Comorbid Depression is Associated with Increased Major Adverse Limb Events in Peripheral Arterial Disease: A systematic review and meta-analysis

Improving Depression Detection and Measuring Its Impact upon Short-Term Survival in Chronic Limb-Threatening Ischemia

BACKGROUND

Depression is underdiagnosed in chronic limb-threatening ischemia (CLTI) patients, and its impact on outcomes is unclear. This study aims to evaluate a CLTI-specific questionnaire designed to detect depression and anxiety, as well as to quantify its impact on early outcomes.

METHODS

A serial cross-sectional study was conducted over the following 2 4-month periods: block I, which retrospectively examined depression prevalence based on medical records, and block II, which prospectively assessed depression using a CLTI-specific questionnaire. Patients were followed for 6 months to assess early outcomes. Data on demographics; comorbidities; wound, ischemia, foot infection (WIfI) grades; perioperative and 6-month limb salvage; and survival were collected and analyzed.

RESULTS

We evaluated 101 CLTI patients (58 in block I; 43 in block II; median age 68 years [interquartile range 62-74]; 67 [66.3%] male). In block I and block II, 20.7% and 23.3% (P = 0.76), respectively, had a prior depression diagnosis. The CLTI-specific questionnaire in block II showed a median depression score of 22 (interquartile range 19-33), identifying 32.6% with moderate/severe depression and 11.9% more patients compared to chart review alone. Active smoking (hazard ratio 5.16, 95% confidence interval 1.9-14.1) and WIfI clinical stage 4 (hazard ratio 4.69, 95% confidence interval 1.39-15.75) were significantly associated with depression. At 6 months, patients with depression had higher rates of major amputation (18.2% vs. 4.0%; P = 0.02) and mortality (27.3% vs. 6.3%; P < 0.01).

CONCLUSIONS

The overall prevalence of depression in CLTI patients is 32.6%. Our novel CLTI-specific questionnaire detects 12% more cases of moderate/severe depression compared to chart review alone. Depression was linked to higher 6-month mortality, though confounders like smoking and WIfI stage 4 may contribute. Identifying and treating depression in high-risk CLTI patients could improve outcomes.

Patients undergoing major amputation for peripheral arterial disease are at high risk for developing major depressive disorder and requiring long-term antidepressants

OBJECTIVE

Amputation is an undesirable outcome of severe peripheral artery disease (PAD), which affects both the mobility and broader lifestyle of the patient. Prior studies have shown that lower extremity amputation is associated with increased risk of developing depression in the postoperative period. However, these studies are primarily single-center studies, confined to specific populations, or do not include analysis over various timepoints. The objective of this study was to assess the association between lower extremity amputation level, level of amputation, and postoperative development of depression. This information will allow vascular surgeons to identify patients who are at a high risk for the development of depression after amputation and make the necessary psychiatric referrals.

METHODS

A total of 48,568 adult patients who underwent PAD-related lower extremity amputation were identified from the TriNetX Research database following exclusion of those with preoperative depression or use of antidepressants. Propensity score matching was used to develop comparable major amputation (above- and below-knee amputations) (I) and minor amputation cohorts (toe and foot amputations) (II), yielding two groups each with 14,853 patients. Primary outcomes included postoperative diagnosis of major depressive disorder (MDD), prescription of antidepressants, and mortality. Outcomes were analyzed at 6-month and 1-year timepoints.

RESULTS

Analysis at 6 months demonstrated that major amputation was associated with a higher risk of developing MDD (6.3% vs 4.6%; P value < .001) and requiring antidepressants (26.8% vs 15.8%; P value < .001) when compared with minor amputation. At 1 year, the incidence of MDD, antidepressant prescriptions, and mortality was 7.7% vs 6.4% (P < .001), 28.6% vs 18.5% (P < .001), and 20.7% vs 12% (P < .001), respectively. Additionally, the 1-year mortality rate was 10.8% vs 21.5% vs 20.7% for the Minor, Minor Followed by Major, and Major amputation groups, respectively. The incidence of MDD diagnosis and antidepressant prescriptions was 5.8% vs 11.4% vs 7.7% (P < .001) and 16.9% vs 32% vs 28.6% (P < .001), for the Minor, Minor Followed by Major and Major amputation groups, respectively.

CONCLUSIONS

The prevalence of MDD and antidepressant medication requirements increases over time in the postoperative period for both major and minor amputees. Patients who underwent major amputations and major amputations after minor amputations were more likely to experience postoperative MDD and require antidepressant prescriptions than patients who underwent minor amputation alone. This suggests that vascular surgeons should understand the high incidence of depression in patients undergoing major amputations and should have a low threshold for referral of major amputees to psychiatric experts in the postoperative period.

Examining Psychological Factors in Peripheral Artery Disease: Affective Temperament, Anxiety, and Depression in Patients Undergoing Revascularization Procedures

Purpose

This study aimed to assess the prevalence of depressive and anxiety symptoms in peripheral artery disease (PAD) patients, correlating these symptoms with clinical parameters and examining affective temperaments within the study group.

Material and Methods

A total of 159 PAD patients, predominantly male, admitted for vascular surgery due to lower limb atherosclerosis, participated in this cross-sectional study. Various assessments were conducted, including the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A) for affective temperaments, the Hospital Anxiety and Depression Scale (HADS) for anxiety and depression symptoms, and the Numerical Rating Scale (NRS) for pain intensity. Additionally, the Ankle-Brachial Index (ABI) was measured to assess circulation in the legs.

