Depressive symptom dimensions and cardiac prognosis following myocardial infarction: results from the ENRICHD clinical trial

Mental Illness Strikes at the Heart: Impact of Psychiatric Diseases on Ventricular Ejection Fraction in Patients with Acute Coronary Syndromes

Mental illnesses can have a significant impact on individuals experiencing acute coronary syndromes (ACS). Mental illnesses are associated with an increased cardiovascular risk profile and early onset of cardiovascular disease. A critical aspect of this interplay is the effect of psychiatric conditions on left ventricular ejection fraction (LVEF), a key parameter in evaluating cardiac function and predicting long-term outcomes in ACS patients. The present single-center, retrospective study investigated the associations between psychiatric conditions and cardiac function, with a focus on LVEF in ACS patients. The inclusion criteria were Italian nationality and 30 years or older. One hundred and sixty-four patients without (Mage = 68.8 ± 10.6, 62 females) and 161 patients with a psychiatric diagnosis (Mage = 68.4 ± 13.7, 63 females) were enrolled. The data collected included sociodemographic variables, psychiatric diagnoses, LVEF, ACS type (STEMI/NSTEMI), smoking status, previous interventions, and pharmacological treatments. Statistical analyses included chi-square, t-tests, ANOVAs, and ANCOVA to assess differences across groups. Findings revealed lower LVEF in patients with a psychiatric diagnosis compared to patients without a psychiatric diagnosis (p = 0.004, d = 0.36). Patients without a psychiatric diagnosis were associated with NSTEMI (p = 0.047, φ = 0.11), hypertension (p = 0.003, φ = -0.16), and dyslipidemia (p = 0.022, φ = -0.13). In contrast, patients with a psychiatric diagnosis were associated with STEMI (p = 0.047, φ = 0.11), neurological dysfunction (p = 0.014, φ = 0.14), and chronic obstructive pulmonary disease (p = 0.010, φ = 0.14). Among psychiatric diagnoses, anxiety disorders were associated with lower LVEF compared to substance abuse disorders (p = 0.012, d = -0.81). The findings underscore the complex relationship between mental illness and cardiac function, emphasising the need to integrate psychiatric evaluations into cardiology care to optimise the management of both mental and cardiovascular health. This study has several limitations, including its design, which prevents causal conclusions, and the use of convenience sampling, which limits the generalizability of the findings.

Types of depression in patients with coronary heart disease: Results from the THORESCI study

BACKGROUND

Both coronary heart diseases (CHD) and depression are highly prevalent and bidirectionally related. The precise nature of this relationship remains unclear. Defining depressive subtypes could help unravel this relationship. Therefore, the aim of this study was to explore depressive subtypes in patients with CHD.

METHODS

1530 patients (21.3 % women, mean age: 64.7 years (SD = 10.1)) were included in latent class analysis with nine indicators derived from the PHQ-9 and BDI-II representing symptoms of depression as described in the DSM-5 criteria. The best-fitting latent class model was confirmed with double cross-validation. Classes were characterized using demographic, medical, psychiatric, and cardiovascular (risk) factors.

RESULTS

A 3-class model demonstrated the best fit to the data, resulting in a depressed (5.4 %), fatigued (13.5 %), and non-depressed class (81.1 %). Having medical comorbidities, a history of psychiatric problems, negative affectivity, and anxiety symptoms increased the odds of belonging to the depressed group (OR 3.02, 95%CI 1.19-7.68, OR 3.61, 95%CI 1.44-9.02, OR 1.16, 95%CI 1.04-1.30, and OR 1.89, 95%CI 1.66-2.15, respectively). Belonging to the fatigued group was associated with increased odds of having an elective PCI (OR 2.12, 95%CI 1.27-3.55), insufficient physical activity (OR 2.19, 95%CI 1.20-3.99), comorbid medical conditions (OR 2.15, 95%CI 1.21-3.81), a history of psychiatric problems (OR 2.25, 95%CI 1.25-4.05), and anxiety symptoms (OR 1.48, 95%CI 1.34-1.63) compared with the non-depressed group.

LIMITATIONS

Future studies should include more people with depressive symptoms.

CONCLUSIONS

Patients with CHD and medical or psychiatric risk factors should be offered support to decrease or prevent depressive or fatigue symptoms.

Linking head and heart health: the association between psychiatric outcomes for patients with major depressive disorder and myocardial ischemia - a systematic review

INTRODUCTION

The development of depression after myocardial infarction is associated with a 2- to 2.5-fold increased risk of all-cause mortality, cardiovascular mortality, and cardiovascular events. The objective of this study was to investigate, through a broad search of the literature, whether major depression is associated with worse psychiatric outcomes in middle-aged patients with myocardial ischemia.

METHODS

An extensive search for studies on the association between major depression and myocardial ischemia was conducted in the PubMed, Embase, PsycINFO, and Web of Science databases. Randomized clinical trials of middle-aged patients with myocardial ischemia and concomitant depressive symptoms were included.

RESULTS

The 14 articles included in this systematic review did not confirm an association between myocardial ischemia and depression with worse psychiatric outcomes in middle-aged patients. However, worse cardiovascular outcomes have been observed in patients with depression after myocardial infarction.

CONCLUSIONS

The findings of this study suggest that major depression increases cardiovascular risk in patients after acute myocardial infarction, possibly because of a more pronounced increase in inflammatory markers.

