Validity of the Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9 to screen for depression in patients with coronary artery disease

Assessment of depression in patients admitted with acute coronary syndrome: a double-blind study

Depression commonly accompanies acute coronary syndrome (ACS), impacting up to 30% of patients and correlating with adverse outcomes. Our study aimed to assess the accuracy of clinical impression compared to the PHQ9 questionnaire for evaluating depression in ACS patients admitted to the cardiac intensive care unit. Screening for depression was conducted at least 48 hours from hospital admission and 24 hours following coronary angiography and PCI. The assessment was performed separately and in a blinded manner by the clinical assessment of the attending medical team and by the PHQ9 questionnaire. The study comprised 150 ACS patients with a mean age of 62 ± 13 years. Baseline clinical and demographic characteristics were typical for ACS patients. Based on the PHQ9 questionnaire, depressive symptoms were above the cutoff for clinical depression in 31 (20.7%) patients, with 10 (32.3%) of them experiencing moderate or severe depression (PHQ9 score >15). There were no significant differences in clinical baseline characteristics between the groups with and without clinical depression. Compared to the PHQ9 questionnaire, the medical team's assessment of depression demonstrated a reasonable specificity of 84% and low sensitivity of 32%. Negative and positive predictive values were 82.6% and 35.8%, respectively. Similar findings were observed in subgroup analyses according to gender, age, type of ACS, and history of cardiovascular disease. Depression is prevalent among ACS patients, highlighting the importance of an increased awareness of this condition. Our findings suggest that detecting clinically significant severity of depressive symptoms by the attending medical team alone may not suffice for depression assessment. Incorporating validated screening tools such as the PHQ9 questionnaire or involving psychological evaluations can enhance the accuracy of depression diagnosis in ACS patients. This multifaceted approach is crucial for ensuring comprehensive care and improving patient outcomes.

Supporting Emotional Recovery After Spontaneous Coronary Artery Dissection: Development and Pilot Testing an Online Facilitated Support-Group Program

Spontaneous coronary artery dissection (SCAD) is a major medical event with a high burden of psychosocial sequelae. SCAD survivors require psychological support to facilitate recovery. This pilot study involved feasibility testing of an online group support program for SCAD survivors, co-designed by clinicians, survivors and researchers. The SCAD Online Support Program uses the principles of Acceptance and Commitment Therapy. The four-session-manualized program, facilitated by a registered psychologist and a SCAD survivor, was delivered to 33 SCAD survivors (6-7 per group). Participant and Project Advisory Group feedback led to iterative program refinements. Qualitative and quantitative acceptability data were evaluated. Participants completed pre- and post-program questionnaires to assess engaged living (life fulfilment and valued living), enrichment, self-efficacy, anxiety, depression and cardiac distress. Changes in proportions classified as anxious, depressed and distressed were identified. Qualitative comments highlighted the support, camaraderie and skills gained through the program. There were improvements in levels of life fulfilment, valued living, enrichment, self-efficacy, anxiety, depression, and cardiac distress, and reductions in proportions classified as anxious, depressed and distressed. The SCAD Online Support Program was successfully co-designed, implemented and modified, shown to be acceptable to SCAD survivors, and demonstrates potential for improving mental health outcomes.

Validation of the Bangla Version of the HeartQoL Health-Related Quality-of-Life Questionnaire for Patients With Coronary Heart Disease in Bangladesh

OBJECTIVES

To evaluate the psychometric properties of the Bangla version of the HeartQoL questionnaire, a core heart disease health-related quality-of-life (HRQoL) instrument, specifically in coronary heart disease (CHD) patients.

METHODS

The English HeartQoL was translated into Bangla and then a cross-sectional and a test-retest study was undertaken in 2 specialized cardiac hospitals in Bangladesh. All patients admitted for percutaneous coronary intervention or coronary artery bypass graft between April and October 2019 and diagnosed with CHD were eligible for recruitment. The Bangla HeartQoL, EQ-5D-3L, PHQ-9, and GAD-7 questionnaires were administered before and after discharge. Factor structure, internal consistency, and construct validity of Bangla HeartQoL were assessed.

RESULTS

A total of 945 patients with CHD were enrolled with a subgroup of 198 patients providing test-retest data. Mokken scale analysis supported the 2-factor structure (physical/mental subscales) of the HeartQoL Bangla questionnaire. Although no floor effects were observed, there was some evidence of a ceiling effect on the HeartQoL emotional subscale in 16.1% of patients. The Bangla HeartQoL questionnaire demonstrated satisfactory internal consistency (Cronbach's alpha > 0.75), discriminative validity (lower scores in patients with poorer health), and responsiveness to change (effect sizes of 0.23 to 0.68).

CONCLUSIONS

The Bangla HeartQoL questionnaire was found to be a valid, reliable, and responsive measure of HRQoL in CHD patients. However, future research is needed around its use, particularly in terms of its potential cultural sensitivity.

Attitudes to and Attendance at Cardiac Rehabilitation After Spontaneous Coronary Artery Dissection

PURPOSE

Cardiac rehabilitation (CR) is standard care for patients after a heart event, including acute myocardial infarction. However, the uptake and relevance of traditional CR after acute myocardial infarction due to spontaneous coronary artery dissection (SCAD) has not been extensively investigated. The present study investigated attitudes toward CR, identified the rate and correlates of CR attendance, and examined the reasons for CR non-attendance after SCAD.

METHODS

Online focus groups (n = 30) explored attitudes toward and experiences of CR of survivors of SCAD, with data analyzed thematically according to recommended guidelines. An online survey (n = 310) then investigated rates of CR attendance and reasons for non-attendance. Correlates of CR attendance were identified using bivariate and multivariable analyses.

RESULTS

Thematic analysis revealed 5 themes in the perceptions of CR of survivors of SCAD: (1) lack of relevance of CR educational content; (2) lack of identification with typical CR attendees; (3) lack of CR health professional knowledge and skills; (4) preference for SCAD-specific CR; and (5) benefits of CR. The survey demonstrated a CR attendance rate of 63% (73% among those referred). The correlates of CR attendance were mid-level education and self-reported lifetime anxiety. Among attendees, the correlates of attending fewer sessions were having a more recent SCAD, not having lifetime anxiety, and not knowing other survivors of SCAD. Reported reasons for non-attendance mirrored qualitative themes identified.

CONCLUSION

While the survey demonstrated high CR attendance, perceptions that CR was unnecessary and irrelevant after SCAD were evident, often based on health professional advice. The findings add to the growing literature highlighting a need for appropriate support for survivors of SCAD.

Fear of Recurrence and Progression in People with Heart Disease: Risk Factors and Implications for Emotional Support

Support to manage fear of recurrence and progression (FoRP) is a major concern and a commonly unmet need for people with chronic illness. The current study identified profiles of and risk factors for FoRP in people with heart disease. A sample of 241 participants completed 44 cardiac-specific FoRP items and provided demographic, clinical, and psychosocial information. Cluster analysis identified three profiles: a high-, moderate-, and low-FoRP group. Patients who were younger, had a comorbid health condition(s), and higher levels of uncertainty and cardiac-related distress were at the most risk of higher FoRP. By characterizing the nature and correlates of cardiac-FoRP, this study enables health professionals to understand the specific concerns of their patients and assists in identifying those at greatest risk. The findings extend the emerging field of cardiac-FoRP research and will assist in the development of a cardiac-specific screening measure and of tailored and targeted interventions to support cardiac patients in their emotional recovery.

A psychological model of predictive factors of distress following long COVID

BACKGROUND

Long COVID, described as "the continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection", is estimated to affect at least 10-20 % of all cases of acute SARS-CoV-2 infection. Because of its novelty, information regarding the experience of Long COVID is still emerging.

METHODS

This study examines psychological distress in two long COVID populations, and their experience of fatigue, cognitive failures, experiential avoidance, rumination, and perceived injustice. Participants were recruited via a long COVID hospital clinic and online self-diagnosing samples. Participants completed a battery of scales to measure psychological distress, fatigue, cognitive dysfunction, avoidance and rumination behaviours and the experience of injustice.

RESULTS

It was found that the regression model tested accounted for a significant amount of the variance in psychological distress (R2 = 0.675). Cognitive failures, avoidance, rumination, and injustice experiences significantly contributed to the experience of psychological distress and a moderated mediation accounted for the effect of fatigue on psychological distress.

LIMITATIONS

The self-report measures in this study did not include objective measures of symptom severity. Cross-sectional data collected at a single time-point may not capture the dynamic nature of long COVID symptoms.

CONCLUSIONS

These findings identify contributing factors to the experience of psychological distress in the long COVID population, providing direction to explore supportive interventions.

Sexual dysfunction, anxiety, depression and reduced quality of life in women with non-radiographic axial spondyloarthritis- a cross-sectional analysis

Axial spondyloarthritis (ax-SpA) is a chronic inflammatory disease which causes a major deterioration of both physical and mental health. This research aimed to assess the prevalence of sexual dysfunction (SD), decreased quality of life (QoL), and depressive and anxiety symptoms in women with non-radiographic axial spondyloarthritis (nr-axSpA). A cross-sectional study was performed, involving 60 sexually active women with nr-axSpA and an age-matched group of 60 healthy women. Data were gathered through patient records and three standardized tools: the Female Sexual Function Index (FSFI), the Hospital Anxiety and Depression Scale (HADS), and the Short Form-36 (SF-36). Sexual dysfunction was found to be more prevalent in the nr-axSpA group (65% vs. 40%, p < 0.01). The mean FSFI result was substantially lower in patients than in healthy controls (19.71 ± 11.32 vs. 24.75 ± 8.36, p < 0.01) with significant differences of the scores in desire, arousal, lubrication and pain caused during intercourse. Women with nr-axSpA also experienced higher levels of anxiety (HADS-A: 8.52 ± 3.62 vs. 5.88 ± 3.83, p < 0.01) and depression (HADS-D: 6.27 ± 3.38 vs. 3.28 ± 2.77, p < 0.01). They also had lower physical (171.0 ± 72.9 vs. 301.5 ± 81.2, p < 0.01) and mental (204.9 ± 83.9 vs. 277.1 ± 74.5, p < 0.01) QoL scores. Women diagnosed with nr-axSpA are more prone to sexual dysfunction, increased anxiety and depression, and have a significantly worsened quality of life. The obtained results accentuate the necessity of addressing the patients' physical as well as their emotional issues through a comprehensive approach.

