Can doctors and nurses recognize depression in patients hospitalized with an acute myocardial infarction in the absence of formal screening?

Mental health conditions in older multimorbid patients presenting to the emergency department for acute cardiac symptoms: Cross-sectional findings from the EMASPOT study

BACKGROUND

This study aimed to (1) examine the proportion of patients presenting to an emergency department (ED) for acute cardiac symptoms with comorbid mental health conditions (MHCs) comprising current depression, generalized anxiety disorder, and panic disorder; (2) compare cardiac patients with and without MHCs regarding sociodemographic, medical, and psychological characteristics; and (3) examine recognition and treatment rates of MHCs.

METHODS

Multimorbid patients, aged ≥50 years, presenting to an inner-city ED with acute cardiac symptoms including chest pain, dyspnea, and palpitations, completed validated self-report instruments assessing MHCs and a questionnaire collecting psychosocial and medical information. In addition, routine medical data were extracted from the electronic health record.

RESULTS

A total of 641 patients were included in the study. Mean (±SD) age was 68.8 (±10.8) years and 41.7% were female. Based on screening instruments, 28.4% of patients were affected with comorbid MHCs. Patients reported clinically significant symptoms of depression (23.3% PHQ-9 ≥10), generalized anxiety disorder (12.2% GAD-7 ≥10), and panic disorder (4.7% PHQ-PD). Patients with MHCs were more likely to be younger, female, lower educated, and unemployed. The presence of MHCs was associated with higher cardiac symptom burden and subjective treatment urgency as well as more psychosocial distress (PHQ-stress) and impaired quality of life (SF-12v2). Of all patients, 15.6% were identified with new or unrecognized MHCs.

CONCLUSIONS

MHCs are prevalent in nearly one-third of patients presenting with cardinal cardiac symptoms. Thus, the ED visit offers an opportunity to identify and refer patients with MHCs to appropriate and timely care after exclusion of life-threatening conditions.

Navigating Symptom Management in Heart Failure: The Crucial Role of the Critical Care Nurse

High-acuity, progressive care, and critical care nurses often provide care for patients with heart failure during an exacerbation of acute disease or at the end of life. Identifying and managing heart failure symptoms is complex and requires early recognition and early intervention. Because symptoms of heart failure are not disease specific, patients may not respond to them appropriately, resulting in treatment delays. This article reviews the complexities and issues surrounding the patient's ability to recognize heart failure symptoms and the critical care nurse's role in facilitating early intervention. It outlines the many barriers to symptom recognition and response, including multimorbidities, age, symptom intensity, symptom escalation, and health literacy. The influence of self-care on heart failure management is also described. The critical care nurse plays a crucial role in teaching heart failure patients to identify and respond appropriately to their symptoms, thus promoting early intervention.

Depression and Anxiety in Heart Failure: A Review

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Identify the relationships between depression, anxiety, and heart failure (HF).• Assess methods for accurately diagnosing depression and anxiety disorders in patients with HF.• Evaluate current evidence for treatment of anxiety and depression in patients with HF.

BACKGROUND

In patients with heart failure (HF), depression and anxiety disorders are common and associated with adverse outcomes such as reduced adherence to treatment, poor function, increased hospitalizations, and elevated mortality. Despite the adverse impact of these disorders, anxiety and depression remain underdiagnosed and undertreated in HF patients.

METHODS

We performed a targeted literature review to (1) identify associations between depression, anxiety, and HF, (2) examine mechanisms mediating relationships between these conditions and medical outcomes, (3) identify methods for accurately diagnosing depression and anxiety disorders in HF, and (4) review current evidence for treatments of these conditions in this population.

RESULTS

Both depression and anxiety disorders are associated with the development and progression of HF, including increased rates of mortality, likely mediated through both physiologic and behavioral mechanisms. Given the overlap between cardiac and psychiatric symptoms, accurately diagnosing depression or anxiety disorders in HF patients can be challenging. Adherence to formal diagnostic criteria and utilization of a clinical interview are the best courses of action in the evaluation process. There is limited evidence for the efficacy of pharmacologic and psychotherapy in patients with HF. However, cognitive-behavioral therapy has been shown to improve mental health outcomes in patients with HF, and selective serotonin reuptake inhibitors appear safe in this cohort.

CONCLUSIONS

Depression and anxiety disorders in HF patients are common, underrecognized, and linked to adverse outcomes. Further research to improve detection and develop effective treatments for these disorders in HF patients is badly needed.

Clinical depression and anxiety among ST-elevation myocardial infarction hospitalizations: Results from Nationwide Inpatient Sample 2004-2013

Depression and anxiety are common among patients who have a major cardiovascular event. However, despite their frequency, there is a lack of evidence regarding the relationship between depression and/or anxiety and receiving revascularization in ST-elevation myocardial infarction (STEMI) hospitalizations. Using data from the Nationwide Inpatient Sample (NIS) from the years 2004 to 2013, we assessed whether a clinical co-diagnosis of depression and/or anxiety decreases the likelihood of revascularization among STEMI hospitalizations. Our central finding is that, paradoxically, the odds of in-hospital mortality were lower among STEMI hospitalizations with a clinical co-diagnosis of depression and/or anxiety as compared to those without. We further discovered that clinical diagnoses of depression and/or anxiety were less prevalent among revascularized as compared to non-revascularized STEMI hospitalizations. However, the percentage of clinical diagnoses of depression and/or anxiety among STEMI hospitalizations increased at a similar rate over a 10-year period irrespective of revascularization status. In conclusion, these results are suggestive of the potentially underdiagnosed mental health issues surrounding major cardiovascular events, and indeed, chronic disease as a whole. To our knowledge, this is the first study to document and examine the "depression paradox" among a population of cardiac patients.

Factors associated with anxiety and depression in hospitalized patients with first episode of acute myocardial infarction

Introduction

Evaluation of anxiety and depression in cardiac patients is an area of nursing practice that is frequently neglected. The aim of the study was to explore anxiety and depression in hospitalized patients with their first episode of acute myocardial infarction.