REGISTRATION

This systematic review was registered in the International Prospective Registry of Systematic Reviews (PROSPERO) under the number CRD: 511650.

Construction and Validation of a Nomogram Predicting Depression Risk in Patients with Acute Coronary Syndrome Undergoing Coronary Stenting: A Prospective Cohort Study

PURPOSE

To construct and validate a nomogram for predicting depression after acute coronary stent implantation for risk assessment.

METHODS

This study included 150 patients with acute coronary syndrome (ACS) who underwent stent implantation. Univariate analysis was performed to identify the predictors of postoperative depression among the 24 factors. Subsequently, multivariate logistic regression was performed to incorporate the significant predictors into the prediction model. The model was developed using the "rms" software package in R software, and internal validation was performed using the bootstrap method.

RESULTS

Of the 150 patients, 82 developed depressive symptoms after coronary stent implantation, resulting in an incidence of depression of 54.7%. Univariate analysis showed that sleep duration ≥7 h, baseline GAD-7 score, baseline PHQ-9 score, and postoperative GAD-7 score were associated with the occurrence of depression after stenting in ACS patients (all p < 0.05). Multivariate logistic regression analysis revealed that major life events in the past year (OR = 2.783,95%CI: 1.121-6.907, p = 0.027), GAD-7 score after operation (OR = 1.165, 95% CI: 1.275-2.097, p = 0.000), and baseline PHQ-9 score (OR = 3.221, 95%CI: 2.065-5.023, p = 0.000) were significant independent risk factors for ACS patients after stent implantation. Based on these results, a predictive nomogram was constructed. The model demonstrated good prediction ability, with an AUC of 0.857 (95% CI = 0.799-0.916). The correction curve showed a good correlation between the predicted results and the actual results (Brier score = 0.15). The decision curve analysis and prediction model curve had clinical practical value in the threshold probability range of 7 to 94%.

CONCLUSIONS

This nomogram can help to predict the incidence of depression and has good clinical application value. This trial is registered with ChiCTR2300071408.

Social network interventions to support cardiac rehabilitation and secondary prevention in the management of people with heart disease

BACKGROUND

Globally, cardiovascular diseases (CVD, that is, coronary heart (CHD) and circulatory diseases combined) contribute to 31% of all deaths, more than any other cause. In line with guidance in the UK and globally, cardiac rehabilitation programmes are widely offered to people with heart disease, and include psychosocial, educational, health behaviour change, and risk management components. Social support and social network interventions have potential to improve outcomes of these programmes, but whether and how these interventions work is poorly understood.  OBJECTIVES: To assess the effectiveness of social network and social support interventions to support cardiac rehabilitation and secondary prevention in the management of people with heart disease. The comparator was usual care with no element of social support (i.e. secondary prevention alone or with cardiac rehabilitation).  SEARCH METHODS: We undertook a systematic search of the following databases on 9 August 2022: CENTRAL, MEDLINE, Embase, and the Web of Science. We also searched ClinicalTrials.gov and the WHO ICTRP. We reviewed the reference lists of relevant systematic reviews and included primary studies, and we contacted experts to identify additional studies.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) of social network or social support interventions for people with heart disease. We included studies regardless of their duration of follow-up, and included those reported as full text, published as abstract only, and unpublished data.

DATA COLLECTION AND ANALYSIS

Using Covidence, two review authors independently screened all identified titles. We retrieved full-text study reports and publications marked 'included', and two review authors independently screened these, and conducted data extraction. Two authors independently assessed risk of bias, and assessed the certainty of the evidence using GRADE. Primary outcomes were all-cause mortality, cardiovascular-related mortality, all-cause hospital admission, cardiovascular-related hospital admission, and health-related quality of life (HRQoL) measured at > 12 months follow-up.  MAIN RESULTS: We included 54 RCTs (126 publications) reporting data for a total of 11,445 people with heart disease. The median follow-up was seven months and median sample size was 96 participants. Of included study participants, 6414 (56%) were male, and the mean age ranged from 48.6 to 76.3 years. Studies included heart failure (41%), mixed cardiac disease (31%), post-myocardial infarction (13%), post-revascularisation (7%), CHD (7%), and cardiac X syndrome (1%) patients. The median intervention duration was 12 weeks. We identified notable diversity in social network and social support interventions, across what was delivered, how, and by whom.  We assessed risk of bias (RoB) in primary outcomes at > 12 months follow-up as either 'low' (2/15 studies), 'some concerns' (11/15), or 'high' (2/15). 'Some concerns' or 'high' RoB resulted from insufficient detail on blinding of outcome assessors, data missingness, and absence of pre-agreed statistical analysis plans. In particular, HRQoL outcomes were at high RoB. Using the GRADE method, we assessed the certainty of evidence as low or very low across outcomes. Social network or social support interventions had no clear effect on all-cause mortality (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.49 to 1.13, I2 = 40%) or cardiovascular-related mortality (RR 0.85, 95% CI 0.66 to 1.10, I2 = 0%) at > 12 months follow-up. The evidence suggests that social network or social support interventions for heart disease may result in little to no difference in all-cause hospital admission (RR 1.03, 95% CI 0.86 to 1.22, I2 = 0%), or cardiovascular-related hospital admission (RR 0.92, 95% CI 0.77 to 1.10, I2 = 16%), with a low level of certainty. The evidence was very uncertain regarding the impact of social network interventions on HRQoL at > 12 months follow-up (SF-36 physical component score: mean difference (MD) 31.53, 95% CI -28.65 to 91.71, I2 = 100%, 2 trials/comparisons, 166 participants; mental component score MD 30.62, 95% CI -33.88 to 95.13, I2 = 100%, 2 trials/comparisons, 166 participants).  Regarding secondary outcomes, there may be a decrease in both systolic and diastolic blood pressure with social network or social support interventions. There was no evidence of impact found on psychological well-being, smoking, cholesterol, myocardial infarction, revascularisation, return to work/education, social isolation or connectedness, patient satisfaction, or adverse events.  Results of meta-regression did not suggest that the intervention effect was related to risk of bias, intervention type, duration, setting, and delivery mode, population type, study location, participant age, or percentage of male participants.  AUTHORS' CONCLUSIONS: We found no strong evidence for the effectiveness of such interventions, although modest effects were identified in relation to blood pressure. While the data presented in this review are indicative of potential for positive effects, the review also highlights the lack of sufficient evidence to conclusively support such interventions for people with heart disease. Further high-quality, well-reported RCTs are required to fully explore the potential of social support interventions in this context. Future reporting of social network and social support interventions for people with heart disease needs to be significantly clearer, and more effectively theorised, in order to ascertain causal pathways and effect on outcomes.