Prevalence and correlates of anxiety and depressive symptoms after spontaneous coronary artery dissection: a cross-sectional study

AIMS

Spontaneous coronary artery dissection (SCAD) is recognized as a particularly stressful cause of heart attack. However, few studies have documented the prevalence of post-SCAD anxiety and depressive symptoms, or identified patients most at risk. This study documents the prevalence and correlates of post-SCAD anxiety and depressive symptoms.

METHODS AND RESULTS

Three hundred ten (95% women) SCAD survivors were recruited by the Victor Chang Cardiac Research Institute from a database of 433 SCAD survivors. Participants completed an online questionnaire to gather demographic, medical, and psychosocial information, including the Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9). Bivariate and multivariate analyses were undertaken to identify the significant demographic, psychosocial, and medical correlates of post-SCAD anxiety and depressive symptoms. Time between SCAD and questionnaire completion varied from 2 months to 18 years (mean = 5.5 years; SD = 3.5 years). Rates of anxiety and depressive symptoms were 20.7% (GAD-7 ≥ 10) and 20.9% (PHQ-9 ≥ 10), respectively, and did not vary by time since event. In bivariate analyses, correlates (P < 0.05) of anxiety and depressive symptoms were absence of a close confidante, financial strain, mental health diagnosis pre-SCAD, comorbid obesity, not being in paid employment (anxiety only), younger age (depression only), and not knowing another SCAD survivor (depression only). Variables retained in multivariate models were absence of a close confidante, financial strain, not being in paid employment, mental health diagnosis pre-SCAD (depression only), and younger age (depression only).

CONCLUSION

This study demonstrated that over one in four SCAD survivors experiences either anxiety or depressive symptoms after SCAD, and identified those who may need additional support in their psychological recovery.

Emotional awareness amplifies affective sensitivity to social support for women with breast cancer

Emotional awareness (EA) is thought to facilitate psychological health by aiding emotion regulation in oneself and garnering social support from others. This study tested these potential relationships within a one-year longitudinal study of 460 women (age 23-91 years, mean 56.4 years) recently diagnosed with breast cancer (i.e., within four months). The women completed measures of emotional awareness, social support, social stress, affective symptoms, and well-being. Linear models tested EA as a moderator of social support and stress on affective symptoms and well-being. In those with higher EA, low social support was associated with greater depression and lower optimism. There was some evidence that higher EA predicted greater depression at baseline but lower depression at nine-month follow-up. These results support the idea that EA increases sensitivity to available social support and facilitates emotional adjustment over time, suggesting that assessment of EA could help guide clinicians in identifying those at greatest risk of adverse mental health outcomes in this population.

Lower Perceived Social Support Associated With Greater Hopelessness in Patients After an Acute Ischemic Heart Disease Event

BACKGROUND

Hopelessness is present in up 52% of patients with ischemic heart disease (IHD) and is associated with increased morbidity and mortality. Lower perceived social support (PSS) has been associated with greater hopelessness in a pilot study of patients with IHD reporting moderate-severe hopelessness but has not been examined in a larger sample reporting none-severe levels of hopelessness and while controlling for covariates.

OBJECTIVE

The aim of this study was to determine the relationship between PSS and hopelessness in patients with IHD.

METHODS

Using a cross-sectional design, 178 participants were enrolled while hospitalized for an IHD event at 1 large hospital in the United States. Data collection occurred 2 weeks after hospital discharge using the State-Trait Hopelessness Scale, ENRICHD Social Support Inventory, Patient Health Questionnaire-9, a demographic form, and a medical record abstraction form. Linear models were used to assess the association between variables in unadjusted models and models adjusted for demographic and medical history.

RESULTS

Most participants were male (67%), married (67%), and non-Hispanic White (92%) and underwent coronary artery bypass surgery (61%). There was a moderate inverse correlation between PSS and state (r = -0.31, P < .001) and trait (r = -0.28, P < .001) hopelessness in unadjusted models. The relationships remained significant in adjusted models and did not differ by sex, type of IHD event, or marital status.

CONCLUSIONS

Lower PSS was associated with greater hopelessness in patients with IHD. Assessing PSS and hopelessness during hospitalization for an IHD event may enable clinicians to provide targeted interventions to reduce risk of hopelessness and improve secondary prevention in patients with IHD.

Psychometric properties of the Arabic version of the hospital anxiety and depression scale in hemodialysis patients

The literature lacks a rigorous psychometric evaluation of the Arabic version of Hospital Anxiety and Depression Scale (HADS) in hemodialysis (HD) patients. This study aims to evaluate reliability, determine the underlying factor structure of the Arabic version of HADS and assess its suitability as screening tool for depression and anxiety among Arabic HD patients.A sample of 370 HD patients were recruited from all health districts in Kuwait. Reliability for HADS (all items) and its subscales HADS-A (anxiety) and HADS-D (depression) were estimated using Cronbach's alpha and item analysis was conducted. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted to extract and test the factor structure for the Arabic version of HADS. Eight models were tested using CFA to determine goodness-of-fit.The Cronbach α for the Arabic HADS (all items), HADS-A and HADS-D were 0.884, 0.852 and 0.764, respectively. Pearson correlation coefficient between HADS-A and HADS-D subscales indicated significant correlation (r = +0.69, PV < 0.001). EFA indicated two factors with eigenvalues >1, which accounted for 48.5% of the total variance. CFA revealed the one-factor model had the poorest fit, the two-factor models with acceptable fit, and three-factor models showed good fit.The Arabic HADS has good reliability and internal consistency, which warrants its use in screening for anxiety and depression among Arabic HD patients. Furthermore, the three-factor structure has shown a better fit which warrants further exploration in HD patients with the advancement in theory of psychological models for anxiety and depression.

APPROACH e-PROM system: a user-centered development and evaluation of an electronic patient-reported outcomes measurement system for management of coronary artery disease

BACKGROUND

Coronary artery disease (CAD) confers increased risks of premature mortality, non-fatal morbidity, and significant impairment in functional status and health-related quality of life. Routine administration of electronic patient-reported outcome measures (PROMs) and its real time delivery to care providers is known to have the potential to inform routine cardiac care and to improve quality of care and patient outcomes. This study describes a user-centered development and evaluation of the Alberta Provincial Project for Outcomes Assessment (APPROACH) electronic Patient Reported Outcomes Measurement (e-PROM) system. This e-PROM system is an electronic system for the administration of PROMs to patients with CAD and the delivery of the summarized information to their care providers to facilitate patient-physician communication and shared decision-making. This electronic platform was designed to be accessible via web-based and hand-held devices. Heuristic and user acceptance evaluation were conducted with patients and attending care providers.

RESULTS

The APPROACH e-PROM system was co-developed with patients and care providers, research investigators, informaticians and information technology experts. Five PROMs were selected for inclusion in the online platform after consultations with patient partners, care providers, and PROMs experts: the Seattle Angina Questionnaire, Patient Health Questionnaire, EuroQOL, and Medical Outcomes Study Social Support Survey, and Self-Care of Coronary Heart Disease Inventory. The heuristic evaluation was completed by four design experts who examined the usability of the prototype interfaces. User acceptance testing was completed with 13 patients and 10 cardiologists who evaluated prototype user interfaces of the e-PROM system.

CONCLUSION

Both patients and physicians found the APPROACH e-PROM system to be easy to use, understandable, and acceptable. The APPROACH e-PROM system provides a user-informed electronic platform designed to incorporate PROMs into the delivery of individualized cardiac care for persons with CAD.

Prevalence of Anxiety, Depression, and Distress and Their Association With Problems Encountered by Advanced Cancer Patients in a Tertiary Hospital in Saudi Arabia

BACKGROUND

Patients with advanced cancer often suffer from significant psychological distress, anxiety, and depression, which can profoundly influence their quality of life. This study aimed to evaluate the prevalence and severity of these psychological factors in advanced cancer patients. Additionally, it sought to identify related psychosocial, practical, emotional, and physical problems and their association with the psychological factors. Furthermore, this study provides interventions and strategies to help mitigate the psychological burden experienced by these patients.

METHODS

A cross-sectional survey involving 180 patients with advanced cancer was conducted at a tertiary hospital in Saudi Arabia. Participants were assessed using the Distress Thermometer (DT) and the Hospital Anxiety and Depression Scale (HADS). Data analysis included descriptive statistics, chi-square tests for categorical variables, and multivariate regression to explore the factors associated with distress, anxiety, and depression.

RESULTS

The prevalence of distress, anxiety, and depression among patients was 40.6%, 46.1%, and 52.2%, respectively. Patients who experienced 'changes in urination' which is an item in DT had a 2.86 times higher risk of developing distress. Patients experiencing sadness (item in DT) and fatigue (item in DT) were at a 3.91 and 2.29 times higher risk of developing anxiety, respectively. Practical problems, such as childcare and treatment decisions, emotional problems, and physical problems, such as appearance, bathing/dressing, and eating difficulties, were significantly associated with distress. There was no significant association between patients' demographics and psychological factors.

CONCLUSION

The findings underscore the complex interplay of psychosocial, practical, emotional, and physical problems faced by advanced cancer patients receiving palliative care. These patients exhibit a high percentage of distress, anxiety, and depression. Addressing these multifaceted problems through targeted psychological and social interventions can significantly enhance the overall care and quality of life for this vulnerable population. This study advocates routine psychological screenings and tailored interventions to mitigate the psychological burden in this group.

Two randomized crossover multicenter studies investigating gastrointestinal symptoms after bread consumption in individuals with noncoeliac wheat sensitivity: do wheat species and fermentation type matter?

BACKGROUND

Many individuals reduce their bread intake because they believe wheat causes their gastrointestinal (GI) symptoms. Different wheat species and processing methods may affect these responses.

OBJECTIVES

We investigated the effects of 6 different bread types (prepared from 3 wheat species and 2 fermentation conditions) on GI symptoms in individuals with self-reported noncoeliac wheat sensitivity (NCWS).