Results

The findings revealed a higher prevalence of depressive and anxiety symptoms in the PAD patient group compared to the control group. Notably, depressive and anxiety symptoms correlated with the severity of PAD, as indicated by lower ABI values in the operated leg. Patients undergoing surgical revascularizations exhibited higher depressive symptoms than those undergoing endovascular procedures. Furthermore, correlations were observed between depressive symptoms and the number of previous vascular procedures and amputations, alongside increased pain levels at admission. Clinical factors such as diabetes, hypertension, heart failure, ischemic heart disease, previous revascularization procedures, amputations, and the intensity of affective temperaments did not correlate with HADS scores.

Discussion

The study highlighted the intricate relationship between mood disorders and PAD severity, emphasizing the potential prognostic implications of untreated depression and anxiety in PAD patients. These findings suggest the importance of closely monitoring and addressing psychological well-being in PAD management. However, the study encountered limitations such as varying assessment timing and sample size discrepancies among comorbidities, impacting the observation of associations between mood disorders and certain conditions.

Conclusion

In conclusion, depressive and anxiety symptoms are often in PAD. Further research is needed to explore therapeutic interventions targeting mental health and pain management to improve the course and outcomes of PAD.

Major Depressive Disorder Impacts Peripheral Artery Disease Risk Through Intermediary Risk Factors

BACKGROUND

Major depressive disorder (MDD) has been identified as a causal risk factor for multiple forms of cardiovascular disease. Although observational evidence has linked MDD to peripheral artery disease (PAD), causal evidence of this relationship is lacking.

METHODS AND RESULTS

Inverse variance weighted 2-sample Mendelian randomization was used to test the association the between genetic liability for MDD and genetic liability for PAD. Genetic liability for MDD was associated with increased genetic liability for PAD (odds ratio [OR], 1.17 [95% CI, 1.06-1.29]; P=2.6×10-3). Genetic liability for MDD was also associated with increased genetically determined lifetime smoking (β=0.11 [95% CI, 0.078-0.14]; P=1.2×10-12), decreased alcohol intake (β=-0.078 [95% CI, -0.15 to 0]; P=0.043), and increased body mass index (β=0.10 [95% CI, 0.02-0.19]; P=1.8×10-2), which in turn were associated with genetic liability for PAD (smoking: OR, 2.81 [95% CI, 2.28-3.47], P=9.8×10-22; alcohol: OR, 0.77 [95% CI, 0.66-0.88]; P=1.8×10-4; body mass index: OR, 1.61 [95% CI, 1.52-1.7]; P=1.3×10-57). Controlling for lifetime smoking index, alcohol intake, and body mass index with multivariable Mendelian randomization completely attenuated the association between genetic liability for MDD with genetic liability for PAD.

CONCLUSIONS

This work provides evidence for a possible causal association between MDD and PAD that is dependent on intermediate risk factors, adding to the growing body of evidence suggesting that effective management and treatment of cardiovascular diseases may require a composite of physical and mental health interventions.

Association between depression and macrovascular disease: a mini review

Depression and macrovascular diseases are globally recognized as significant disorders that pose a substantial socioeconomic burden because of their associated disability and mortality. In addition, comorbidities between depression and macrovascular diseases have been widely reported in clinical settings. Patients afflicted with coronary artery disease, cerebrovascular disease or peripheral artery disease exhibit an elevated propensity for depressive symptoms. These symptoms, in turn, augment the risk of macrovascular diseases, thereby reflecting a bidirectional relationship. This review examines the physiological and pathological mechanisms behind comorbidity while also examining the intricate connection between depression and macrovascular diseases. The present mechanisms are significantly impacted by atypical activity in the hypothalamic-pituitary-adrenal axis. Elevated levels of cortisol and other hormones may disrupt normal endothelial cell function, resulting in vascular narrowing. At the same time, proinflammatory cytokines like interleukin-1 and C-reactive protein have been shown to disrupt the normal function of neurons and microglia by affecting blood-brain barrier permeability in the brain, exacerbating depressive symptoms. In addition, platelet hyperactivation or aggregation, endothelial dysfunction, and autonomic nervous system dysfunction are important comorbidity mechanisms. Collectively, these mechanisms provide a plausible physiological basis for the interplay between these two diseases. Interdisciplinary collaboration is crucial for future research aiming to reveal the pathogenesis of comorbidity and develop customised prevention and treatment strategies.

The enigma of vascular depression in old age: a critical update

Depression is common in older individuals and is associated with high disability and increased mortality, yet the factors predicting late-life depression (LLD) are poorly understood. The relationship between of depressive disorder, age- and disease-related processes have generated pathogenic hypotheses and provided new treatment options. LLD syndrome is often related to a variety of vascular mechanisms, in particular hypertension, cerebral small vessel disease, white matter lesions, subcortical vascular impairment, and other processes (e.g., inflammation, neuroimmune regulatory dysmechanisms, neurodegenerative changes, amyloid accumulation) that may represent etiological factors by affecting frontolimbic and other neuronal networks predisposing to depression. The "vascular depression" hypothesis suggests that cerebrovascular disease (CVD) and vascular risk factors may predispose, induce or perpetuate geriatric depressive disorders. It is based on the presence of various cerebrovascular risk factors in many patients with LLD, its co-morbidity with cerebrovascular lesions, and the frequent development of depression after stroke. Other findings related to vascular depression are atrophy of the medial temporal cortex or generalized cortical atrophy that are usually associated with cognitive impairment. Other pathogenetic hypotheses of LLD, such as metabolic or inflammatory ones, are briefly discussed. Treatment planning should consider there may be a modest response to antidepressants, but several evidence-based and novel treatment options for LLD exist, such as electroconvulsive therapy, transcranial magnetic stimulation, neurobiology-based psychotherapy, as well as antihypertension and antiinflammatory drugs. However, their effectiveness needs further investigation, and new methodologies for prevention and treatment of depression in older individuals should be developed.