Association Between Depression and Outcomes in Chinese Patients With Myocardial Infarction and Nonobstructive Coronary Arteries

Background Myocardial infarction with nonobstructive coronary arteries ( MINOCA ) occurs in ≈10% of all patients with myocardial infarction. Studies on effects of depression on MINOCA outcomes are lacking. Therefore, the aim of this study was to examine the association of depression with clinical outcomes in Chinese patients with MINOCA . Methods and Results We conducted a prospective cohort study of 633 participants with MINOCA and followed up for 3 years. End points were defined as all-cause mortality and cardiovascular events. Diagnosis of depression was ascertained using the psychiatric interview based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). During the follow-up period, all-cause death occurred in 93 individuals and cardiovascular events developed in 170 individuals. Kaplan-Meier curves showed a significant association of depression with all-cause mortality (log-rank P<0.001) and cardiovascular events (log-rank P<0.001). Multiple Cox regression identified the new diagnosis of depression as an independent prognostic factor for all-cause mortality as well as cardiovascular events (adjusted hazard ratio, 7.250; 95% CI, 4.735-11.100; P<0.001; and hazard ratio, 3.411; 95% CI , 2.490-4.674; P<0.001, respectively). Conclusions The new diagnosis of depression at the time of myocardial infarction is associated with increased risk of adverse clinical outcomes in patients with MINOCA.

Frequency and clinical correlates of bipolar features in acute coronary syndrome patients

Background:

Depression and acute coronary syndrome (ACS) are both extremely prevalent diseases. Studies aimed at evaluating whether depression is an independent risk factor for cardiac events provided no definitive results. In most of these studies, depression has been broadly defined with no differentiation between unipolar (MDD) versus bipolar forms (BD). The aim of this study was to evaluate the frequency of DSM-IV BD (bipolar I and bipolar II subtypes, cyclothymia), as well as temperamental or isolated bipolar features in a sample of 171 patients hospitalized for ACS. We also explored whether these psychopathological conditions were associated with some clinical characteristics of ACS.

Methods:

Patients with ACS admitted to three neighboring Cardiac Intensive Care Units (CICUs) in a 12-month continuative period of time were eligible for inclusion if they met the criteria for either acute myocardial infarct with or without ST-segment elevation or unstable angina, verified by standard ACS criteria. All patients underwent standardized cardiological and psychopathological evaluations.

Results:

Of the 171 ACS patients enrolled, 37 patients (21.7%) were found to have a DSM-IV mood disorder. Of these, 20 (11.7%) had bipolar type I or type II or cyclothymia, while 17 (10%) were the cases of MDD. Rapid mood switches ranged from 11% of ACS patients with no mood disorders, to 47% of those with MDD to 55% of those with BD. Linear regression analysis showed that a diagnosis of BD (p = .023), but not that of MDD (p = .721), was associated with a significant younger age at the index episode of ACS. A history of previous coronary events was more frequent in ACS patients with BD than in those with MDD.

Conclusions:

Our data indicate that bipolar features and diagnosis are frequent in ACS patients. Bipolar disorder has a negative impact on cardiac symptomatology. Further research in this area is warranted.

Patients with ST segment elevation myocardial infarction: moderating effect of perceived control on the relationship between depression and in-hospital complications

BACKGROUND

Cardiovascular diseases remain the top global killer, with nearly 80% of related mortalities occurring in developing countries. Over half of cardiovascular diseases' mortality is due to coronary heart disease, which is commonly linked to acute myocardial infarction. Psychological factors (i.e., depression and anxiety) after acute myocardial infarction are associated with higher levels of complications and mortality. Perceived control moderated the effect of anxiety on complications in different cardiac populations, but impacts on depression and complications after acute myocardial infarction are not well studied. This study explores the moderating effect of perceived control on the relationship between depression and complications after ST segment elevation myocardial infarction.

METHODS

Three hundred patients with a confirmed diagnosis of ST segment elevation myocardial infarction participated in this prospective observational study. Patients answered socio-demographic data, the depression subscale of the Hospital Anxiety and Depression Scale (HADS), and the Control Attitude Scale-Revised (CAS-R) questionnaires. In-hospital complications and all other necessary data were extracted from medical records after discharge. Data were analyzed using logistic regression.