METHODS

Two parallel, randomized, double-blind, crossover, multicenter studies were conducted. NCWS individuals, in whom coeliac disease and wheat allergy were ruled out, received 5 slices of yeast fermented (YF) (study A, n = 20) or sourdough fermented (SF) (study B, n = 20) bread made of bread wheat, spelt, or emmer in a randomized order on 3 separate test days. Each test day was preceded by a run-in period of 3 d of a symptom-free diet and separated by a wash-out period of ≥7 d. GI symptoms were evaluated by change in symptom score (test day minus average of the 3-d run-in period) on a 0-100 mm visual analogue scale (ΔVAS), comparing medians using the Friedman test. Responders were defined as an increase in ΔVAS of ≥15 mm for overall GI symptoms, abdominal discomfort, abdominal pain, bloating, and/or flatulence.

RESULTS

GI symptoms did not differ significantly between breads of different grains [YF bread wheat median ΔVAS 10.4 mm (IQR 0.0-17.8 mm), spelt 4.9 mm (-7.6 to 9.4 mm), emmer 11.0 mm (0.0-21.3 mm), P = 0.267; SF bread wheat 10.5 mm (-3.1 to 31.5 mm), spelt 11.3 mm (0.0-15.3 mm), emmer 4.0 mm (-2.9 to 9.3 mm), P = 0.144]. The number of responders was also comparable for both YF (6 to wheat, 5 to spelt, and 7 to emmer, P = 0.761) and SF breads (9 to wheat, 7 to spelt, and 8 to emmer, P = 0.761).

CONCLUSIONS

The majority of NCWS individuals experienced some GI symptoms for ≥1 of the breads, but on a group level, no differences were found between different grains for either YF or SF breads.

CLINICAL TRIAL REGISTRY

clinicaltrials.gov, NCT04084470 (https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04084470).

Unsupervised item response theory models for assessing sample heterogeneity in patient-reported outcomes measures

PURPOSE

Unsupervised item-response theory (IRT) models such as polytomous IRT based on recursive partitioning (IRTrees) and mixture IRT (MixIRT) models can be used to assess differential item functioning (DIF) in patient-reported outcome measures (PROMs) when the covariates associated with DIF are unknown a priori. This study examines the consistency of results for IRTrees and MixIRT models.

METHODS

Data were from 4478 individuals in the Alberta Provincial Project on Outcome Assessment in Coronary Heart Disease registry who received cardiac angiography in Alberta, Canada, and completed the Hospital Anxiety and Depression Scale (HADS) depression subscale items. The partial credit model (PCM) based on recursive partitioning (PCTree) and mixture PCM (MixPCM) were used to identify covariates associated with differential response patterns to HADS depression subscale items. Model covariates included demographic and clinical characteristics.

RESULTS

The median (interquartile range) age was 64.5(15.7) years, and 3522(78.5%) patients were male. The PCTree identified 4 terminal nodes (subgroups) defined by smoking status, age, and body mass index. A 3-class PCM fits the data well. The MixPCM latent classes were defined by age, disease indication, smoking status, comorbid diabetes, congestive heart failure, and chronic obstructive pulmonary disease.

CONCLUSION

PCTree and MixPCM were not consistent in detecting covariates associated with differential interpretations of PROM items. Future research will use computer simulations to assess these models' Type I error and statistical power for identifying covariates associated with DIF.

Behavioural and psychological telehealth support for people with cardiac conditions: randomized trial of the 'back on track' self-management programme

AIMS

Behaviour modification and mood management are essential to recovery after a cardiac event. Recent times have seen a major shift to remote delivery of cardiac services. This study assessed behavioural and psychological outcomes of the Back on Track online self-management programme, comparing the programme undertaken alone (self-directed) vs. with telephone support (supported). Relevance for people with depression was also assessed.

METHODS AND RESULTS

Participants with cardiac conditions (n = 122) were randomly assigned to self-directed or supported groups and given access to the online programme for 2 months. The programme addressed depression, anxiety, physical activity, and healthy eating. Supported group participants also received two telephone sessions facilitated by a trained counsellor to further enhance their self-management skills and engagement with the online modules. The Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Active Australia Survey and Diet Quality Tool were administered at baseline, 2, and 6 months. χ2 tests were used to compare self-directed and supported groups. Cochrane's Q tests assessed changes over time in depression, anxiety, and physical activity (PA) and healthy diet guideline achievement. Participants in both groups showed reduced depression rates (self-directed, P < 0.05) and increased PA after programme completion (both groups, P < 0.05). Amongst those classified as depressed at baseline, significantly fewer were classified as depressed over time (P < 0.001) and significantly more were achieving the PA guidelines (P < 0.01) compared to those who were not depressed at baseline.

CONCLUSIONS

The Back on Track telehealth programme was effective in assisting with behavioural and emotional recovery after a cardiac event. The programme may be particularly beneficial for those who are depressed early in their recovery period.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12620000102976.

Psychosocial and lifestyle impacts of spontaneous coronary artery dissection: A quantitative study

INTRODUCTION

Recent studies suggest that acute myocardial infarction due to spontaneous coronary artery dissection (SCAD) carries significant psychosocial burden. This survey-based quantitative study builds on our earlier qualitative investigation of the psychosocial impacts of SCAD in Australian SCAD survivors. The study aimed to document the prevalence and predictors of a broad range of psychosocial and lifestyle impacts of SCAD.

METHOD

Australian SCAD survivors currently enrolled in the Victor Chang Cardiac Research Institute genetics study were invited to participate in an online survey to assess the psychosocial impacts of SCAD. Participants completed a questionnaire, developed using findings from our earlier qualitative research, which assessed 48 psychosocial and five lifestyle impacts of SCAD. Participants also provided demographic and medical data and completed validated measures of anxiety and depression.

RESULTS

Of 433 SCAD survivors invited to participate, 310 (72%) completed the questionnaire. The most common psychosocial impacts were 'shock about having a heart attack' (experienced by 87% respondents), 'worry about having another SCAD' (81%), 'concern about triggering another SCAD' (77%), 'uncertainty about exercise and physical activity' (73%) and 'confusion about safe levels of activity and exertion' (73.0%) and 'being overly aware of bodily sensations' (73%). In terms of lifestyle impacts, the SCAD had impacted on work capacity for almost two thirds of participants, while one in ten had sought financial assistance. The key predictors of psychosocial impacts were being under 50, current financial strain, and trade-level education. The key predictors of lifestyle impacts were being over 50, SCAD recurrence, trade-level education, and current financial strain. All psychosocial impacts and some lifestyle impacts were associated with increased risk of anxiety and/or depression.

CONCLUSION AND IMPLICATIONS

This quantitative study extends our previous qualitative investigation by documenting the prevalence of each of 48 psychosocial and five lifestyle impacts identified in our earlier focus group research, and by providing risk factors for greater SCAD impacts. The findings suggest the need for supports to address initial experiences of shock, as well as fears and uncertainties regarding the future, including SCAD recurrence and exercise resumption. Support could be targeted to those with identified risk factors. Strategies to enable SCAD survivors to remain in or return to the paid workforce are also indicated.

Association between Body-Image Satisfaction and Anxiety, Depressive Symptoms among Women with PCOS: The Mediating Role of Emotion Regulation Strategies

Anxiety and depressive symptoms are prevalent in women with polycystic ovary syndrome (PCOS), and there is a great need for culturally relevant interventions to improve anxiety and depressive symptoms in women with PCOS. The current study aimed to analyze the factors influencing body-image satisfaction, anxiety, and depressive symptoms in Chinese women with PCOS. It also aimed to clarify the association between body-image satisfaction and anxiety and depressive symptoms in women with PCOS, and whether this association was mediated by cognitive reappraisal and expressive suppression. A total of 477 women with PCOS were recruited from the Department of Gynecology and Reproductive Medicine Center of one university-affiliated tertiary hospital in China. They completed the Generalized Anxiety Disorder-7 scale, the Patient Health Questionnaire-9, the Body Image States Scale, and the Emotion Regulation Questionnaire. The study found body-image satisfaction showed significant associations with anxiety and depressive symptoms. This association was mediated by cognitive reappraisal and expressive suppression. The findings of this study offer new insights into the relationship between body image and anxiety and depressive symptoms in women with PCOS. They also emphasize the potential value of promoting body-image satisfaction and enhancing cognitive reappraisal abilities to improve the mental health of women with PCOS.

Anxiety and depression in maintenance hemodialysis patients: prevalence and their effects on health-related quality of life

PURPOSE

The aims of the study are to explore the prevalence and risk factors of anxiety and depression in hemodialysis (HD) patients and to study their relationship with quality of life (QOL).

METHODS

This cross-sectional study involved 298 HD patients. Sociodemographic, clinical, and laboratory data of the patients were obtained from their records. Anxiety and depression were assessed by utilizing Hospital Anxiety and Depression Scale (HADS). In addition, QOL of the patients were evaluated by fulfilling the Kidney Disease Quality of Life-36.

RESULTS

This study included 298 HD patients (male 59.1%) with a median age of 49 years. Abnormal and borderline cases of anxiety were recognized in 49.6%, 26.2% of the patients, respectively, while depression cases and borderline cases were identified in 55 and 28.2% of the patients, respectively. Percentages of females (41 and 48% vs 26.4%, respectively), and patients who were not working (92.3 and 93.9% vs 72.2%, respectively) increased significantly in borderline and abnormal anxiety groups. Patients who did not work, led an inactive lifestyle, and smoked had considerably greater percentages in the borderline and abnormal HADS-depression categories than normal patients. Abnormal cases of depression and anxiety had significantly longer duration of HD than other two groups. Abnormal and borderline cases of anxiety and depression had worse QOL components than the normal patients.

CONCLUSION

Anxiety and depression are prevalent among HD patients in Egypt, and several sociodemographic and clinical risk factors are associated. In addition, these mental disorders are associated with poor QOL.

Cardiac rehabilitation engagement and associated factors among heart failure patients: a cross-sectional study

BACKGROUND

Chronic Heart Failure (CHF) still affects millions of people worldwide despite great advances in therapeutic approaches in the cardiovascular field. Cardiac rehabilitation (CR) is known to improve disease-related symptoms, quality of life and clinical outcomes, yet implementation is suboptimal, a frequently low engagement in rehabilitation programs has been found globally.

OBJECTIVE

To quantify diverse CR-engaged processes and elucidate associated factors of the various levels of CR engagement in CHF patients.