Material and methods

The study sample included 148 hospitalized patients who had a first episode of acute myocardial infarction. Data collection was performed by the interview method using a specially designed questionnaire which included socio-demographic, clinical and other patients’ characteristics as well as the Hospital Anxiety and Depression Scale (HADS) to assess patients’ levels of anxiety and depression.

Results

Analysis of data showed that 52% and 38% of participants had high levels of anxiety and depression, respectively. Furthermore, anxiety levels revealed a statistically significant association with anxiolytics (p = 0.005) and antidepressant medication (p = 0.026) in hospital, the belief that they will face difficulties in relations with the social and family environment (p = 0.009 and p = 0.002, respectively) and whether they considered themselves anxious (p = 0.003). Depression was statistically significantly associated with education level (p = 0.001), profession (p = 0.007), antidepressant medication in hospital (p ≤ 0.001), patients’ relations with nursing staff (p = 0.019) and patients’ belief that they will face difficulties in relations with the social and family environment (p ≤ 0.001 and p ≤ 0.001, respectively).

Conclusions

The results showed that socio-demographic and clinical characteristics should be taken into serious consideration when exploring anxiety and depression in patients with a first episode of acute myocardial infarction in order to implement appropriate interventions.

Depression following acute coronary syndrome: a Danish nationwide study of potential risk factors

PURPOSE

Depression is common following acute coronary syndrome, and thus, it is important to provide knowledge to improve prevention and detection of depression in this patient group. The objectives of this study were to examine: (1) whether indicators of stressors and coping resources were risk factors for developing depression early and later after an acute coronary syndrome and (2) whether prior depression modified these associations.

METHODS

The study was a register-based cohort study, which includes 87,118 patients with a first time diagnosis of acute coronary syndrome during the period 2001-2009 in Denmark. Cox regression models were used to analyse hazard ratios (HRs) for depression.

RESULTS

1.5 and 9.5 % develop early (≤30 days) and later (31 days-2 years) depression after the acute coronary syndrome. Among all patients with depression, 69.2 % had first onset depression, while 30.8 % developed a recurrent depression. Most patient characteristics (demographic factors, socioeconomic status, psychosocial factors, health-related behavioural factors, somatic comorbidities, and severity of acute coronary syndrome) were significantly associated with increased HRs for both early and later depressions. Prior depression modified most of these associations in such a way that the association was attenuated in patients with a prior depression.

CONCLUSION

Our results indicate that first time and recurrent depression following acute coronary syndrome have different risk profiles. This is important knowledge that may be used to focus future interventions for prevention and detection.

Time trend in depression diagnoses among acute coronary syndrome patients and a reference population from 2001 to 2009 in Denmark

Introduction In the last decade a range of recommendations to increase awareness of depression in acute coronary syndrome patients have been published. To test the impact of those recommendations we examine and compare recent time trends in depression among acute coronary syndrome patients and a reference population. Methods 87 218 patients registered with acute coronary syndrome from 2001-2009 in Denmark and a match reference population were followed through hospital registries and medication prescriptions for early (≤30 days), intermediate (31 days to 6 months) and later (6 months to 2 years) depression in the acute coronary syndrome population and overall depression in the reference population. Cox regression models were used to compare hazard ratios (HRs) for depression over calendar years. Results During the study period, 11.0% and 6.2% were diagnosed with depression in the acute coronary syndrome population and in the reference population, respectively. For the acute coronary syndrome population, the adjusted HRs increased for early (HR (95% CI) 1.04 (1.01-1.06)) and intermediate depression (HR (95% CI) 1.01 (1.00-1.03)), whereas the adjusted HRs did not change for later depression (HR (95% CI) 0.99 (0.98-1.00)). For the reference population the adjusted HRs for depression increased through the study period (HR (95% CI) 1.01 (1.01-1.03)). Conclusion Increase in diagnoses of depressions within 6 months of acute coronary syndrome may be explained by increased focus on depression in this patient group in combination with increased awareness of depression in the general population.

Effects of depression screening on psychiatric outcomes in patients with acute coronary syndrome: Findings from the K-DEPACS and EsDEPACS studies

BACKGROUND

It has been controversial whether routine screening for depression should be recommended in all patients with acute coronary syndrome (ACS) due to lack of evidence for psychiatric as well as for cardiac outcomes. This study aimed to evaluate the result of screening for treatment and subsequent treatment of depression on one-year psychiatric outcomes in ACS.

METHODS

At baseline 1152 patients with recently developed ACS were screened with the Beck Depression Inventory (BDI) and depressive disorder diagnoses were applied according to DSM-IV criteria. Of the 446 patients with depressive disorder, 300 were randomized to a 24-week double-blind trial of escitalopram or placebo, while the remaining 146 received conventional medical treatment only (MTO) without randomization. Of all baseline participants, 828 were followed up one year later. Psychiatric outcomes included BDI, Hamilton Depression Rating Scale (HAMD), Montgomery Asberg Depression Rating Scale (MADRS), Social and Occupational Functioning Assessment Scale (SOFAS) and the World Health Organization Disability Assessment Schedule-12 (WHODAS-12).

RESULTS

BDI screen-positive ACS patients showed worse one-year outcomes on MADRS, SOFAS, and WHODAS scores (p-values<0.01) compared to BDI screen-negative patients. Escitalopram treatment was associated with beneficial effects compared to placebo and MTO on one-year outcomes on HAMD, MADRS and SOFAS (p-values<0.01). Of patients screening positive on the BDI, those with depressive disorder treated with escitalopram had similar outcomes to those without depressive disorder.

CONCLUSIONS

Routine screening of depressive symptom in ACS patients is helpful to plan further management. Moreover, successive accurate diagnosis of depressive disorder with appropriated treatment is effective at least for psychiatric outcomes.

Beck Depression Inventory II: determination and comparison of its diagnostic accuracy in cardiac outpatients

OBJECTIVES

To evaluate the impact of covariates on performance accuracy of the Beck Depression Inventory II (BDI-II) and to determine the optimal cut-off score for the BDI-II in cardiac outpatients. Differences of optimal cut-off scores were also verified across covariate subgroups.