RESULTS

24% developed at least one complication. Patients with high depression scores (8-21) were more likely to develop complications (χ² = 34.15, p < .001) than those with low depression scores (0-7). Patients with high levels of perceived control had lower levels of depression than those with low perceived control (mean [SD], 9.47 [6.43] vs. 12.31 [6.66], p < .001). The results of logistic regression showed that perceived control moderated the association between depression and complications, since depression scores, perceived control scores, and the interaction between depression and perceived control were significant predictors of complications. Participants with high depression and low perceived control had the highest rate of complications (31.5% vs. 15.4%, P < .001).

CONCLUSIONS

Depression increased complications after ST segment elevation myocardial infarction. Perceived control moderated this relationship. Assessment of depression and enhancement of perceived control in patients with acute myocardial infarction can decrease complications and improve outcomes.

A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians

OBJECTIVE

The objective of this study was to evaluate the performance of the Professional Fulfillment Index (PFI), a 16-item instrument to assess physicians' professional fulfillment and burnout, designed for sensitivity to change attributable to interventions or other factors affecting physician well-being.

METHODS

A sample of 250 physicians completed the PFI, a measure of self-reported medical errors, and previously validated measures including the Maslach Burnout Inventory (MBI), a one-item burnout measure, the World Health Organization's abbreviated quality of life assessment (WHOQOL-BREF), and PROMIS short-form depression, anxiety, and sleep-related impairment scales. Between 2 and 3 weeks later, 227 (91%) repeated the PFI and the sleep-related impairment scale.

RESULTS

Principal components analysis justified PFI subscales for professional fulfillment, work exhaustion, and interpersonal disengagement. Test-retest reliability estimates were 0.82 for professional fulfillment (α = 0.91), 0.80 for work exhaustion (α = 0.86), 0.71 for interpersonal disengagement (α = 0.92), and 0.80 for overall burnout (α = 0.92). PFI burnout measures correlated highly (r ≥ 0.50) with their closest related MBI equivalents. Cohen's d effect size differences in self-reported medical errors for high versus low burnout classified using the PFI and the MBI were 0.55 and 0.44, respectively. PFI scales correlated in expected directions with sleep-related impairment, depression, anxiety, and WHOQOL-BREF scores. PFI scales demonstrated sufficient sensitivity to detect expected effects of a two-point (range 8-40) change in sleep-related impairment.

CONCLUSIONS

PFI scales have good performance characteristics including sensitivity to change and offer a novel contribution by assessing professional fulfillment in addition to burnout.

Psychological mediators related to clinical outcome in cognitive behavioural therapy for coronary heart disease: A sub-analysis from the SUPRIM trial

Background

The Secondary Prevention in Uppsala Primary Healthcare Project (SUPRIM) was a randomized controlled trial of a group-based cognitive behavioural therapy stress management programme for patients with coronary heart disease. The project was successful in reducing the risk of fatal or non-fatal first recurrent cardiovascular events. The aim of this study was to analyse the effect of cognitive behavioural therapy on self-rated stress, somatic anxiety, vital exhaustion and depression and to study the associations of these factors with the reduction in cardiovascular events.

Methods

A total of 362 patients were randomly assigned to intervention or usual care groups. The psychological outcomes were assessed five times during 24 months and analysed using linear mixed models. The mediating roles of the outcomes were analysed using joint modelling of the longitudinal and time to event data.

Results

The intervention had a positive effect on somatic anxiety (p < 0.05), reflecting a beneficial development over time compared with the controls. Stress, vital exhaustion and depression did not differ between the groups over time. Mediator analysis suggested that somatic anxiety may have mediated the effect of treatment on cardiovascular events.

Conclusions

The intervention had a small positive effect on somatic anxiety, but did not affect stress, vital exhaustion or depression in patients with coronary heart disease. Somatic anxiety was associated with an increased risk of cardiovascular events and might act as a partial mediator in the treatment effect on cardiovascular events. However, the mechanisms between the intervention and the protective cardiovascular outcome remain to be identified.

Depression trajectories and the association with metabolic adversities among the middle-aged adults

BACKGROUND

Despite both depression and metabolic disturbances confer substantial burden of disease, natural course of depressive symptoms and the relationship with metabolic adversities have not examined. We explore associations between trajectories of depressive symptoms and metabolic disturbance, lifestyle factors and comorbidities.

METHODS

This retrospective cohort study included 13,745 subjects (8113 men and 5632 women) 40-59 years of age who underwent health examinations at the Seoul National University Hospital Healthcare System, Gangnam Center, in Korea. The median follow-up duration was 4.0 years. We estimated the mean trajectories of the Beck Depression Inventory scores using latent-class growth-curve analysis.

RESULTS

We identified four distinctive trajectories of depressive symptoms in both sex. The probabilities of group membership were 35.1% (n=2374) in minimal, 47.4% (n=4545) in persistent-mild, 14.4% (n=987) in persistent-moderate, and 3.0% (n=207) in persistent-severe in men, and 36.3% (n=1883), 50.0% (n=3069), 12.3% (n=601) and 1.5% (n=79) in women. We found significant increasing trend in the prevalence of metabolic abnormalities in more severe depressive trajectory. The adjusted odds ratios of persistent-severe were significantly increased for the following variables: low HDL, hypertriglyceridemia, and metabolic syndrome (MetS) in men and hypertriglyceridemia, MetS in women, and smoking, alcohol consumption and lack of exercise in both genders.