METHODS

Discharged patients admitted from cardiology departments between May 2022 to July 2022 were enrolled by mobile phone text messaging, CHF patients from same department between August 2022 to December 2022 were enrolled by face-to-face. Individuals who met the inclusion criteria filled the questionnaires, including the generalized anxiety disorders scale, patient health questionnaire, cardiac rehabilitation inventory, patient activation measure, Tampa scale for kinesiophobia heart, social frailty, Patient Health Engagement Scale (PHE-s®). We obtained sociodemographic characteristics and clinical data from medical records. Chi-square tests and multivariable logistic regression analyses were performed to examine the factors associated with CR engagement phases.

RESULTS

A total of 684 patients were included in the study. 52.49% patients were in the Adhesion phase. At the multivariate level, compared with the blackout phase process anxiety, monthly income (RMB yuan) equal to or more than 5,000 were the most important factor impacting CHF patients CR engagement. Compared with the Blackout phase, regular exercise or not, severe depression, previous cardiac-related hospitalizations 1 or 2 times, Age influenced patient CR engagement in the Arousal phase. Besides, compared with the Blackout phase, outcome anxiety and activation level were independent factors in the Eudaimonic Project phase.

CONCLUSION

This study characterized CR engagement, and explored demographic, medical, and psychological factors-with the most important being process anxiety, monthly income, patient activation, severe depression, and previous cardiac-related hospitalizations. The associated factors of CR engagement were not identical among different phases. Our findings suggested that factors could potentially be targeted in clinical practice to identify low CR engagement patients, and strategies implemented to strengthen or overcome these associations to address low CR engagement in CHF patients.

The prognostic study of mental stress-induced myocardial ischemia in coronary revascularization patients with depression/anxiety: rationale and design

BACKGROUND

Mental stress-induced myocardial ischemia (MSIMI) frequently occurs in patients with coronary artery disease (CAD), and is even more common in patients with co-occurring CAD and depression/anxiety. MSIMI appears to be a poor prognostic factor for CAD, but existing data on depression/anxiety patients are limited.

METHODS

This cohort study will consecutively screen 2,647 CAD patients between 2023 and 2025. Included subjects will need to have received coronary revascularization and also have depression and/or anxiety at baseline. This study will enroll 360 subjects who meet the criteria. Two mental stress tests will be carried out in each patient at 1 month and 1 year timelines after coronary revascularization, using Stroop color word tests. MSIMI will be assessed by ^99 m-Tc-sestamibi myocardial perfusion imaging. The endothelial function will be assessed by EndoPAT. Furthermore, we will dynamically monitor patients' health and mental conditions every 3 months. The mean follow-up time will be 1 year. The primary endpoint is the major adverse cardiac events, a composite of all-cause death, cardiac death, myocardial infarction, stroke, or unplanned revascularization. Secondary endpoints will include overall health and mental conditions. The reproducibility of mental stress combined with myocardial perfusion for detecting MSIMI and comparisons between coronary stenosis and ischemic segments will also be included.

CONCLUSIONS

This cohort study will provide information on MSIMI outcomes in CAD patients who also have comorbid depression/anxiety after revascularization. In addition, understanding the long-term dynamics of MSIMI and the match between coronary stenosis and ischemia will provide insight into MSIMI mechanisms.

TRAIL REGISTRATION

ChiCTR2200055792, 2022.1.20, www.medresman.org.cn.

Effectiveness of a behavioral medicine intervention in physical therapy on secondary psychological outcomes and health-related quality of life in exercise-based cardiac rehabilitation: a randomized, controlled trial

BACKGROUND

Interventions promoting adherence to exercise-based cardiac rehabilitation (exCR) are important to achieve positive physical and psychological outcomes, but knowledge of the added value of behavioral medicine interventions for these measures is limited. The aim of the study was to investigate the added value of a behavioral medicine intervention in physical therapy (BMIP) in routine exCR on psychological outcomes and health-related quality of life (HRQoL) versus routine exCR alone (RC).

METHODS

A total of 170 patients with coronary artery disease (136 men), mean age 62.3 ± 7.9 years, were randomized at a Swedish university hospital to a BMIP plus routine exCR or to RC for four months. The outcome assessments included HRQoL (SF-36, EQ-5D), anxiety and depression (HADS), patient enablement and self-efficacy and was performed at baseline, four and 12 months. Between-group differences were tested with an independent samples t-test and, for comparisons within groups, a paired t-test was used. An intention-to-treat and a per-protocol analysis were performed.

RESULTS

No significant differences in outcomes between the groups were shown between baseline and four months or between four and 12 months. Both groups improved in most SF-36 domains, EQ-VAS and HADS anxiety at the four-month follow-up and sufficient enablement remained at the 12-months follow-up.

CONCLUSION

A BMIP added to routine exCR care had no significant effect on psychological outcomes and HRQoL compared with RC, but significant improvements in several measures were shown in both groups at the four-month follow-up. Since recruited participants showed a better psychological profile than the general coronary artery disease population, further studies on BMIP in exCR, tailored to meet individual needs in broader patient groups, are needed. Trial registration number NCT02895451, 09/09/2016, retrospectively registered.

Depressive symptomology and cancer incidence in men and women: Longitudinal evidence from the HUNT study

BACKGROUND

Depressive symptoms and mood disorders are associated with a host of physical conditions. However, it is inconclusive whether depressive symptoms are also associated with cancer onset. The aim of this study was to investigate whether depressive symptoms are associated with cancer incidence in a large population-based sample of men and women.

METHODS

This study examined data from waves two (HUNT 2, 1995-97) and three (HUNT 3, 2006-08) of the Trøndelag Health Study (HUNT). Depressive symptoms were ascertained using the Hospital Anxiety and Depression Scale (HADS-D ≥ 8), cancer onset was identified via linkage with the Cancer Registry of Norway, death records by the national Cause of Death Register (CDR), and information on lifestyle and demographic factors was self-reported. Cox-proportional hazard regression models were used to test associations. Unadjusted, age-adjusted and multivariable best models accounting for smoking, education, marital status and current employment are presented.

RESULTS

Men and women (n = 61,985; 46.0 % men) were followed from baseline over a period of 778,802 person-years. During the 20-year study period, there were 6856 (11.1 %) individuals with incident cancers and 12,480 (20.1 %) deaths (n = 2498 attributed to cancer). For men with depressive symptoms, 505 (15.3 %) developed incident cancer during the follow-up period, whereas among those without depressive symptoms, 3164 (12.5 %) developed incident cancer. Following adjustment for age, depressive symptomology was not significantly associated with risk of overall cancer onset, nor among prostate, colon or melanoma subtypes. Depressive symptoms were associated with an increased risk of bronchus and lung cancer both before (HR 1.90, 95 % CI 1.43-2.50, p ≤0.001) and after adjustment for age (HR 1.38, 95 % CI 1.04-1.80, p = 0.025). However, further adjustment for additional possible confounders explained this association. For women with depressive symptoms, 384 (11.2 %) developed incident cancer during the follow-up period, whereas among those with no depressive symptomology, 2803 (9.3 %) developed incident cancer. After accounting for age, depressive symptomology was not associated with risk of overall cancer onset, nor among breast, colon, lung and bronchus, or melanoma subtypes. Additional analyses evaluating relationship of depression symptom severity and cancer onset did not alter findings for men or women.

LIMITATIONS

This report is limited by the post-hoc study design and subsequent non-randomised nature. Future prospective studies are required.

CONCLUSION

These results suggest that depressive symptoms are not associated with an increased risk of overall or site-specific cancer onset in these men and women. Given the increased co-occurrence of other medical conditions such as cardiovascular disease, diabetes, stroke and musculoskeletal disorders in people with depression, the role of clinically diagnosed depression and other psychiatric disorders in association with cancer onset necessitates further consideration.

Assessment of mental health in patients with chronic liver disease

Content available: Audio Recording.

Associations of Cardiovascular Agents and Metformin with Depression Symptoms: A Cross-Sectional Analysis from the HUNT Study, Norway

BACKGROUND

Cardiovascular agents, including angiotensin-converting enzyme inhibitors, angiotensin II receptor inhibitors, acetylsalicylic acid, statins, and metformin, have demonstrated benefits for depression. However, there is scant evaluation of these drugs' antidepressant properties in large population settings.

OBJECTIVE

This study aimed to examine cross-sectional associations between depression symptoms and the use of cardiovascular agents and metformin in populations with cardiovascular diseases or diabetes mellitus.

METHODS

Participants in the Trøndelag Health Study 2006-08 (HUNT3, n = 40,516) and 2017-19 (HUNT4, n = 42,103) were included and data on their drug use from 2006 to 2019 was retrieved from the Norwegian Prescription Database. The outcome was self-reported depression symptoms defined by the Hospital Anxiety and Depression Scale. Associations between cardiovascular agents or metformin use and self-reported depression were analyzed by multi-level logistic regression in sex-stratified samples.

RESULTS

Among men with cardiovascular diseases, use of acetylsalicylic acid was associated with reduced depression symptoms compared with acetylsalicylic acid non-users (reference) in HUNT3 and HUNT4 [risk ratio = 0.76; 95% confidence interval 0.59-0.94, risk ratio = 0.67; 95% CI 0.52-0.82, respectively]. Similarly, male statin users had a lower likelihood of reporting depression than statin non-users in HUNT3 (risk ratio = 0.70; 95% confidence interval 0.54-0.86) and HUNT4 (risk ratio = 0.67; 95% confidence interval 0.51-0.84). Associations between statins or acetylsalicylic acid use and reduced depression symptoms were detected in women with cardiovascular diseases in HUNT4. We found no statistical support for associations between other cardiovascular agents or metformin use and a reduced or increased depression symptom risk.

CONCLUSIONS

Results suggest negative associations between acetylsalicylic acid or statin use and depression symptoms. However, longitudinal cohort studies and randomized controlled trials are required to confirm the antidepressant effects of these drugs.