DESIGN AND SETTING

Prospective cross-sectional study at the Department of Nuclear Medicine of the Montreal Heart Institute (Quebec, Canada).

METHODS

A total of 750 adult cardiac outpatients (mean ± SD age 58 ± 10 years, 31% women) completed the BDI-II and the Primary Care Evaluation of Mental Disorders (PRIME-MD; a psychiatric interview used as the reference standard for determining diagnosis of major depressive disorder). The receiver operating characteristics (ROC) curve of the BDI-II was adjusted for age, sex, level of education, smoking status, obesity, anxiety disorder, psychotropic medication, and history of coronary artery disease. The ROC analyses were conducted to determine optimal cut-off scores.

RESULTS

Forty-two (6%) patients met criteria for current major depressive disorder according to the PRIME-MD. After adjusted for covariates, the area under the ROC curve was significantly smaller than the unadjusted curve (0.76, 95% CI 0.66 to 0.85 vs. 0.84, 95% CI 0.77 to 0.89; ΔAUC = -0.07, 95% CI -0.13 to -0.02). While the optimal cut-off score was 10 for the total sample (sensitivity 83%, specificity 73%), the analyses indicated different cut-off scores across covariate subgroups: e.g. sex (women 13; men 10), and anxiety disorders (yes 15; no 10).

CONCLUSIONS

BDI-II is a good screening instrument for depression in cardiac outpatients. However, the present results suggest that covariates can affect the classification accuracy of the BDI-II's original recommended cut-off score. Scholars and clinicians should be aware of the principle that a screening score established in one population may not be relevant to another.

Assessing depression in cardiac patients: what measures should be considered?

It is highly recommended to promptly assess depression in heart disease patients as it represents a crucial risk factor which may result in premature deaths following acute cardiac events and a more severe psychopathology, even in cases of subsequent nonfatal cardiac events. Patients and professionals often underestimate or misjudge depressive symptomatology as cardiac symptoms; hence, quick, reliable, and early mood changes assessments are warranted. Failing to detect depressive signals may have detrimental effects on these patients' wellbeing and full recovery. Choosing gold-standard depression investigations in cardiac patients that fit a hospitalised cardiac setting well is fundamental. This paper will examine eight well established tools following Italian and international guidelines on mood disorders diagnosis in cardiac patients: the Hospital Anxiety and Depression Scale (HADS), the Cognitive Behavioural Assessment Hospital Form (CBA-H), the Beck Depression Inventory (BDI), the two and nine-item Patient Health Questionnaire (PHQ-2, PHQ-9), the Depression Interview and Structured Hamilton (DISH), the Hamilton Rating Scale for Depression (HAM-D/HRSD), and the Composite International Diagnostic Interview (CIDI). Though their strengths and weaknesses may appear to be homogeneous, the BDI-II and the PHQ are more efficient towards an early depression assessment within cardiac hospitalised patients.

Design and baseline data from the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized controlled trial

BACKGROUND

Depression and anxiety in cardiac patients are independently associated with adverse cardiovascular outcomes, including mortality. Collaborative care (CC) programs, which use care managers to assess patients, coordinate care, and perform therapeutic interventions, have proven effective in managing depression in this population. However, no prior CC intervention has simultaneously managed depression and anxiety disorders, and there has been minimal study of CC in high-risk cardiac inpatients.

MATERIALS AND METHODS

The Management of Sadness and Anxiety in Cardiology (MOSAIC) study was a prospective randomized trial of a low-intensity CC intervention, compared to enhanced usual care, for patients hospitalized for acute coronary syndrome, heart failure, or arrhythmia, and diagnosed with depression, generalized anxiety disorder (GAD), or panic disorder (PD). The primary outcome measure for MOSAIC was mental health-related quality of life (HRQoL), measured using the Medical Outcomes Study Short Form-12. Additional outcomes included psychological, functional, and medical outcomes, including rehospitalizations.

RESULTS

A total of 183 eligible participants were enrolled (92 collaborative care, 91 enhanced usual care); 94% of depressed patients reported being depressed for >1month, and 53% of those with GAD reported clinically significant anxiety for >1year. One hundred thirty-three patients had depression, 118 had GAD, and 19 had PD; 74 participants (40%) had two or more of the disorders.

CONCLUSION

The MOSAIC trial will provide data regarding whether an intervention that concurrently manages these common psychiatric disorders results in meaningful improvements in HRQoL, psychiatric symptoms, and medical outcomes in cardiac patients at high risk for adverse outcomes.

Depression and cardiac disease: epidemiology, mechanisms, and diagnosis

In patients with cardiovascular disease (CVD), depression is common, persistent, and associated with worse health-related quality of life, recurrent cardiac events, and mortality. Both physiological and behavioral factors—including endothelial dysfunction, platelet abnormalities, inflammation, autonomic nervous system dysfunction, and reduced engagement in health-promoting activities—may link depression with adverse cardiac outcomes. Because of the potential impact of depression on quality of life and cardiac outcomes, the American Heart Association has recommended routine depression screening of all cardiac patients with the 2- and 9-item Patient Health Questionnaires. However, despite the availability of these easy-to-use screening tools and effective treatments, depression is underrecognized and undertreated in patients with CVD. In this paper, we review the literature on epidemiology, phenomenology, comorbid conditions, and risk factors for depression in cardiac disease. We outline the associations between depression and cardiac outcomes, as well as the mechanisms that may mediate these links. Finally, we discuss the evidence for and against routine depression screening in patients with CVD and make specific recommendations for when and how to assess for depression in this high-risk population.

Depression screening: utility of the patient health questionnaire in patients with acute coronary syndrome

BACKGROUND

Depression screening in cardiac patients has been recommended by the American Heart Association, but the best approach remains unclear.

OBJECTIVES

To evaluate nurse-administered versions of the Patient Health Questionnaire for depression screening in patients hospitalized for acute coronary syndrome.