LIMITATIONS

Medical and psychiatric histories were obtained using a self-reported questionnaire rather than formal diagnostic assessments.

CONCLUSIONS

The higher level of depressive symptoms trajectory was associated with MetS, especially lipid abnormalities, and several modifiable lifestyle factors. Our findings provide important implications for developing health policy and guidelines for reducing depressive symptom burden.

Acute coronary syndrome-associated depression: the salience of a sickness response analogy?

Depression emerging in conjunction with acute coronary syndrome (ACS) is thought to constitute a distinct high-risk phenotype with inflammatory determinants. This review critically examines the notion put forward in the literature that ACS-associated depression constitutes a meaningful subtype that is qualitatively different from depressive syndromes observed in psychiatric patients; and evaluates the salience of an analogy to the acute sickness response to infection or injury as an explanatory model. Specific features differentiating ACS-associated depression from other phenotypes are discussed, including differences in depression symptom profiles, timing of the depressive episode in relation to ACS, severity of the cardiac event, and associated immune activation. While an acute sickness response analogy offers a plausible conceptual framework, concrete evidence is lacking for inflammatory activity as the triggering mechanism. It is likely that ACS-associated depression encompasses several causative scenarios.

Depressive symptom trajectories over a 6-year period following myocardial infarction: predictive function of cognitive appraisal and coping

The association between distinct patterns of depression and coping variables in myocardial infarction (MI) survivors over the long-term is unclear. The study aims to evaluate depressive trajectories and their covariates, including coping and cognitive appraisal, following MI over a period of 6 years. Depressive symptoms were assessed in 200 patients a few days after the first MI, and 1 month, 6 months and 6 years later. Cognitive appraisal and coping were assessed during the first three time points. Three latent depressive trajectories were identified: chronic (high; increasing then decreasing; n = 49), rising (moderate; decreasing then increasing; n = 121) and low (low; decreasing then stabilizing; n = 30). The chronic trajectory was associated with higher negative appraisal and emotion-focused coping. The findings clarify the long-term longitudinal trajectories of post-MI depressive symptoms and their association with coping variables, revealing the unfavorable impact of negative cognition and palliative coping.

Treatment of affective disorders in cardiac disease

Patients with cardiovascular disease (CVD) commonly have syndromal major depression, and depression has been associated with an increased risk of morbidity and mortality. Prevalence of depression is between 17% and 47% in CVD patients. Pharmacologic and psychotherapeutic interventions have long been studied, and in general are safe and somewhat efficacious in decreasing depressive symptoms in patients with CVD. The impact on cardiac outcomes remains unclear. The evidence from randomized controlled clinical trials indicates that antidepressants, especially selective serotonin uptake inhibitors, are overwhelmingly safe, and likely to be effective in the treatment of depression in patients with CVD. This review describes the prevalence of depression in patients with CVD, the physiological links between depression and CVD, the treatment options for affective disorders, and the clinical trials that demonstrate efficacy and safety of antidepressant medications and psychotherapy in this patient population. Great progress has been made in understanding potential mediators between major depressive disorder and CVD—both health behaviors and shared biological risks such as inflammation.

Cognitive/affective and somatic/affective symptoms of depression in patients with heart disease and their association with cardiovascular prognosis: a meta-analysis

BACKGROUND

Several prospective longitudinal studies have suggested that somatic/affective depressive symptoms, but not cognitive/affective depressive symptoms, are related to prognosis in patients with heart disease, but findings have been inconsistent. The aim of this study was to investigate the association of cognitive/affective and somatic/affective symptoms of depression with cardiovascular prognosis in patients with heart disease using a meta-analytic perspective.

METHOD

A systematic search was performed in PubMed, EMBASE and PsycInfo. Thirteen prospective studies on symptom dimensions of depression and cardiovascular prognosis fulfilled the inclusion criteria, providing data on a total of 11,128 subjects. The risk estimates for each dimension of depressive symptoms, demographic and methodological variables were extracted from the included articles.

RESULTS

In least-adjusted analyses, both the somatic/affective [hazard ratio (HR) 1.30, 95% confidence interval (CI) 1.19-1.41, p < 0.001] and cognitive/affective (HR 1.07, 95% CI 1.00-1.15, p = 0.05) dimensions of depressive symptoms were associated with cardiovascular prognosis. In fully adjusted analyses, somatic/affective symptoms were significantly associated with adverse prognosis (HR 1.19, 95% CI 1.10-1.29, p < 0.001) but cognitive/affective symptoms were not (HR 1.04, 95% CI 0.97-1.12, p = 0.25). An increase of one standard deviation (±1 s.d.) in the scores of the somatic/affective dimension was associated with a 32% increased risk of adverse outcomes (HR 1.32, 95% CI 1.17-1.48, p < 0.001).

CONCLUSIONS

Somatic/affective depressive symptoms were more strongly and consistently associated with mortality and cardiovascular events in patients with heart disease compared with cognitive/affective symptoms. Future research should focus on the mechanisms by which somatic/affective depressive symptoms may affect cardiovascular prognosis.