Assessing Knowledge, Preventive Practices, and Depression Among Chinese International Students and Local Korean Students in South Korea During the COVID-19 Pandemic: An Online Cross-Sectional Study

Depression among university students and international university students is an increasing problem globally. This study aimed to clarify the differences on the conditions and determinants of the knowledge, preventive practices and depression of the Chinese international students and local Korean students in South Korea during the COVID-19 pandemic. An online cross-sectional questionnaire including general demographic characteristics, COVID-19-related knowledge, preventive practice, and the Patient Health Questionnaire (PHQ-9) was applied from March 23 to April 22, 2020. A total of 533 university students (171 Chinese international students and 362 local South Korean students) were included in the study. The majority of both Chinese international students and local South Korean students had a good comprehension of COVID-19. Chinese international students in South Korea showed better preventive practice than local Korean students, while the proportion of moderate to severe depression of Chinese international students was relatively higher (28.07%) than that of local Korean students (22.38%). Determinants of depression of Chinese international students in South Korea were information satisfaction, likelihood of survival after infection, symptoms of a cough and feelings of discrimination, while for local Korean students were gender, educational level, family, suspected symptoms, self-assessed physical health status, COVID-19 detection, population contact history and online sources of information. These results could be used as a reference for decreasing the depressive symptoms among the university students.

Collaborative care compared to enhanced standard treatment of depression with co-morbid medical conditions among patients from rural South India: a cluster randomized controlled trial (HOPE Study)

BACKGROUND

Depression is common among primary care patients in LMIC but treatments are largely ineffective. In this cluster-randomized controlled trial, we tested whether depression outcomes are different among recipients of a collaborative care model compared to enhanced standard treatment in patients with co-morbid chronic medical conditions.

METHODS

We conducted a cluster randomized controlled trial among participants 30 years or older seeking care at 49 primary health centers (PHCs) in rural Karnataka, diagnosed with major depressive disorder, dysthymia, generalized anxiety disorder, or panic disorder on the MINI-International Neuropsychiatric Interview plus either hypertension, diabetes, or ischemic heart disease. From a list of all PHCs in the district, 24 PHCs were randomized a priori to deliver collaborative care and 25 PHCs enhanced standard treatment. The collaborative care model consisted of a clinic-based and a community-based component. Study assessment staff was blinded to treatment arm allocation. The primary outcome was the individual-level PHQ-9 score over time.

RESULTS

Between May 2015 and Nov 2018, 2486 participants were enrolled, 1264 in the control arm, and 1222 in the intervention arm. They were assessed at baseline, 3, 6 and 12 months. The mean PHQ-9 depression score was around 8.5 at baseline. At each follow-up PHQ-9 scores were significantly lower in the intervention (5.24, 4.81 and 4.22 at respective follow-ups) than in the control group (6.69, 6.13, 5.23, respectively). A significant time-by-treatment interaction (p < 0.001) in a multi-level model over all waves, nested within individuals who were nested within PHCs, confirmed that the decrease in depression score from baseline was larger for collaborative care than enhanced standard care throughout follow-up.

CONCLUSIONS

The collaborative care intervention resulted in significantly lower depression scores compared to enhanced standard care among participants with co-morbid physical conditions. The findings have potential implications for integrating mental health and chronic disease treatment in resource constrained settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02310932 , registered on December 8, 2014, and Clinical Trials Registry India CTRI/2018/04/013001 , registered on April 4, 2018. Retrospectively registered.

Benchmarking Depressive Symptoms in Cardiac Rehabilitation

PURPOSE

Depression affects cardiac health and is important to track within cardiac rehabilitation (CR). Using two depression screeners within one sample, we calculated prevalence of baseline depressive symptomology, improvements during CR, and predictors of both.

METHODS

Data were drawn from the University of Vermont Medical Center CR program prospectively collected database. A total of 1781 patients who attended between January 2011 and July 2019 were included. Two depression screeners (Geriatric Depression Scale-Short Form [GDS-SF] and Patient Health Questionnaire-9 [PHQ-9]) were compared on proportion of the sample categorized with ≥ mild or moderate levels of depressive symptoms (PHQ-9 ≥5, ≥10; GDS-SF ≥6, ≥10). Changes in depressive symptoms by screener were examined within patients who had completed ≥9 sessions of CR. Patient characteristics associated with depressive symptoms at entry, and changes in symptoms were identified.

RESULTS

Within those who completed ≥9 sessions of CR with exit scores on both screeners (n = 1201), entrance prevalence of ≥ mild and ≥ moderate depressive symptoms differed by screener (32% and 9% PHQ-9; 12% and 3% GDS-SF; both P< .001). Patients who were younger, female, with lower cardiorespiratory fitness (CRF) scores were more likely to have ≥ mild depressive symptoms at entry. Most patients with ≥ mild symptoms decreased severity by ≥1 category by exit (PHQ-9 = 73%; GDS-SF = 77%). Nonsurgical diagnosis and lower CRF were associated with less improvement in symptoms on the PHQ-9 (both P< .05).

CONCLUSION

Our results provide initial benchmarks of depressive symptoms in CR. They identify younger patients, women, patients with lower CRF, and those with nonsurgical diagnosis as higher risk groups for having depressive symptoms or lack of improvement in symptoms.

How is type D personality associated with the major psychological outcomes in noncardiac chest pain patients?

Noncardiac chest pain (NCCP) may lead many problems on the health-care system. Having type D personality has been shown to adversely affect NCCP patients. This study aimed to determine the psychological comorbidities that type D personality is associated with, in patients with NCCP. The participants of this cross-sectional study were 360 patients diagnosed with NCCP. Patients filled out questionnaires about sociodemographic, behavioral, and clinical factors (severity of pain, somatization, cardiac anxiety, fear of body sensations, depression, and type D personality). Type D personality was more prevalent among female (p < 0.005), and those people having this personality showed lower sleep quality (p = 0.001) and sexual life satisfaction (p < 0.001) and more likely to be smoker (p < 0.001). Type D personality is strongly associated with fear of body sensations (β = 5.92, SE = 1.95, p = 0.003), pain intensity (β = 3.53, SE = 0.98, p < 0.001), depression (β = 2.91, SE = 0.62, p < 0.001), and somatization (β = 1.75, SE = 0.55, p < 0.001). Type D personality and major psychological comorbidities were strongly associated. Physicians should consider that having type D personality can be linked to NCCP in an effort to help patients receive effective psychological consultations.

Anxiety and Depression in Adults With Congenital Heart Disease

INTRODUCTION

Anxiety and depression can worsen outcome in patients with heart disease. We elucidate the prevalence of anxiety and depression in a cohort of adults with congenital heart disease (ACHD).

MATERIALS AND METHODS

Prospective screening for anxiety or depression was performed in 204 consecutive patients of the outpatient clinic of our tertiary care center using the Hospital Anxiety and Depression Scale (HADS) questionnaire and the distress thermometer (DT) as a potential ultra-short screening test. Functional data were assessed at liberty of the responsible physician. HADS scores ≥ 8 were considered doubtful and scores ≥ 11 as confirmed cases of anxiety or depression, respectively. HADS results were compared with a historical group of 100 patients with non-Hodgkin Lymphoma (NHL) as well as German reference values from the literature.

RESULTS

Patients from the ACHD cohort were 28 ± 10 years old (mean ± SD, 54% male), 34% had a simple, 51% a moderate, including 52 patients with transposition of the great arteries after arterial switch operation, and 15% a heart defect of severe complexity. Prevalence of depression in ACHD was comparable to the German normal population (5.9% ACHD vs. 5.4% control). In contrast, prevalence of anxiety was higher than expected from reference values (12.7% ACHD vs. 5.6% control). There was a positive association between psychological distress and NYHA class [anxiety: OR 2.67 (95% CI, 1.50-4.76) p = 0.001; depression: OR 2.93 (95% CI, 1.60-5.35) p = 0.0005], but not with age, gender, or heart defect severity. Percentages of patients with ACHD with anxiety were significantly higher than in a cohort of patients with indolent non-Hodgkin lymphoma (NHL) but comparable to those with aggressive NHL (HADS-A ≥ 11: ACHD 12.7%, indolent NHL 2.2%, aggressive NHL 13.2%; p = 0.037 ACHD vs. indolent NHL; p = 0.929 ACHD vs. aggressive NHL). The distress thermometer screening test had only a fair discriminatory ability (AUC 0.708; p = 0.002) and is therefore of limited usability.

CONCLUSION

Adults with congenital heart disease exhibit an increased risk for anxiety disorders independently of the severity of the underlying heart defect. Anxiety prevalence was comparable to a historical cohort of patients with aggressive NHL underlining the importance of a routine screening for psychosocial distress in adults with congenital heart disease.

Getting "Back on Track" After a Cardiac Event: Protocol for a Randomized Controlled Trial of a Web-Based Self-management Program

Background

After a cardiac event, a large majority of patients with cardiac conditions do not achieve recommended behavior change targets for secondary prevention. Mental health issues can also impact the ability to engage in health behavior change. There is a need for innovative, flexible, and theory-driven eHealth programs, which include evidence-based strategies to assist patients with cardiac conditions with their recovery, especially in behavioral and emotional self-management.

Objective

The aim of this study is to determine the short- and longer-term behavioral and emotional well-being outcomes of the Back on Track web-based self-management program. In addition, this study will test whether there is enhanced benefit of providing one-on-one telephone support from a trained lifestyle counselor, over and above benefit obtained through completing the web-based program alone.

Methods

People who have experienced a cardiac event in the previous 12 months and have access to the internet will be eligible for this study (N=120). Participants will be randomly assigned to one of the two study conditions: either “self-directed” completion of the Back on Track program (without assistance) or “supported” completion of the Back on Track program (additional 2 telephone sessions with a lifestyle counselor). All participants will have access to the web-based Back on Track program for 2 months. Telephone sessions with the supported arm participants will occur at approximately 2 and 6 weeks post enrollment. Measures will be assessed at baseline, and then 2 and 6 months later. Outcome measures assessed at all 3 timepoints include dietary intake, physical activity and sitting time, smoking status, anxiety and depression, stage of change, and self-efficacy in relation to behavioral and emotional self-management, quality of life, and self-rated health and well-being. A demographic questionnaire will be included at baseline only and program acceptability at 2 months only.

Results

Recruitment began in May 2020 and concluded in August 2021. Data collection for the 6-month follow-up will be completed by February 2022, and data analysis and publication of results will be completed by June 2022. A total of 122 participants were enrolled in this study.