METHODS

Staff nurses in an urban cardiac care unit administered versions 2, 9, and 10 of the questionnaire to 100 patients with acute coronary syndrome. The Depression Interview and Structured Hamilton was administered by advanced practice nurses blinded to the results of the Patient Health Questionnaire. With the results of the Depression Interview and Structured Hamilton as a criterion, receiver operating characteristic analyses were done for each version of the Patient Health Questionnaire. The Delong method was used for pairwise comparisons. Cutoff scores balancing false-negatives and false-positives were determined by using the Youden Index.

RESULTS

Each version of the questionnaire had excellent area-under- the-curve statistics: 91.2%, 92.6%, and 93.4% for versions 2, 9, and 10, respectively. Differences among the 3 versions were not significant. Each version yielded higher symptom scores in depressed patients than in nondepressed patients: version 2 scores, 3.4 vs 0.6, P = .001; version 9 scores, 13 vs 3.4, P < .001; and version 10 scores, 14.5 vs 3.6, P < .001.

CONCLUSIONS

For depression screening in hospitalized patients with acute coronary syndrome, the Patient Health Questionnaire 2 is as accurate as longer versions when administered by nurses. Further study is needed to determine if screening with this tool changes clinical decision making or improves outcomes in these patients.

Psychometrics of the PHQ-9 as a measure of depressive symptoms in patients with heart failure

BACKGROUND

Depression in patients with heart failure commonly goes undiagnosed and untreated. The Patient Health Questionnaire-9 (PHQ-9) is a simple, valid measure of depressive symptoms that may facilitate clinical assessment. It has not been validated in patients with heart failure.

AIMS

To test the reliability, and concurrent and construct validity of the PHQ-9 in patients with heart failure.

METHODS

A total of 322 heart failure patients (32% female, 61 ± 12 years, 56% New York Heart Association class III/IV) completed the PHQ-9, the Beck Depression Inventory-II (BDI-II), and the Control Attitudes Scale (CAS).

RESULTS

Cronbach's alpha of .83 supported the internal consistency reliability of the PHQ-9 in this sample. Inter-item correlations (range .22-.66) and item-total correlation (except item 9) supported homogeneity of the PHQ-9. Spearman's rho of .80, (p < .001) between the PHQ-9 and the BDI-II supported the concurrent validity as did the agreement between the PHQ-9 and the BDI-II (Kappa = 0.64, p < .001). At cut-off score of 10, the PHQ-9 was 70% sensitive and 92% specific in identifying depressive symptoms, using the BDI-II scores as the criterion for comparison. Differences in PHQ-9 scores by level of perceived control measured by CAS (t(318) = -5.05, p < .001) supported construct validity.

CONCLUSION

The PHQ-9 is a reliable, valid measure of depressive symptoms in patients with heart failure.

Health-care professionals' documentation of wellbeing in patients following open heart surgery: a content analysis of medical records

AIM

To explore health-care professionals' documentation of patient wellbeing in the first five months after open heart surgery.

BACKGROUND

Open heart surgery (coronary artery bypass grafting or heart valve replacement) is an intervention aimed at relief of symptoms and increased wellbeing. It is a complex procedure with deep experiences encompassing physiological, psychological and social aspects. Health-care professionals' documentation of expressions of decreased wellbeing related to open heart surgery is an important basis for decisions and for the understanding of patients' overall health situation.

METHOD

Eighty medical records were examined by means of qualitative and quantitative methods in order to explore documentation of patient wellbeing at four points in time. The analysis was performed by content analysis and descriptive statistics.

RESULTS

Documentation of physical wellbeing was dominant on all occasions, while psychological wellbeing was moderately well documented and social aspects of wellbeing were rarely documented.

CONCLUSION

The medical records did not adequately reflect the complexity of undergoing open heart surgery. Hence the holistic approach was not confirmed in health-care professionals' documentation.

IMPLICATIONS FOR NURSING MANAGEMENT

Managers need to support and work for a patient-centred approach in cardiac care, resulting in patient documentation that reflects patient wellbeing as a whole.

Depressive symptoms and healthcare utilization in patients with noncardiac chest pain compared to patients with ischemic heart disease

OBJECTIVES

We compared depressive symptoms and healthcare utilization in patients admitted for noncardiac chest pain, acute myocardial infarction, and angina pectoris after hospitalization and at 1-year follow-up.

METHODS

One hundred and thirty-one patients with noncardiac chest pain, 66 with acute myocardial infarction, and 70 with angina pectoris completed a depression screening questionnaire and the Montgomery Åsberg Depression Rating Scale. Healthcare utilization data were collected from a population-based, diagnosis-related database.

RESULTS

More than 25% of respondents reported depressive symptoms, regardless of diagnosis. At follow-up, 9% had recovered, 19% were still experiencing depressive symptoms, and 13% had developed depressive symptoms. Noncardiac patients with chest pain had similar primary care contacts, but fewer hospital admissions, than patients with an acute myocardial infarction. Patients with angina pectoris and depressive symptoms used the most healthcare services.

CONCLUSIONS

Depressive symptoms were common. Patients with noncardiac chest pain used as much primary care as did patients with an acute myocardial infarction. Interventions should focus on identifying and treating depressive symptoms.

Recognition and referral of depression in patients with heart disease

BACKGROUND

Routine screening and assessment for depression occurs rarely in clinical practice for a variety of reasons, including the absence of systems to facilitate the process.

AIM

To identify nurses' knowledge and practice regarding depression screening and referral for cardiac patients following the implementation of education workshops and a validated screening tool with referral actions.

METHODS

Pre and post-test design using surveys and semi-structured interviews was conducted with a purposive sample of nurses in a large Australian metropolitan tertiary referral hospital. Prior to the introduction of the screening and referral tool, nurses engaged in an interactive one hour education workshop on the topic of depression and the tool; introduced to improve depression screening following an acute cardiac event.

RESULTS

In the pre and post-survey 40 and 30 nurses, respectively, participated with 14 also engaging in semi-structured interviews. Eighty percent reported a 'good' understanding of depression post-program compared to 30% at baseline. Sixty percent reported routinely using the depression screening and referral tool. The interviews identified three main themes that supported the utility of the education and instrument: knowledge improvement; perceived self-efficacy and new knowledge into practice.