[Depression in Acute Coronary Syndromes: Application of the Beck Depression Inventory]

BACKGROUND

Depression has been related to the occurrence of cardiovascular diseases, and also appears to increase the risk of death from coronary artery disease. The presence of depression after the occurrence of an acute coronary syndrome (ACS) and its relationship with socioeconomic factors has not been studied in Colombia.

OBJECTIVE

To describe the frequency of depression and associated factors in patients hospitalized with an ACS.

METHODS

A cross-sectional study was carried out between April and May 2008 in three coronary care units in Santa Marta, Colombia. The presence of depression was evaluated with the Beck Depression Inventory (BDI). Depression was considered to be present if BDI was equal or greater than 10. The relationship between the presence of depression and demographic, clinic and laboratory characteristics was analyzed.

RESULTS

A BDI score ≥10 (any degree of depression) was seen in 21 (63.64%) of the patients. In 9 out of 10 (91.66%) patients without stable income had depression in contrast to 12 out of 23 (57.14%) with stable income (P=.037). Depression was found in in 8 of the 8 (100%) patients with electrocardiographic pathological T wave inversion, in contrast to 13 out of the 25 (52%) without changes in T wave (P=.014). Depression was detected in 17 of 22 (77.27%) patients who smoked cigarettes versus 4 of 11 (36.36%) of patients who have never smoked (P=.021).

CONCLUSIONS

Depressive symptoms are significantly present in patients suffering an acute coronary syndrome. Unemployment, pathological T wave inversion, and smoking seem to be associated with the presence of depressive symptoms after an acute coronary event.

Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association

BACKGROUND

Although prospective studies, systematic reviews, and meta-analyses have documented an association between depression and increased morbidity and mortality in a variety of cardiac populations, depression has not yet achieved formal recognition as a risk factor for poor prognosis in patients with acute coronary syndrome by the American Heart Association and other health organizations. The purpose of this scientific statement is to review available evidence and recommend whether depression should be elevated to the status of a risk factor for patients with acute coronary syndrome.

METHODS AND RESULTS

Writing group members were approved by the American Heart Association's Scientific Statement and Manuscript Oversight Committees. A systematic literature review on depression and adverse medical outcomes after acute coronary syndrome was conducted that included all-cause mortality, cardiac mortality, and composite outcomes for mortality and nonfatal events. The review assessed the strength, consistency, independence, and generalizability of the published studies. A total of 53 individual studies (32 reported on associations with all-cause mortality, 12 on cardiac mortality, and 22 on composite outcomes) and 4 meta-analyses met inclusion criteria. There was heterogeneity across studies in terms of the demographic composition of study samples, definition and measurement of depression, length of follow-up, and covariates included in the multivariable models. Despite limitations in some individual studies, our review identified generally consistent associations between depression and adverse outcomes.

CONCLUSIONS

Despite the heterogeneity of published studies included in this review, the preponderance of evidence supports the recommendation that the American Heart Association should elevate depression to the status of a risk factor for adverse medical outcomes in patients with acute coronary syndrome.

The burden of chronic diseases in a rural North Florida sample

BACKGROUND

The degree of health disparities present in rural communities is of growing concern and is considered "urgent" since rural residents lag behind their urban counterparts in health status. Understanding the prevalence and type of chronic diseases in rural communities is often difficult since Americans living in rural areas are reportedly less likely to have access to quality health care, although there are some exceptions. Data suggest that rural residents are more likely to engage in higher levels of behavioral and health risk-taking than urban residents, and newer evidence suggests that there are differences in health risk behavior within rural subgroups. The objective of this report is to characterize the prevalence of four major and costly chronic diseases (diabetes, cardiovascular disease, cancer, and arthritis) and putative risk factors including depressive symptoms within an understudied rural region of the United States. These four chronic conditions remain among the most common and preventable of health problems across the United States.

METHODS

Using survey data (N = 2526), logistic regression models were used to assess the association of the outcome and risk factors adjusting for age, gender, and race.

RESULTS

Key findings are (1) Lower financial security was associated with higher prevalence of cardiovascular disease, arthritis, and diabetes, but not cancer. (2) Higher levels of depressive symptoms were associated with higher prevalence of cardiovascular disease, arthritis, and diabetes. (3) Former or current smoking was associated with higher prevalence of cardiovascular disease and cancer. (4) Blacks reported higher prevalence of diabetes than Whites; Black women were more likely to report diabetes than all other groups; prevalence of diabetes was greater among women with lower education than among women with higher education. (5) Overall, the prevalence of diabetes and arthritis was higher than that reported by Florida and national data.

CONCLUSIONS

The findings presented in this paper are derived from one of only a few studies examining patterns of chronic disease among residents of both a rural and lower income geographic region. Overall, the prevalence of these conditions compared to the state and nation as a whole is elevated and calls for increased attention and tailored public health interventions.