Conclusions

The Back on Track trial will enable us to quantify the behavioral and emotional improvements obtained and maintained for patients with cardiac conditions and, in particular, to compare two modes of delivery: (1) fully self-directed delivery and (2) supported by a lifestyle counselor. We anticipate that the web-based Back on Track program will assist patients in their recovery and self-management after an acute event, and represents an effective, flexible, and easily accessible adjunct to center-based rehabilitation programs.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620000102976; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378920&isReview=true

International Registered Report Identifier (IRRID)

DERR1-10.2196/34534

Examining the optimal cutoff values of HADS, PHQ-9 and GAD-7 as screening instruments for depression and anxiety in irritable bowel syndrome

BACKGROUND

Self-rating scales are frequently used to screen for anxiety and depression in patients with irritable bowel syndrome (IBS). Different cutoff values are recommended in literature, and guidelines have suggested the use of other screening instruments over time. The aim of this study was to assess the correlation between the most commonly used psychological screening instruments for anxiety and depression in IBS and to compare custom cutoff scores for these instruments.

METHODS

Irritable bowel syndrome patients (n = 192) completed several questionnaires including the Hospital Anxiety and Depression Scale (HADS, HADS-A and HADS-D subscale), Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7). Agreement at different cutoff points, for depressive and anxiety disorder, was assessed by use of the Gwet AC1 coefficient.

KEY RESULTS

Hospital Anxiety and Depression Scale (HADS)-D and PHQ-9 scores, and HADS-A and GAD-7 scores showed high correlations (r_s  = 0.735 and r_s  = 0.805, respectively). For depressive disorder, a Gwet AC1 value of 0.829 was found when recommended cutoff points from literature were compared (PHQ-9 cutoff ≥10, HADS-D cutoff ≥8). For anxiety disorder, a Gwet AC1 value of 0.806 was found when recommended cutoff points from literature were compared (GAD-7 cutoff ≥10, HADS-A cutoff ≥8). Even higher agreements were found when higher HADS cutoff values were chosen, with impact on sensitivity and specificity.

CONCLUSIONS & INFERENCES

Custom cutoff values deem the HADS subscales (HADS-D and HADS-A) concordant to PHQ-9 and GAD-7 scores. The choice of a cutoff value has substantial impact on sensitivity/specificity and is dependent on patient population, setting, and the purpose of use.

Determinants of depression in non-cardiac chest pain patients: a cross sectional study

BACKGROUND

Non-cardiac chest pain (NCCP) is a common patient complaint imposing great costs on the healthcare system. It is associated with psychological factors such as depression. The aim of the present study is determining depression predictors in NCCP patients.

METHODS

The participants of this cross-sectional study were 361 NCCP patients. Patients filled out questionnaires concerning their sociodemographic, lifestyle, and clinical factors (severity of pain, type D personality, somatization, cardiac anxiety, fear of body sensations, and depression).

RESULTS

Based on multiple ordinal logistic regression, lack of physical activity (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.09-2.87), sleep quality (OR, 2.98; 95% CI, 1.15-7.69), being a smoker (OR, 1.33; 95% CI, 2.41-4.03), present pain intensity (OR, 1.08; 95% CI, 1.05-1.11), type D personality (OR, 2.43; 95% CI, 1.47- 4.03), and somatization (OR, 1.22; 95% CI, 1.15-1.3) were significant predictors of depression in NCCP patients. Additionally, multiple linear regression showed that being unmarried (β = 1.51, P = 0.008), lack of physical activity (β = 1.22, P = 0.015), sleep quality (β = 2.26, P = 0.022), present pain intensity (β = 0.07, P = 0.045), type D personality (β = 1.87, P < 0.001), somatization (β = 0.45, P < 0.001), and fear of bodily sensation (β = 0.04, P = 0.032) increased significantly depression scores in NCCP patients.

CONCLUSIONS

Physicians should consider the predictors of depression in NCCP patients which can lead to receiving effective psychological consultations and reducing the costs and ineffectual referrals to medical centers.

Selective cutoff reporting in studies of the accuracy of the Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale: Comparison of results based on published cutoffs versus all cutoffs using individual participant data meta-analysis

OBJECTIVES

Selectively reported results from only well-performing cutoffs in diagnostic accuracy studies may bias estimates in meta-analyses. We investigated cutoff reporting patterns for the Patient Health Questionnaire-9 (PHQ-9; standard cutoff 10) and Edinburgh Postnatal Depression Scale (EPDS; no standard cutoff, commonly used 10-13) and compared accuracy estimates based on published cutoffs versus all cutoffs.

METHODS

We conducted bivariate random effects meta-analyses using individual participant data to compare accuracy from published versus all cutoffs.

RESULTS

For the PHQ-9 (30 studies, N = 11,773), published results underestimated sensitivity for cutoffs below 10 (median difference: -0.06) and overestimated for cutoffs above 10 (median difference: 0.07). EPDS (19 studies, N = 3637) sensitivity estimates from published results were similar for cutoffs below 10 (median difference: 0.00) but higher for cutoffs above 13 (median difference: 0.14). Specificity estimates from published and all cutoffs were similar for both tools. The mean cutoff of all reported cutoffs in PHQ-9 studies with optimal cutoff below 10 was 8.8 compared to 11.8 for those with optimal cutoffs above 10. Mean for EPDS studies with optimal cutoffs below 10 was 9.9 compared to 11.8 for those with optimal cutoffs greater than 10.

CONCLUSION

Selective cutoff reporting was more pronounced for the PHQ-9 than EPDS.

Prevalence trends of depression and anxiety symptoms in adults with cardiovascular diseases and diabetes 1995-2019: The HUNT studies, Norway

Background

Symptoms of depression and anxiety are common in adults with cardiovascular diseases (CVDs) and diabetes mellitus (DM). The literature on depression and anxiety in CVDs and DM populations is extensive; however, studies examining these relationships over time, directly compared to adults without these conditions, are still lacking. This study aimed to investigate trends in depression and anxiety symptom prevalence over more than 20 years in adults with CVDs and DM compared to the general population.

Methods

We used data from the population-based Trøndelag Health Study (HUNT), Norway, including adults (≥ 20 years) from three waves; the HUNT2 (1995–97; n = 65,228), HUNT3 (2006–08; n = 50,800) and HUNT4 (2017–19; n = 56,042). Depressive and anxiety symptom prevalence was measured independently by the Hospital Anxiety and Depressions scale (HADS) in sex-stratified samples. We analyzed associations of these common psychological symptoms with CVDs and DM over time using multi-level random-effects models, accounting for repeated measurements and individual variation.

Results

Overall, the CVDs groups reported higher levels of depression than those free of CVDs in all waves of the study. Further, depressive and anxiety symptom prevalence in adults with and without CVDs and DM declined from HUNT2 to HUNT4, whereas women reported more anxiety than men. Positive associations of depression and anxiety symptoms with CVDs and DM in HUNT2 declined over time. However, associations of CVDs with depression symptoms remained over time in men. Moreover, in women, DM was associated with increased depression symptom risk in HUNT2 and HUNT4.

Conclusions

Depression and anxiety symptoms are frequent in adults with CVDs. Further, our time trend analysis indicates that anxiety and depression are differentially related to CVDs and DM and sex. This study highlights the importance of awareness and management of psychological symptoms in CVDs and DM populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00636-0.

Smartwatch monitoring for atrial fibrillation after stroke—The Pulsewatch Study: Protocol for a multiphase randomized controlled trial

Background

Atrial fibrillation (AF) is a common heart rhythm disorder that elevates stroke risk. Stroke survivors undergo routine heart rhythm monitoring for AF. Smartwatches are capable of AF detection and potentially can replace traditional cardiac monitoring in stroke patients.

Objective

The goal of Pulsewatch is to assess the accuracy, usability, and adherence of a smartwatch-based AF detection system in stroke patients.

Methods

The study will consist of two parts. Part I will have 6 focus groups with stroke patients, caretakers, and physicians, and a Hack-a-thon, to inform development of the Pulsewatch system. Part II is a randomized clinical trial with 2 phases designed to assess the accuracy and usability in the first phase (14 days) and adherence in the second phase (30 days). Participants will be randomized in a 3:1 ratio (intervention to control) for the first phase, and both arms will receive gold-standard electrocardiographic (ECG) monitoring. The intervention group additionally will receive a smartphone/smartwatch dyad with the Pulsewatch applications. Upon completion of 14 days, participants will be re-randomized in a 1:1 ratio. The intervention group will receive the Pulsewatch system and a handheld ECG device, while the control group will be passively monitored. Participants will complete questionnaires at enrollment and at 14- and 44-day follow-up visits to assess various psychosocial measures and health behaviors.

Results

Part I was completed in August 2019. Enrollment for Part II began September 2019, with expected completion by the end of 2021.

Conclusion

Pulsewatch aims to demonstrate that a smartwatch can be accurate for real-time AF detection, and that older stroke patients will find the system usable and will adhere to monitoring.

Effects of high-load and low-load resistance training in patients with coronary artery disease: rationale and design of a randomised controlled clinical trial

INTRODUCTION

Resistance training (RT) combined with aerobic training (AT) enhances the effects of cardiac rehabilitation (CR) in patients with coronary artery disease (CAD). However, it remains to be investigated which type of RT (high loads (HLs) vs low loads (LLs)) is more efficacious in improving exercise performance, cardio-metabolic health and quality of life.

METHODS AND ANALYSIS

A randomised, controlled, clinical trial will enrol 20 patients with CAD into each of three study arms (total 60 patients): HL-RT (70%-80% of one repetition maximum (1-RM)) combined with AT; LL-RT (30%-40% of 1-RM) combined with AT and AT alone as standard care. Primary outcomes (maximal aerobic capacity, maximal leg isometric strength) will be assessed at baseline and after 36 training sessions. Other outcomes will include acute haemodynamic responses to LL-RT and HL-RT, body composition, physical performance, blood biomarkers (lipids, glucose metabolism, inflammation, growth factors), physical activity and quality of life. The intention-to-treat principle will be used to analyse the data.

ETHICS AND DISSEMINATION

The study design and protocol have been approved by the National Medical Ethics Committee of Slovenia (registration number: 0120-573/2019/15). The study will be conducted in accordance with the Declaration of Helsinki. The results of the study will be published as peer-reviewed manuscripts and congress presentations, communicated with patients and the clinical community, and shared through posts on social media. The findings of the study will be disseminated among the national CR clinical community (CR centres, Slovenian association of coronary clubs) with active participation of the patients enrolled in the study. This study will expand our knowledge of RT in combination with AT in CR. We expect to find different effects of HL-RT versus LL-RT, with implications for RT strategies in rehabilitation of patients with CAD.