CONCLUSION

The vast majority of participants reported increased skill, knowledge and confidence to screen and refer for depression post an acute cardiac event. The substantial increase in the number of nurses who engaged in screening and referral actions further demonstrated the success of the program. These encouraging results provide evidence that screening for depression can be achieved through adopting formalised processes.

Accuracy and prognostic value of American Heart Association: recommended depression screening in patients with coronary heart disease: data from the Heart and Soul Study

BACKGROUND- In 2008, the American Heart Association (AHA) recommended a 2-step screening method, consisting of the 2-item Patient Health Questionnaire (PHQ-2) followed by the 9-item Patient Health Questionnaire (PHQ-9), for identifying depression in cardiovascular patients. The accuracy and prognostic value of this screening method have not been evaluated. METHODS AND RESULTS- We administered the 2-step AHA-recommended screening algorithm to 1024 patients with stable coronary heart disease and calculated sensitivity and specificity against a gold standard interview for major depressive disorder. Subsequent cardiovascular events (myocardial infarction, stroke, transient ischemic attack, heart failure, or death) were determined during a mean of 6.27 ± 2.11 years of follow-up. The AHA-recommended screening method had high specificity (0.91; 95% confidence interval, 0.89 to 0.93) but low sensitivity (0.52; 95% confidence interval, 0.46 to 0.59) for a diagnosis of major depressive disorder. Participants who screened positive on the AHA depression protocol had a 55% greater risk of events than those who screened negative (age-adjusted hazard ratio, 1.55; 95% confidence interval, 1.21 to 1.97; P=0.0005). After adjustment for age, sex, body mass index, history of myocardial infarction, hypertension, diabetes, heart failure, and high-density lipoprotein levels, screening positive remained associated with a 41% greater rate of cardiovascular events (hazard ratio, 1.41; 95% confidence interval, 1.10 to 1.81; P=0.008). CONCLUSIONS- Among outpatients with stable coronary heart disease, the AHA-recommended depression screening protocol is highly specific for depression and identifies patients at risk for adverse cardiovascular outcomes.

Depression and cardiac disease: a review

Depression is highly prevalent in cardiac patients, with 20% to 40% of patients meeting criteria for major depressive disorder or experiencing an elevation in depressive symptoms. These depressive symptoms are often chronic and persistent, and they have been associated with the development and progression of coronary artery disease, worse health-related quality of life, poor physical functioning, recurrent cardiac events, and a 2- to 2.5-fold increased risk of mortality. Impaired adherence to health behaviors and adverse physiological effects of depression, including inflammation, endothelial dysfunction, platelet hyperactivity, and autonomic nervous system abnormalities, may link depression with adverse cardiac outcomes. Pharmacologic and psychotherapeutic interventions appear to be safe and effective at reducing depressive symptoms in patients with cardiovascular disease and may impact cardiac outcomes. Unfortunately, depression often is unrecognized and untreated in this population, despite the availability of brief screening tools that can be used for this purpose. We recommend the routine screening of cardiac patients for depression when there are adequate mechanisms for management and referral, such as available consulting psychiatrists or care management programs that facilitate the delivery of pharmacologic and psychotherapeutic treatments in this vulnerable population.

A collaborative care depression management program for cardiac inpatients: depression characteristics and in-hospital outcomes

BACKGROUND

Depression in cardiac patients is common, under-recognized, and independently associated with mortality.

OBJECTIVES

Our objectives in this initial report from a 6-month longitudinal trial were to determine whether a collaborative care program improves rates of depression treatment by discharge among patients hospitalized with acute cardiovascular disease, and to assess key clinical characteristics of depression in this cohort.

METHOD

This was a prospective, randomized trial comparing collaborative care and usual care interventions for depressed cardiac patients who were admitted to cardiac units in an urban academic medical center. For collaborative care subjects, the care manager performed a multi-component depression intervention in the hospital that included patient education and treatment coordination; usual care subjects' inpatient providers were informed of the depression diagnosis.

RESULTS

The mean Patient Health Questionnaire-9 for subjects (N = 175) was 17.6 (SD 3.5; range 11-26), consistent with moderate-severe depression. The majority of subjects had depression for over one month (n = 134; 76.6%) and a prior depressive episode (n = 124; 70.8%); nearly one-half (n = 75; 42.9%) had thoughts that life was not worth living in the preceding 2 weeks. Collaborative care subjects were far more likely to receive adequate depression treatment by discharge (71.9% collaborative care vs. 9.5% usual care; p < 0.001).

CONCLUSION

Depression identified by systematic screening in hospitalized cardiac patients appears was prolonged, and of substantial severity. A collaborative care depression management model appears to vastly increase rates of appropriate treatment by discharge.

Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly patients with heart failure, myocardial infarction, and a coronary artery bypass graft

OBJECTIVE

This study sought to compare the prevalence of anxiety, depression, and hostility among 3 clinically diverse elderly cardiac patient cohorts and a reference group of healthy elders.

METHODS

This was a multicenter, comparative study. A total of 1167 individuals participated: 260 healthy elders, and 907 elderly cardiac patients who were at least 3 months past a hospitalization (478 heart-failure patients, 298 postmyocardial infarction patients, and 131 postcoronary artery bypass graft patients). Symptoms of anxiety, depression, and hostility were measured using the Multiple Affect Adjective Checklist.

RESULTS

The prevalence of anxiety, depression, and hostility was higher in patients in each of the cardiac patient groups than in the group of healthy elders. Almost three quarters of patients with heart failure reported experiencing symptoms of depression, and the heart-failure group manifested the greatest percentage of patients with depressive symptoms.

CONCLUSIONS

The high levels of emotional distress common in cardiac patients are not a function of aging, because healthy elders exhibit low levels of anxiety, depression, and hostility.