Inflammation and symptoms of depression and anxiety in patients with acute coronary heart disease

Depression following an acute coronary syndrome (ACS, including myocardial infarction or unstable angina) is associated with recurrent cardiovascular events, but the depressive symptoms that are cardiotoxic appear to have particular characteristics: they are 'incident' rather than being a continuation of prior depression, and they are somatic rather than cognitive in nature. We tested the hypothesis that the magnitude of inflammatory responses during the ACS would predict somatic symptoms of depression 3 weeks and 6 months later, specifically in patients without a history of depressive illness. White cell count and C-reactive protein were measured on the day after admission in 216 ACS patients. ACS was associated with very high levels of inflammation, averaging 13.23×10(9)/l and 17.06 mg/l for white cell count and C-reactive protein respectively. White cell count during ACS predicted somatic symptom intensity on the Beck Depression Inventory 3 weeks later (β=0.122, 95% C.I. 0.015-0.230, p=0.025) independently of age, sex, ethnicity, socioeconomic status, marital status, smoking, cardiac arrest during admission and clinical cardiac risk, but only in patients without a history of depression. At 6 months, white cell count during ACS was associated with elevated anxiety on the Hospital Anxiety and Depression Scale independently of covariates including anxiety measured at 3 weeks (adjusted odds ratio 1.08, 95% C.I. 1.01-1.15, p=0.022). An unpredicted relationship between white cell count during ACS and cognitive symptoms of depression at 6 months was also observed. The study provides some support for the hypothesis that the marked inflammation during ACS contributes to later depression in a subset of patients, but the evidence is not conclusive.

Changes in cognitive versus somatic symptoms of depression and event-free survival following acute myocardial infarction in the Enhancing Recovery In Coronary Heart Disease (ENRICHD) study

BACKGROUND

Randomized controlled trials focusing on the effects of antidepressant treatment in cardiac patients have found modest effects on depressive symptoms but not on cardiac outcomes. A secondary analysis was conducted on data from the Enhancing Recovery in Coronary Heart Disease trial to assess whether changes in somatic or cognitive depressive symptoms following acute MI predicted event-free survival and whether the results differed per treatment arm (cognitive behavior therapy or care as usual).

METHODS

Patients who met depression criteria and completed the 6th month depression assessment (n=1254) were included in this study. Measurements included demographic and clinical data and the Beck Depression Inventory at baseline and 6 months. The primary endpoint was a composite of recurrent MI and mortality over 2.4 years (standard deviation=0.9 years).

RESULTS

Positive changes (per 1 point increase) in somatic depressive symptoms (HR: 0.95; 95% CI: 0.92-0.98; p=0.001) but not in cognitive depressive symptoms (HR: 0.98; 95% CI: 0.96-1.01; p=0.19) were related to a reduced risk of recurrent MI and mortality after adjustment for baseline depression scores. There was a trend for an interaction effect between changes in somatic depressive symptoms and the intervention (p=0.08). After controlling for demographic and clinical variables, the association between changes in somatic depressive symptoms and event-free survival remained significant in the intervention arm (HR: 0.93; 95% CI: 0.88-0.98; p=0.01) only.

LIMITATIONS

Secondary analyses.

CONCLUSIONS

Changes in somatic depressive symptoms, and not cognitive symptoms, were related to improved outcomes in the intervention arm, independent of demographic and clinical variables.

Depression as a non-causal variable risk marker in coronary heart disease

BACKGROUND

After decades of investigations, explanations for the prospective association between depression and coronary heart disease (CHD) are still incomplete.

DISCUSSION

Depression is often suggested to be causally related to CHD. Based on the available literature, we would rather argue that depression can best be regarded as a variable risk marker, that is, a variable that fluctuates together with mechanisms leading to poor cardiovascular fitness. Despite numerous efforts, no evidence is found that manipulation of depression alters cardiovascular outcomes--a key premise for determining causality. To explain the concept of a variable risk marker, we discuss several studies on the heterogeneity of depression suggesting that depression is particularly harmful for the course of cardiovascular disease when it appears to be a physiological consequence of the cardiovascular disease itself.

SUMMARY

We conclude that instead of depression being a causal risk factor for CHD, the association between depression and CHD is likely confounded, at least by the cardiac disease itself.

Treatment of depression in cardiovascular disease

BACKGROUND AND OBJECTIVES

Depression in patients with Cardiovascular Disease (CVD) is extremely common, with a prevalence of 17-47%, and is associated with increased risk of morbidity and mortality. Treatment of depression has been hypothesized to reduce cardiac mortality. Pharmacologic and psychotherapeutic interventions have been studied and appear to be safe and in some studies effective in reducing depressive symptoms in patients with cardiac disease. The impact on cardiac outcomes remains unclear. This review briefly focuses on the prevalence of depression in patients with CVD, the physiological links between depression and CVD, and largely is concerned with the clinical trials that seek to demonstrate efficacy and safety of antidepressant medications and psychotherapy in this patient population.

METHODS

PubMed and PsycINFO databases were searched through July 2012. Publications were included if they were in English, a review article, or a clinical trial in the CVD population with comorbid depression. The search was completed with key words of antidepressants, CVD, coronary artery syndrome, SSRIs, depression, treatment of depression, post-MI (where MI is myocardial infarction), major depression, and cardiac disease. Trials were included if the patients were above the age of 18, both male and female genders, and had cardiac comorbidity. No trials were excluded.

RESULTS

A total of 61 articles and/or book chapters were included. The majority were from North America and Europe. There were 7 clinical trials of tricyclic antidepressants (TCAs), one of TCAs and bupropion, and 10 trials of selective serotonin reuptake inhibitors (SSRIs). We also evaluated five trials involving psychotherapeutic techniques and/or collaborative care.