TRIAL REGISTRATION NUMBER

NCT04638764.

Community-Dwelling Individuals with Coronary Artery Disease Have Higher Risk of Depression than the General Population in Female, But Not in Male

Few studies have been conducted to evaluate the sex difference in the risk of depression in patients with coronary artery disease (CAD), compared with those without CAD in a community-dwelling population. Females with CAD had a 2.68-fold higher risk for depression than females without CAD, while no significant association between CAD diagnosis and depression was observed in males. The contribution of sex should be more intensively considered in the association between CAD status and depression, not only in clinical settings but also in community settings.

Background and Objectives

The aim of this study was to assess sex difference in the association between coronary artery disease (CAD) status and depression in a representative nationwide Korean population.

Methods

In total, 4,620 male and 6,151 female aged ≥40 years, who participated in the Korea National Health and Nutrition Examination Survey conducted in 2014, 2016, and 2018, were included in the analysis. Depression was defined as ≥10 points on the 9-item Patient Health Questionnaire.

Results

Among male participants, no significant association between CAD status and depression was observed. However, female with CAD had higher odds ratio (OR) for depression (OR, 2.68; 95% confidence interval [CI], 1.78–4.03) compared with those without CAD in a multiple logistic regression analysis after adjustment for covariates. Younger age at diagnosis of CAD was a significant relating factor for depression in female; OR (95% CI) was 1.73 (0.88–3.40), 3.01 (1.52–5.97), and 4.11 (2.04–8.28) for age ≥65 years, 55–64 years, and ≤54 years, respectively, compared with that in non-CAD controls. In addition, shorter duration of CAD was a significant relating factor for depression in female; OR (95% CI) was 2.42 (1.26–4.67), 2.61 (1.32–5.16), and 3.13 (1.54–6.34) for duration ≥10 years, 5-9 years, and ≤4 years, respectively, compared with that in non-CAD controls.

Conclusions

Consistent screening and psychosocial supports for depression after discharge are required to improve the mental health care of CAD survivors in the community, especially for female diagnosed at a younger age and recently diagnosed.

Depression and anxiety symptoms are related to pain and frailty but not cognition or delirium in older surgical patients

OBJECTIVE

In community dwelling older adults, depression and anxiety symptoms can be associated with early cognitive decline. Symptoms of depression and anxiety are common in older adults prior to surgery. However, their significance is unknown. Our objective was to determine whether preoperative depression and anxiety symptoms are associated with postoperative cognitive decline (POCD) and in-hospital delirium, in older surgical patients.

METHODS

We conducted a secondary data analysis of postoperative cognitive dysfunction in a cohort study of patients 65 and older undergoing elective noncardiac surgery. We used the Hospital Anxiety and Depression Scale (HADS) to screen for depression and anxiety symptoms at a home visit prior to surgery and 3 months after surgery. Patients with a history of psychiatric (major depressive disorder, bipolar disorder, and schizophrenia) or neurologic disorder (Parkinson's disease and stroke) were excluded from the parent study.

RESULTS

Out of the 167 patients, 9.6% (n = 16) reported significant depressive symptoms and 21.6% (n = 36) reported significant anxiety symptoms on preoperative screening. There was no association between preoperative or new-onset postoperative depression and anxiety symptoms and the incidence of delirium or POCD three months after surgery. Patients with preoperative depressive symptoms had higher preoperative pain (scores 69 vs. 35.7, p = .002) and frailty (56 vs. 14.6, p <.001).

CONCLUSION

In our cohort, we did not detect an association between preoperative depression and anxiety symptoms and neurocognitive disorders. Preoperative depression and anxiety symptoms were related to physical pain and frailty. Taken together, these suggest that in patients without a formal psychiatric diagnosis, preoperative depression and anxiety symptoms are related to physical state rather than a harbinger of early cognitive decline. Future studies are needed to understand the nature of the relationship between depression and anxiety symptoms and physical state in surgical patients.

Sex differences in risk factors for depressive symptoms in patients with COPD: The 2014 and 2016 Korea National Health and Nutrition Examination Survey

Background

Although depression is a common comorbidity of chronic obstructive pulmonary disease (COPD), the role of sex remains unexplored. We evaluated sex differences of risk factors of depressive symptoms in adults with COPD.

Methods

This was a population-based cross-sectional study using data from the 2014 and 2016 Korea National Health and Nutrition Examination Survey. Spirometry was used to identify patients with COPD, defined as a FEV₁/FVC ratio < 0.7. Presence of depressive symptoms was defined as a total score ≥ 5 on the Patient Health Questionnaire-9.

Results

17.8% of participants expressed depressive symptoms. Relative regression analysis revealed that female sex (RR 2.38; 95% CI 1.55–3.66; p < 0.001), living alone (RR 1.46; 95% CI 1.08–1.97; p = 0.013), current smoker (RR 1.70; 95% CI 1.15–2.52; p = 0.008), underweight (RR 1.58 95% CI 1.00–2.49; p = 0.049), and GOLD Stage III/IV (RR 1.92; 95% CI 1.19–3.09; p = 0.007) were the risk factors for depressive symptoms. Low income, living alone, multiple chronic disorders, and low BMI were risk factors of depressive symptoms in male, whereas low educational attainment, urban living, and current smoking were risk factors in female.

Conclusions

Female sex is a main risk factor of depressive symptoms in adults with COPD. As risk factors of depressive symptoms in COPD patients vary according to their sex, different approaches are needed to manage depression in males and females with COPD.

Clinical Psychology Services for Patients Hospitalized Due to COVID-19 During the Pandemic in Northern Italy: From Isolation to Rehabilitation

The objective of this paper is to describe the organization and modality of provision of clinical psychology services for those patients who had to be hospitalized due to COVID-19 during the pandemic in Northern Italy. The IRCCS Policlinico San Donato hospital in Milan was converted into a COVID-19 center in March 2020, and all the staff, including the Clinical Psychology Service Team, were diverted to assist these patients. A description is given of how the service was organized and the modalities which were utilized to assist the patients. Following the pertinent ministerial decrees, guidelines, and relevant literature, the patients were followed up through telehealth (via phone, smartphone, or tablet with audio or audio-visual calls). A COVID-19 rehabilitation unit was later opened in April 2020, where all patients were seen and followed up by the Clinical Psychology team, the last patient being discharged at the end of June. Details are given about the type of services provided during the hospitalization at the different points in time. At admittance and subsequent isolation, patients indicated by the medical and nursing staff, and those who specifically requested it, were given psychological support. Patients transferred to the COVID-19 rehabilitation unit were all evaluated for anxiety, depression, posttraumatic stress disorder, and sleep disorders both on admission and at discharge when possible.

Prevalence of Symptoms of Anxiety Disorders and Depression in Cardiac Rehabilitation Patients in an Academic Hospital: a Case Study

The relationship between body and mind is increasingly recognized in the occurrence and prognosis of cardiac disease. Based on reports detailing the potential (and the influence of certain risk factors) of developing depression and anxiety following cardiovascular disease, or a cardiac event, most notably acute coronary syndrome (ACS), we investigated whether such symptoms also existed in patient cases found at the cardiac rehabilitation unit of an academic hospital of Eastern Ontario. We examined data from charts during a 6-year period (2012-2017). The Hospital Anxiety and Depression Scale cumulated data within a retrospective cross-sectional study, was used to estimate the prevalence of anxious and depressive symptoms that might reflect the presence of psychological distress. Overall, our sample included 1178 patient files, 81.3% of which were diagnosed with ACS and 69.6% were male. 63.1% of the patients were between 60 and 79 years old at the time of diagnosis. Most patients were Caucasian (81.1%), married (60.3%), and living with their family (74.3%), and 49.7% were recorded as overweight or obese. We found that 29.3% of patients reported symptoms of psychological distress. Regression analyses revealed strong negative correlations between the proportion of symptoms of psychological distress and factors like age and functional capacity as measured by metabolic equivalents. Significant associations were also established between symptoms of psychological distress and factors such as obesity, sedentary lifestyle, smoking, and sex (female). This study was undertaken as part of a business case to implement a new cardiac rehabilitation programme in an academic hospital of Eastern Ontario and illustrate to the managers and decision-makers, the important factors to consider and to target when developing a stepped-care program for patients in cardiac rehabilitation in order to prevent psychological distress and how such a program was relevant to their institution.

Physical activity after cardiac arrest; protocol of a sub-study in the Targeted Hypothermia versus Targeted Normothermia after Out-of-Hospital Cardiac Arrest trial (TTM2)

•

The results of this study will provide novel information about physical activity among OHCA-survivors.

•

Physical activity after a cardiac arrest is currently an important knowledge-gap.

•

The results of this study have a potential to improve support and rehabilitation for OHCA-survivors.

Aims

The primary aim of this study is to investigate whether out-of-hospital cardiac arrest (OHCA) survivors have lower levels of self-reported physical activity compared to a non-cardiac arrest (CA) control group who had acute myocardial infarction (MI). Additional aims are to explore potential predictors of physical inactivity (older age, female gender, problems with general physical function, global cognition, mental processing speed/attention, anxiety symptoms, depression symptoms, kinesiophobia, fatigue), and to investigate the relationship between self-reported and objectively measured physical activity among OHCA-survivors.

Methods

The Targeted Hypothermia versus Targeted Normothermia after Out-of-Hospital Cardiac Arrest trial (TTM2-trial) collects information regarding age, gender, self-reported physical activity, general physical function, global cognition and mental processing speed/attention at 6 months after OHCA. In this TTM2-trial cross-sectional prospective sub-study, participants at selected sites are invited to an additional follow-up meeting within 4 weeks from the main study follow-up. At this meeting, information regarding anxiety symptoms, depression symptoms, kinesiophobia and fatigue is collected. The OHCA-survivors are then provided with an objective measure of physical activity, a hip-placed accelerometer, to wear for one week, together with a training diary. At the end of the week, participants are asked to once again answer two self-reported questions regarding physical activity for that specific week. MI-controls attend a single follow-up meeting and perform the same assessments as the OHCA-survivors, except from wearing the accelerometer. We aim to include 110 OHCA-survivors and 110 MI-controls in Sweden, Denmark and the United Kingdom.

Conclusion

The results from this sub-study will provide novel information about physical activity among OHCA-survivors.