Impact of a depression care management program for hospitalized cardiac patients

BACKGROUND

Depression is independently associated with poor outcomes among patients with acute cardiac disease. Collaborative care depression management programs have been used in outpatients to improve depression outcomes, but such a program had never been initiated in the hospital or used for patients with a wide range of cardiac illnesses.

METHODS AND RESULTS

This was a prospective, randomized trial of a low-intensity, 12-week collaborative care program versus usual care for 175 depressed patients hospitalized for acute coronary syndrome, arrhythmia, or heart failure. Study outcomes, assessed using mixed regression models to compare groups at 6 weeks, 12 weeks, and 6 months, included mental health (depression, cognitive symptoms of depression, anxiety, and mental health-related quality of life) and medical (physical health-related quality of life, adherence to medical recommendations, and cardiac symptoms) outcomes. Collaborative care subjects (n=90) had significantly greater improvements on all mental health outcomes at 6 and 12 weeks, including rates of depression response (collaborative care, 59.7% versus usual care 33.7%; odds ratio, 2.91; P=0.003 at 6 weeks; 51.5% versus 34.4%; odds ratio, 2.02; P=0.04 at 12 weeks), though these effects decreased after intervention. At 6 months, intervention subjects had significantly greater self-reported adherence and significantly reduced number and intensity of cardiac symptoms.

CONCLUSIONS

Among patients with a broad range of cardiac diagnoses, a collaborative care depression management program initiated during hospitalization led to significant improvements in multiple clinically important mental health outcomes and had promising effects on relevant medical outcomes after intervention. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00847132.

Screening for major depression in post-myocardial infarction patients: operating characteristics of the Beck Depression Inventory-II

OBJECTIVE

To assess the operating characteristics of the Beck-Depression Inventory-II (BDI-II) and the BDI-II cognitive subscale (BDI-II-cog) in screening for major depression (MDD) in post-myocardial infarction (MI) patients.

METHODS

Between October 2003 and July 2005, 131 post-MI patients admitted to an urban academic medical center completed the BDI-II and a semi-structured interview for depression within 72 hours of symptom onset. Sensitivity, specificity, positive and negative predictive values, overall correct classification, and likelihood ratios for various cutoff values on both scales were evaluated by comparing scores to interview diagnosis of MDD. Receiver-operator curves (ROC) were also calculated and area under the curve (AUC) measured.

RESULTS

The optimal cutoff value for the BDI-II was > or = 16, with a sensitivity of 88.2% and a specificity of 92.1%. Cutoff values of > or = 3 or > or = 4 were both acceptable for the BDI-II-cog (sensitivity = 88.2% and 82.4%, respectively; specificity = 81.6% and 88.6 %, respectively). AUC was 0.96 for the BDI-II and 0.89 for the cognitive subscale.

CONCLUSIONS

Effective depression screening is important in post-MI patients because of depression's independent association with morbidity and mortality following MI. Our results suggest that the BDI-II and its cognitive subscale are effective tools for screening for MDD in post-MI patients.

Ability of nurses to identify depression in primary care, secondary care and nursing homes--a meta-analysis of routine clinical accuracy

PURPOSE

To clarify the ability of nurses and nursing assistants working in primary care, secondary care and nursing homes to identify depressed individuals using their clinical skills using meta-analysis of published studies.

METHODS

Literature search, appraisal and meta-analysis. We located 22 studies reporting on the detection of depression, 4 involving primary care or community nurses; 7 involving hospital nurses and 11 from nursing homes.17 of 22 studies had specificity data.

RESULTS

Across all 22 studies involving 7061 individuals, and a prevalence of 28.1% (95% CI=22.6-33.9%), practice and community nurses correctly identified 26.3% (95% CI=16.2-37.8%) of people with depression. They also correctly identified 94.8% (95% CI=91.3-97.4%) of the non-depressed. Nurses working in hospital settings correctly identified 43.1% (95% CI=31.9-54.8%) of people with depression and 79.6% (95% CI=71.5-86.7%) of the non-depressed. Those working in nursing homes correctly identified 45.8% (95% CI=38.1-53.6%) of people with depression and 80.0% (95% CI=68.6-88.7%) of the non-depressed.

CONCLUSIONS

Nurses have considerable difficulty accurately identifying depression but are probably at least as accurate as medical staff.

The relationship between depression, anxiety, and cardiovascular outcomes in patients with acute coronary syndromes

Depression and anxiety occur at high rates among patients suffering an acute coronary syndrome (ACS). Both depressive symptoms and anxiety appear to adversely affect in-hospital and long term cardiac outcomes of post-ACS patients, independent of traditional risk factors. Despite their high prevalence and serious impact, mood and anxiety symptoms go unrecognized and untreated in most ACS patients and such symptoms (rather than being transient reactions to ACS) persist for months and beyond. The mechanisms by which depression and anxiety are linked to these negative medical outcomes are likely a combination of the effects of these conditions on inflammation, catecholamines, heart rate variability, and endothelial function, along with effects on health-promoting behavior. Fortunately, standard treatments for these disorders appear to be safe, well-tolerated and efficacious in this population; indeed, selective serotonin reuptake inhibitors may actually improve cardiac outcomes. Future research goals include gaining a better understanding of the combined effects of depression and anxiety, as well as definitive prospective studies of the impact of treatment on cardiac outcomes. Clinically, protocols that allow for efficient and systematic screening, evaluation, and treatment for depression and anxiety in cardiac patients are critical to help patients avoid the devastating effects of these illnesses on quality of life and cardiac health.

Detection of depression in cardiac inpatients: feasibility and results of systematic screening

BACKGROUND

A recent American Heart Association (AHA) Prevention Committee report recommended depression screening of all coronary heart disease patients using 2- and 9-item instruments from the Patient Health Questionnaire (PHQ-2 and PHQ-9) to identify patients who may need further assessment and treatment. Our objective was to assess the feasibility and results of such screening on inpatient cardiac units.

METHODS

In September 2007, the PHQ-2 was added to the nursing interview dataset on 3 cardiac units in a general hospital; this screen was completed as part of routine clinical care. Rates and results of depression screening, reasons for patients not being screened, and results of a nursing satisfaction survey were tabulated, and differences in baseline characteristics between screened and unscreened patients were analyzed via chi(2) and independent-samples t tests.