CONCLUSIONS

There is considerable evidence from randomized controlled clinical trials that antidepressants, especially SSRIs, are safe in the treatment of major depression in patients with CVD. Although efficacy has been demonstrated in some, but not all, trials for both antidepressants and certain psychotherapies, large, well-powered trials are urgently needed. There are virtually no data available on predictors of antidepressant response in depressed patients with CVD. Whether successful treatment of depression is associated with a reduction in cardiac morbidity and mortality remains unknown.

Symptoms of heart disease or its treatment may increase Beck Depression Inventory Scores in hospitalized post-myocardial infarction patients

OBJECTIVE

The Beck Depression Inventory (BDI) is one of the most commonly used self-report depression symptom questionnaires in medical settings. The revised BDI-II was developed in 1996, partially due to concerns about the influence of somatic symptoms from medical illness on BDI scores. The BDI, however, continues to be frequently used in medical settings. The objective of this study was to examine the degree to which somatic symptom items influence BDI scores among hospitalized post-myocardial infarction (MI) patients with major depressive disorder (MDD) compared to psychiatry outpatients with MDD matched on cognitive/affective scores, sex, and age.

METHODS

Somatic scores of post-MI patients with MDD and matched psychiatry outpatients with MDD were compared using independent samples t-tests.

RESULTS

A total of 579 post-MI patients with MDD (mean age=54.4 years, SD=9.9) and 579 psychiatry outpatients with MDD (mean age=51.2 years, SD=9.7) were matched on cognitive/affective scores, sex, and age. Somatic symptoms accounted for 47% of BDI total scores among post-MI patients (mean total=22.6, SD=8.8) versus 37% among psychiatry outpatients (mean total=19.2, SD=9.7). Somatic scores of post-MI patients were 3.4 points higher than for matched psychiatry outpatients (95% confidence interval 3.0 to 3.9; p<.001), a difference that is equivalent to 15% of total post-MI patient scores.

CONCLUSION

BDI scores of hospitalized post-MI patients with MDD may, in part, reflect symptoms of the acute medical condition or its treatment, rather than depression. The BDI-II was designed to reduce the influence of somatic symptoms on total scores and may be preferable to the 'BDI among heart disease patients.

Cognitive depressive symptoms associated with delayed heart rate recovery following interpersonal stress in healthy men and women

Among cardiac patients, research suggests that somatic depressive symptoms are more strongly associated with altered cardiovascular responses to stress than cognitive depressive symptoms. This study sought to determine whether this was also the case in healthy individuals. One hundred and ninety-nine adults from the community completed the Beck Depression Inventory II (BDI-II) and underwent psychological laboratory stressors while their blood pressure, heart rate, and heart rate variability were monitored. A cognitive-affective factor and somatic-affective factor were identified within the BDI-II, but only the cognitive factor was associated with reduced heart rate recovery following the stressors in multivariate analyses examining both factors simultaneously. This suggests that cognitive depressive symptoms may be more strongly related to altered stress physiology following psychological stressors.

A longitudinal study of poor sleep after inpatient post-acute rehabilitation: the role of depression and pre-illness sleep quality

OBJECTIVES

To explore the unique impact of poor sleep and symptoms of depression on sleep quality for up to 1 year after inpatient post-acute rehabilitation among older adults.

DESIGN

Prospective longitudinal cohort study.

SETTING

Two inpatient post-acute rehabilitation facilities.

PARTICIPANTS

A total of 245 individuals older than 65 years (mean age = 80 years, 38% women).

INTERVENTIONS

None.

MEASUREMENTS

Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI) during the post-acute care stay twice to evaluate pre-illness sleep quality and sleep quality during the post-acute care stay, and again at 3-, 6-, 9-, and 12-month follow-up. Demographics, symptoms of depression, cognitive functioning, and comorbidities were also assessed.

RESULTS

Across time points, sleep was significantly disturbed for many individuals. Nested regression models predicting PSQI total score at 3, 6, 9, and 12 months showed that variables entered in Block 1 (age, gender, cognitive functioning, and comorbidities) were significant predictors of poor sleep at 6-month follow-up but not at 3-, 9-, or 12-month follow-up. Depression (Block 2) and pre-illness PSQI total score (Block 3) were significant predictors of PSQI total score at all follow-up time points. PSQI total score during post-acute care (Block 4) explained a significant proportion of variance only at the 3-month follow-up.

CONCLUSIONS

This study confirms that chronic poor sleep is common among older adults during post-acute rehabilitation and resolution of sleep disturbance after acute health events may be a lengthy process. Our findings expand understanding of the role of depressive symptoms and preexisting sleep complaints in predicting poor sleep over time among these vulnerable older adults.

Epidemiology and Management of Depression Following Coronary Heart Disease Diagnosis in Women

Coronary heart disease (CHD) and depression are both highly prevalent in women. Importantly, depression is associated with significantly elevated morbidity and mortality in women with CHD. There are intriguing speculations about biological mechanisms underlying this association, such as endothelial dysfunction, subclinical atherosclerosis, inflammation, and autonomic dysregulation. Social and behavioral mechanisms, such as lack of social support and physical inactivity, have also been shown to play important roles. Unfortunately, many randomized clinical trials of counseling and pharmacologic interventions for depression in patients with CHD have failed to improve cardiovascular outcomes, and in fact have raised the possibility that interventions might be harmful in women. Several recent trials of new treatment strategies, however, have been more effective in improving depressive symptoms and quality of life and deserve further investigation. In this review, we summarize recent findings with regards to the epidemiology, etiology, diagnosis, and management of depression in women diagnosed with CHD.