving antidepressant medication and both tend to be better than the placebo in patients with MDD. Placebo response rates were high, suggesting that a considerable portion of the therapeutic response is determined by patient expectations, ongoing symptom monitoring, attention, and other nonspecific factors.

Heart rate turbulence, depression, and survival after acute myocardial infarction

OBJECTIVE

Depression is a risk factor for mortality after acute myocardial infarction (AMI), possibly as a result of altered autonomic nervous system (ANS) modulation of heart rate (HR) and rhythm. The purposes of this study were to determine: a) whether depressed patients are more likely to have an abnormal HR response (i.e., abnormal turbulence) to premature ventricular contractions (VPCs), and b) whether abnormal HR turbulence accounts for the effect of depression on increased mortality after AMI.

METHODS

Ambulatory electrocardiographic data were obtained from 666 (316 depressed, 350 nondepressed) patients with a recent AMI; 498 had VPCs with measurable HR turbulence. Of these, 260 had normal, 152 had equivocal, and 86 had abnormal HR turbulence. Patients were followed for up to 30 (median = 24) months.

RESULTS

Depressed patients were more likely to have abnormal HR turbulence (risk factor adjusted odds ratio = 1.8; 95% confidence interval [CI] = 1.0-3.0; p = .03) and have worse survival (odds ratio = 2.4; 95% CI = 1.2-4.6; p = .02) than nondepressed patients. When HR turbulence was added to the model, the adjusted hazard ratio for depression decreased to 1.9 (95% CI = 0.9-3.8; p = .08), and to 1.6 (95% CI = 0.8-3.4; p = .18) when a measure of HR variability (LnVLF) was added. The hazard was found to differ over time with depression posing little risk for mortality in year 1 but greater risk in years 2 and 3 of the follow up.

CONCLUSION

ANS dysregulation may partially mediate the increased risk for mortality in depressed patients with frequent VPCs after an AMI.

Association between hot flashes, sleep complaints, and psychological functioning among healthy menopausal women

Self-report data suggest that sleep hot flashes among menopausal women are associated with sleep problems and in turn impaired psychological functioning. However, few studies have examined these relations with physiologic hot flash measures. A total of 41 perimenopausal and postmenopausal women with daily hot flashes underwent nighttime sternal skin conductance monitoring to quantify hot flashes. Participants completed sleep diaries; the Sleep-Wake Experience List (van Diest, 1990); and depression, anxiety, and daily stress measures. Participants experienced a median of 2 physiologically monitored and 1 reported sleep hot flash nightly. Although sleep complaints were significantly and positively associated with psychological functioning, neither sleep complaints nor psychological functioning was significantly related to frequency of physiologically monitored sleep hot flashes. Conversely, results indicate an association between reported sleep hot flashes and acute sleep problems. The frequency of physiologically monitored sleep hot flashes, as opposed to reported sleep hot flashes, may be independent of problems with sleep and mood among menopausal women.

Telephone-based coping skills training for patients awaiting lung transplantation

Impaired quality of life is associated with increased mortality in patients with advanced lung disease. Using a randomized controlled trial with allocation concealment and blinded outcome assessment at 2 tertiary care teaching hospitals, the authors randomly assigned 328 patients with end-stage lung disease awaiting lung transplantation to 12 weeks of telephone-based coping skills training (CST) or to usual medical care (UMC). Patients completed a battery of quality of life instruments and were followed for up to 3.4 years to assess all-cause mortality. Compared with UMC, CST produced lower scores on perceived stress, anxiety, depressive symptoms, and negative affect and improved scores on mental health functioning, optimism, vitality, and perceived social support. There were 29 deaths (9%) over a mean follow-up period of 1.1 year. Survival analyses revealed that there was no difference in survival between the 2 groups. The authors conclude that a telephone-based CST intervention can be effectively delivered to patients awaiting lung transplantation. Despite the severity of pulmonary disease in this patient population, significant improvements in quality of life, but not somatic measures or survival to transplant, were achieved.

Phobic anxiety, depression, and risk of ventricular arrhythmias in patients with coronary heart disease

OBJECTIVE

Findings of an association between phobic anxiety and elevated risks of sudden cardiac death suggest that phobic anxiety may be related to increased risk of ventricular arrhythmias. The purpose of this study was to examine whether phobic anxiety is associated with ventricular arrhythmias in patients with documented coronary artery disease (CAD).

METHODS

Phobic anxiety level was measured using the Crown-Crisp phobic anxiety scale in 940 patients (660 men, 280 women) hospitalized for diagnostic cardiac catheterization between April 1999 and June 2002. Depressive symptomatology was assessed using the Beck Depression Inventory. Patients were followed for a median follow-up period of 3 years, and the occurrence of ventricular arrhythmias was determined through review of medical records.

RESULTS

Ventricular arrhythmias occurred in 97 patients and were significantly related to higher phobic anxiety after statistical adjustment for established medical and demographic determinants of arrhythmias (odds ratio = 1.40; p = .012). Depressive symptomatology was significantly correlated with phobic anxiety (r = 0.44, p < .001) and was also related to ventricular arrhythmias (odds ratio = 1.40; p = .006). The composite of depression and phobic anxiety predicted ventricular arrhythmias with a larger effect size than either depression or phobic anxiety score alone (odds ratio = 1.6, 95% confidence interval, 1.2-2.1, p = .002).

CONCLUSIONS

Both phobic anxiety and depressive symptomatology predict ventricular arrhythmias in patients with CAD and may share a common factor predictive of ventricular arrhythmias.

Central nervous system injury associated with cardiac surgery

Millions of individuals with coronary artery or valvular heart disease have been given a new chance at life by heart surgery, but the potential for neurological injury is an Achilles heel. Technological advancements and innovations in surgical and anaesthetic technique have allowed us to offer surgical treatment to patients at the extremes of age and infirmity-the group at greatest risk for neurological injury. Neurocognitive dysfunction is a complication of cardiac surgery that can restrict the improved quality of life that patients usually experience after heart surgery. With a broader understanding of the frequency and effects of neurological injury from cardiac surgery and its implications for patients in both the short term and the long term, we should be able to give personalised treatments and thus preserve both their quantity and quality of life. We describe these issues and the controversies that merit continued investigation.