RESULTS

For a 12-month period, 4,783 patients were admitted to the cardiac units; 3,504 (73.3%) received PHQ-2 depression screening. Approximately 9% of screened patients had a PHQ-2 score > or =3 and were approached for further depression evaluation (PHQ-9) by a social worker; 74.1% of the positive-screen patients had a PHQ-9 score of > or =10, suggestive of major depression. Nurses (n = 66) reported high satisfaction with the screening process, and mean reported PHQ-2 screening time was 1.4 (+/-1.1) minutes.

CONCLUSIONS

Systematic depression screening of cardiac patients using methods outlined by the AHA Prevention Committee is feasible, well-accepted, and does not appear markedly resource-intensive. Future studies should link these methods to an efficient and effective program of depression management in this vulnerable population.

Broken-Hearted Women: The Complex Relationship between Depression and Cardiovascular Disease

The importance of mind–body health relationships has been recognized for decades, but only recently has the wider medical and cardiovascular community become engaged in understanding and addressing the complex, bidirectional risk relationship between cardiovascular disease (CVD) and depression. Furthermore, it has become increasingly clear that there are incompletely understood sex differences in incidence and outcomes for both conditions that should guide treatment and future research efforts. This review will explore the role of depression in women as a risk factor for incident CVD, its impact on women already suffering from CVD, proposed psychobiologic mechanisms and links, and the implications of sex differences on diagnosis and treatment.

Sensitivity and specificity of the Beck Depression Inventory in cardiologic inpatients: how useful is the conventional cut-off score?

OBJECTIVE

The Beck Depression Inventory (BDI) is widely used for depression screening in various patient populations. However, there are still insufficient data about its sensitivity and specificity in nonpsychiatric patients. Furthermore, some research suggests that somatic BDI items heighten its sum score artificially in physically ill patients. The aim of the present study was to validate the conventional BDI cut-off score by examination of its sensitivity and specificity in a mixed sample of cardiac inpatients and compare it to a modified "cognitive-emotional" BDI (BDI(c/e)) after exclusion of somatic items.

METHODS

A total of 126 cardiologic inpatients were assessed. Receiver operating characteristic curves (ROC) were calculated for total BDI (BDI(t)) and BDI(c/e). Screening performance of cut-off scores was evaluated using the Youden Index (Y).

RESULTS

With the application of the conventional BDI cut-off score, ROC analysis revealed a moderate overall screening performance with Y=52.6 and an area under the curve (AUC) of 0.83. In contrast, Y improved to 57.5 at a cut-off score of >9, but screening performance was still not optimal. BDI(c/e) showed also a moderate screening performance (AUC=.82); Y was maximized at a cut-off score of >8 (Y=0.53.5). Again, no cut-off score provided optimal screening performance.

CONCLUSION

The BDI cannot be recommended as a formal screening instrument in cardiac inpatients since no cut-off score for either BDI(t) or BDI(c/e) combined both sufficiently high sensitivity and specificity. However, the shorter BDI(c/e) could be used as alternative to BDI(t) which may be confounded in physically ill patients. Generally, researchers should consider using alternative screening instruments (e.g., the Hospital Anxiety and Depression Scale) instead.

The association of cognitive and somatic depressive symptoms with depression recognition and outcomes after myocardial infarction

BACKGROUND

Among patients with acute myocardial infarction (AMI), depression is both common and underrecognized. The association of different manifestations of depression, somatic and cognitive, with depression recognition and long-term prognosis is poorly understood.

METHODS AND RESULTS

Depression was confirmed in 481 AMI patients enrolled from 21 sites during their index hospitalization with a Patient Health Questionnaire (PHQ-9) score > or =10. Within the PHQ-9, separate somatic and cognitive symptom scores were derived, and the independent association between these domains and the clinical recognition of depression, as documented in the medical records, was evaluated. In a separate multisite AMI registry of 2347 patients, the association between somatic and cognitive depressive symptoms and 4-year all-cause mortality and 1-year all-cause rehospitalization was evaluated. Depression was clinically recognized in 29% (n=140) of patients. Cognitive depressive symptoms (relative risk per SD increase, 1.14; 95% CI, 1.03 to 1.26; P=0.01) were independently associated with depression recognition, whereas the association for somatic symptoms and recognition (relative risk, 1.04; 95% CI, 0.87 to 1.26; P=0.66) was not significant. However, unadjusted Cox regression analyses found that only somatic depressive symptoms were associated with 4-year mortality (hazard ratio [HR] per SD increase, 1.22; 95% CI, 1.08 to 1.39) or 1-year rehospitalization (HR, 1.22; 95% CI, 1.11 to 1.33), whereas cognitive manifestations were not (HR for mortality, 1.01; 95% CI, 0.89 to 1.14; HR for rehospitalization, 1.01; 95% CI, 0.93 to 1.11). After multivariable adjustment, the association between somatic symptoms and rehospitalization persisted (HR, 1.16; 95% CI, 1.06 to 1.27; P=0.01) but was attenuated for mortality (HR, 1.07; 95% CI, 0.94 to 1.21; P=0.30).

CONCLUSIONS

Depression after AMI was recognized in fewer than 1 in 3 patients. Although cognitive symptoms were associated with recognition of depression, somatic symptoms were associated with long-term outcomes. Comprehensive screening and treatment of both somatic and cognitive symptoms may be necessary to optimize depression recognition and treatment in AMI patients.

Depression and cardiovascular health care costs among women with suspected myocardial ischemia: prospective results from the WISE (Women's Ischemia Syndrome Evaluation) Study

OBJECTIVES

This study evaluated 3 novel questions in a prospective clinical cohort of women undergoing evaluation for suspected myocardial ischemia: 1) What is the relationship between depression and cardiovascular costs? 2) Does the relationship vary by definition of depression? 3) Do depression-cost relationship patterns differ among women with versus without coronary artery disease (CAD)?

BACKGROUND

Comorbid depression has been linked to higher medical costs in previous studies of cardiovascular patients.