Trial registration

Registered at ClinicalTrials.gov: NCT03543332, date of registration June 1, 2018

Depression in patients with knee osteoarthritis: risk factors and associations with joint symptoms

BACKGROUND

To describe demographic and clinical factors associated with the presence and incidence of depression and explore the temporal relationship between depression and joint symptoms in patients with symptomatic knee osteoarthritis (OA).

METHODS

Three hundred ninety-seven participants were selected from a randomized controlled trial in people with symptomatic knee OA and vitamin D deficiency (age 63.3 ± 7.1 year, 48.6% female). Depression severity and knee joint symptoms were assessed using the patient health questionnaire (PHQ-9) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), respectively, at baseline and 24 months.

RESULTS

The presence and incidence of depression was 25.4 and 11.2%, respectively. At baseline, having younger age, a higher body mass index (BMI), greater scores of WOMAC pain (PR: 1.05, 95%CI:1.03, 1.07), dysfunction (PR: 1.02, 95%CI:1.01, 1.02) and stiffness (PR: 1.05, 95%CI: 1.02, 1.09), lower education level, having more than one comorbidity and having two or more painful body sites were significantly associated with a higher presence of depression. Over 24 months, being female, having a higher WOMAC pain (RR: 1.05, 95%CI: 1.02, 1.09) and dysfunction score (RR: 1.02, 95%CI: 1.01, 1.03) at baseline and having two or more painful sites were significantly associated with a higher incidence of depression. In contrast, baseline depression was not associated with changes in knee joint symptoms over 24 months.

CONCLUSION

Knee OA risk factors and joint symptoms, along with co-existing multi-site pain are associated with the presence and development of depression. This suggests that managing common OA risk factors and joint symptoms may be important for prevention and treatment depression in patients with knee OA.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01176344 . Anzctr.org.au identifier: ACTRN12610000495022 .

The Effectiveness of Depression Treatment for Adults with ESKD: A Systematic Review

Adults with dialysis-dependent ESKD experience higher rates of depression than the general population, yet efficacy of depression treatments in this population is not well understood. We conducted a systematic review of the benefits and harms of depression treatment in adults with ESKD. We searched multiple data sources through June 2020 for English-language, controlled trials that compared interventions for depression in adults with ESKD to another intervention, placebo, or usual care, and reported depression treatment-related outcomes. Observational studies were included for harms. Two investigators independently screened all studies using prespecified criteria. One reviewer abstracted data on study design, interventions, implementation characteristics, and outcomes, and a second reviewer provided confirmation. Two reviewers independently assessed study quality and resolved any discords through discussion or a third reviewer. Strength of evidence (SOE) was assessed and agreed upon by review-team consensus. We qualitatively analyzed the data and present syntheses in text and tables. We included 26 RCTs and three observational studies. SSRIs were the most studied type of drug and the evidence was largely insufficient. We found moderate SOE that long-term, high-dose vitamin D3 is ineffective for reducing depression severity. Cognitive behavioral therapy is more effective than (undefined) psychotherapy and placebo for depression improvement and quality of life (low SOE), and acupressure is more effective than usual care or sham acupressure in reducing depression severity (low SOE). There is limited research evaluating treatment for depression in adults with ESKD, and existing studies may not be generalizable to adults in the United States. Studies suffer from limitations related to methodologic quality or reporting. More research replicating studies of promising interventions in US populations, with larger samples, is needed. Systematic Review registry name and registration number: PROSPERO, CRD42020140227.

Sociodemographic, behavioral, and clinical factors associated with low atrial fibrillation knowledge among older adults with atrial fibrillation: The SAGE-AF study

BACKGROUND

Management of AF requires patient engagement in disease management which requires adequate knowledge about AF.

OBJECTIVE

To identify the patient characteristics associated with low AF knowledge among older adults with AF.

METHODS

The SAGE-AF cohort enrolled adults aged ≥65 diagnosed with AF in 2016-2018. Patient characteristics associated with low AF knowledge (<6/8 JAKQ items correct) were examined using multivariable adjusted logistic regression models.

RESULTS

Participants (N = 950) were on average 74 years old (SD: 6.7), 50 % female, and 87 % non-Hispanic white. The average JAKQ score was 68.7 (SD: 17.1), and 78 % had low AF knowledge. Participants aged ≥ 75 (OR: 1.55, 95 % CI: 1.03, 2.33), without a college degree (OR: 0.46, 95 % CI: 0.32, 0.65), cognitively impaired (OR: 1.72, 95 % CI: 1.15, 2.58), with a history of anxiety (OR: 1.76, 95 % CI: 1.09, 2.83), myocardial infarction (OR: 1.82, 95 % CI: 1.08, 3.07), and heart failure (OR: 1.84, 95 % CI: 1.16, 2.91) were more likely to have low AF knowledge.

PRACTICE IMPLICATIONS

Characteristics available in the electronic medical record may identify patients at risk for low AF knowledge. Formal assessment of AF knowledge may identify areas of weakness and allow for targeted education.

Cardiac Rehabilitation Component Attendance and Impact of Intervening Clinical Events, as Well as Disease Severity and Risk Factor Burden

PURPOSE

To examine: (1) the rate of clinical events precluding cardiac rehabilitation (CR) continuation, (2) CR attendance by component in those without events, and (3) the association between disease severity (eg, tobacco use, diabetes, and depression) and component attendance (eg, exercise, diet, stress management, and tobacco cessation).

METHODS

Retrospective analysis of electronic records of the CR program in London, Ontario, from 1999 to 2017. Patients in the supervised program are offered exercise sessions 2 times/wk with a minimum of 48 prescribed sessions tailored to patient need. Patients attending ≥1 session without major factors that would limit their exercise ability were included. Intervening events were recorded, as was component attendance.

RESULTS

Of 5508 enrolled, supervised patients, 3696 did not have a condition that could preclude exercise. Of those enrolled, one-sixth (n = 912) had an intervening event; these patients were less likely to work, more likely to have medical risk factors, had more severe angina and depression, and lower functional capacity. The remaining cohort attended a mean of 26.5 ± 21.3 sessions overall (median = 27; 19% attending ≥48 sessions), including 20.5 ± 17.4 exercise sessions (median = 21). After exercise, the most common components attended were individual dietary and psychological counseling. Patients with more severe angina and depressive symptoms as well as tobacco users attended significantly fewer total sessions, but more of some specific components.

CONCLUSIONS

In one-sixth of patients, CR attendance and completion are impacted by clinical factors beyond their control. Many patients are taking advantage of components specific to their risk factors, buttressing the value of individually tailored, menu-based programming.

A smartphone app for sedentary behaviour change in cardiac rehabilitation and the effect on hospital admissions: the ToDo-CR randomised controlled trial study protocol

INTRODUCTION

Cardiac rehabilitation (CR) is recommended for secondary prevention of cardiovascular disease and reducing the risk of repeat cardiac events. Physical activity is a core component of CR; however, studies show that participants remain largely sedentary. Sedentary behaviour is an independent risk factor for all-cause mortality. Strategies to encourage sedentary behaviour change are needed. This study will explore the effectiveness and costs of a smartphone application (Vire) and an individualised online behaviour change program (ToDo-CR) in reducing sedentary behaviour, all-cause hospital admissions and emergency department visits over 12 months after commencing CR.

METHODS AND ANALYSIS

A multicentre, assessor-blind parallel randomised controlled trial will be conducted with 144 participants (18+ years). Participants will be recruited from three phase-II CR centres. They will be assessed on admission to CR and randomly assigned (1:1) to one of two groups: CR plus the ToDo-CR 6-month programme or usual care CR. Both groups will be re-assessed at 6 months and 12 months for the primary outcome of all-cause hospital admissions and presentations to the emergency department. Accelerometer-measured changes in sedentary behaviour and physical activity will also be assessed. Logistic regression models will be used for the primary outcome of hospital admissions and emergency department visits. Methods for repeated measures analysis will be used for all other outcomes. A cost-effectiveness analysis will be conducted to evaluate the effects of the intervention on the rates of hospital admissions and emergency department visits within the 12 months post commencing CR.

ETHICS AND DISSEMINATION

This study received ethical approval from the Australian Capital Territory Health (2019.ETH.00162), Calvary Public Hospital Bruce (20-2019) and the University of Canberra (HREC-2325) Human Research Ethics Committees (HREC). Results will be disseminated through peer-reviewed academic journals. Results will be made available to participants on request.

TRIAL REGISTRATION NUMBER

ACTRN12619001223123.

Psychometric evaluation of a Canadian version of the Seattle Angina Questionnaire (SAQ-CAN)

BACKGROUND

The Seattle Angina Questionnaire (SAQ) is a widely-used patient-reported outcomes measure in patients with heart disease. This study assesses the validity and reliability of the SAQ in a Canadian cohort of individuals with stable angina.

METHODS AND RESULTS

Data are from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry, a population-based registry of patients who received cardiac catheterization in Alberta, Canada. The cohort consists of 4052 patients undergoing cardiac catheterization for stable angina and completed the SAQ within 2 weeks. Exploratory factor analysis and confirmatory factor analysis (CFA) were used to assess the factorial structure of the SAQ. Internal and test-retest reliabilities of a new measure (i.e., SAQ-CAN) was measured using Cronbach α and intraclass correlation coefficient, respectively. CFA model fit was assessed using the root mean square error of approximation (RMSEA) and comparative fit index (CFI). Construct validity of the SAQ-CAN was assessed in relation to Hospital Anxiety and Depression Scales (HADS), Euro Quality of life 5 dimension (EQ5D), and original SAQ. Of the 4052 patients included in this analysis, 3281 (80.97%) were younger than 75 years old, while 3239 (79.94%) were male. Both exploratory and confirmatory factor analyses revealed a four-factorial structure consisting of 16 items that provided a better fit to the data (RMSEA = 0.049 [90% CI = (0.047, 0.052)]; CFI = 0.975). The 16-item SAQ demonstrated good to excellent internal reliability (Cronbach's α range from 0.77 to 0.90), moderate to strong correlation with the Original SAQ and EQ5D but negligible correlations with HADS.

CONCLUSION

The SAQ-CAN has acceptable psychometric properties that are comparable to the original SAQ. We recommend its use for assessing coronary health outcomes in Canadian patients with Coronary Artery Disease.