METHODS

A total of 868 women presenting with suspected myocardial ischemia completed an extensive baseline examination including cardiovascular risk factor assessment and coronary angiogram. Depression was defined by: 1) current use of antidepressants; 2) a reported history of depression treatment; and 3) Beck Depression Inventory scores. Direct (hospitalizations, office visits, procedures, and medications) and indirect (out-of-pocket, lost productivity, and travel) costs were collected through 5 years of follow-up to estimate cardiovascular costs.

RESULTS

Using the study criteria, 17% to 45% of the women studied met study depression criteria. Depressed women showed adjusted annual cardiovascular costs $1,550 to $3,300 higher than nondepressed groups (r = 0.08 to 0.12, p < 0.05). Depression-cost relationships also varied by CAD status, with stronger associations present among women without evidence of significant CAD.

CONCLUSIONS

Depression was associated with 15% to 53% increases in 5-year cardiovascular costs, and cost differences were present using 3 definitions of depression. The results reinforce the importance of assessing depression in clinical populations and support the hypothesis that improved management of depression in women with suspected myocardial ischemia could reduce medical costs.

Depressed Mood Over Time after Open Heart Surgery Impacts Patient Well-Being: A Combined Study

Background: Depression is a common cause of decreased well-being after open heart surgery (OHS) and a risk factor for new cardiac events. Little is known about the long-term prevalence of depressive symptoms after OHS or their effect on well-being. The aim of this study was to explore the presence of depressed mood in patients during the recovery phase after open heart surgery as well as depressed mood and well-being 3 years later.

Method: Eighty consecutively included patients completed a questionnaire about depressed mood at 5 weeks, 5 months and 3 years after OHS. A telephone interview took place after receipt of the third questionnaire to explore their well-being. Quantitative and qualitative data were analysed separately and thereafter together.

Result: Depressed mood occurred in 52% of the patients during recovery or 3 years after OHS. The qualitative content analysis produced the theme of transition, which was based on three categories.

Conclusion: Depressed mood was reported by the majority of patients during recovery after OHS and had a long-term effect on their well-being. OHS constituted a transition for all patients, but those with depressed mood had difficulty finishing the transition process and reorientating life.

Comparison of the Short Form 36 and the Hospital Anxiety and Depression Scale measuring emotional distress in patients admitted for elective coronary angiography

BACKGROUND

Anxiety and depression are frequently observed in patients with coronary artery disease. Because emotional distress is of prognostic importance in these patients, screening is recommended.

OBJECTIVE

We compared the Short Form 36 (SF-36) and the Hospital Anxiety and Depression Scale (HADS) in measuring emotional distress in patients admitted for elective coronary angiography.

METHODS

A total of 587 patients were consecutively included (mean age 62 years, 75% were male). Gender-specific partial correlations were calculated for the associations between their SF-36 and HADS scores, whereas subgroup differences were evaluated using t tests or analysis of variance.

RESULTS

In both genders, the HADS subscales for anxiety and depression were significantly related to all SF-36 subscales and most strongly related to the Mental Health subscale. Both HADS and the Mental Health subscale demonstrated a high occurrence of emotional distress and discriminated significantly between patients with and without severe angina. The HADS, but not the SF-36, demonstrated high levels of emotional distress (anxiety) among men without verified coronary artery disease.

CONCLUSION

Both instruments seem appropriate as screening instruments for emotional distress in patients with suspected coronary artery disease. Although the Mental Health subscale has the advantage of being shorter, we recommend the HADS because it shows anxiety more specifically.

Screening, diagnosis & monitoring of depression/distress in CHF patients

Objective and validated measures of depression/distress (anxiety and anger) are available and readily usable at the bedside or in clinic. Foremost among these is the Patient's Health Questionnaire--an adaptation of DSM IV criteria for Major Depressive Disorder that permits administration and scoring by nursing or physician personnel, and quantification of the intensity of depression. A score of 10 or greater indicates a need for evaluation/treatment. Because of patient denial/minimization/alexithymia, PHQ negatives should undergo further screening by having a spouse or friend complete a depression/distress rating scale. The only standardized, normed, and validated spouse/friend scale presently available is the Ketterer Stress Symptom Frequency Checklist, which is available by internet.

Empirically Derived Psychometric Screening for Emotional Distress in Coronary Artery Disease Patients

BACKGROUND AND RESEARCH OBJECTIVES

Multiple types of evidence implicate emotional distress as a cause of adverse outcomes in individuals with coronary artery disease. The present study was intended to determine the most accurate and user-friendly means of screening patients with coronary artery disease for emotional distress using age at initial diagnosis as the criterion.

SUBJECTS AND METHODS

Two clinical databases consisting of patients with documented coronary artery disease, each contained multiple measures of emotional distress, were used. These databases were investigated by tests of covariation of the emotional distress measures with age at initial diagnosis. If these were statistically significant, sequential testing of cutpoints yielded the minimum score for positivity. Sensitivity, specificity, and positive predictive value calculations were made for the significant measures. Single-sex tests of covariation were also examined.

RESULTS AND CONCLUSIONS

The Patient Health Questionnaire was the only significant bedside measure of emotional distress (Pearson r = -0.149, P = .058), with a cutpoint of 10 or greater. The Beck Depression Inventory, Hospital Anxiety and Depression Scale, and Crown-Crisp Phobic Anxiety Scale failed to reach significance as covariates of age at initial diagnosis. Substantially greater sensitivity occurs with larger and more cumbersome measures of emotional distress. For example, the Ketterer Stress Symptom Frequency Checklist yielded consistent results with greater variance explained, particularly in men (Pearson r for self-ratings of anger = -0.339, P = .001; depression = -0.363, P = .005; anxiety = -0.273, P = .028). Brief bedside/clinic screening of emotional in populations with coronary artery disease is possible and necessary to improve quality of life, compliance (eg, smoking cessation), and possibly morbidity/mortality. Initial screening can and should occur at the bedside/clinic by cardiology or primary care personnel using the Patient Health Questionnaire.