Depression in male and female patients undergoing cardiac surgery

J147 affects cognition and anxiety after surgery in Zucker rats

Vulnerable patients are at risk for neuroinflammation-mediated post-operative complications, including depression (POD) and cognitive dysfunction (POCD). Zucker rats, expressing multiple risk factors for post-operative complications in humans, may provide a clinically relevant model to study pathophysiology and explore potential interventions. J147, a newly developed anti-dementia drug, was shown to prevent POCD in young healthy rats, and improved early post-surgical recovery in Zucker rats. Aim of the present study was to investigate POCD and the therapeutic potential of J147 in male Zucker rats. Risk factors in the Zucker rat strain were evaluated by comparison with lean littermates. Zucker rats were subjected to major abdominal surgery. Acute J147 treatment was provided by a single iv injection (10 mg/kg) at the start of surgery, while chronic J147 treatment was provided in the food (aimed at 30 mg/kg/day), starting one week before surgery and up to end of protocol. Effects on behavior were assessed, and plasma, urine and brain tissue were collected and processed for immunohistochemistry and molecular analyses. Indeed, Zucker rats displayed increased risk factors for POCD, including obesity, high plasma triglycerides, low grade systemic inflammation, impaired spatial learning and decreased neurogenesis. Surgery in Zucker rats reduced exploration and increased anxiety in the Open Field test, impaired short-term spatial memory, induced a shift in circadian rhythm and increased plasma neutrophil gelatinase-associated lipocalin (NGAL), microglia activity in the CA1 and blood brain barrier leakage. Chronic, but not acute J147 treatment reduced anxiety in the Open Field test and protected against the spatial memory decline. Moreover, chronic J147 increased glucose sensitivity. Acute J147 treatment improved long-term spatial memory and reversed the circadian rhythm shift. No anti-inflammatory effects were seen for J147. Although Zucker rats displayed risk factors, surgery did not induce extensive POCD. However, increased anxiety may indicate POD. Treatment with J147 showed positive effects on behavioral and metabolic parameters, but did not affect (neuro)inflammation. The mixed effect of acute and chronic treatment may suggest a combination for optimal treatment.

The pathophysiology and management of depression in cardiac surgery patients

Background

Depression is common in the cardiac surgery population. This contemporary narrative review aims to explore the main pathophysiological disturbances underpinning depression specifically within the cardiac surgery population. The common non-pharmacological and pharmacological management strategies used to manage depression within the cardiac surgery patient population are also explored.

Methods

A total of 1291 articles were identified through Ovid Medline and Embase. The findings from 39 studies were included for qualitative analysis in this narrative review.

Results

Depression is associated with several pathophysiological and behavioral factors which increase the likelihood of developing coronary heart disease which may ultimately require surgical intervention. The main pathophysiological factors contributing to depression are well characterized and include autonomic nervous system dysregulation, excessive inflammation and disruption of the hypothalamic-pituitary-adrenal axis. There are also several behavioral factors in depressed patients associated with the development of coronary heart disease including poor diet, insufficient exercise, poor compliance with medications and reduced adherence to cardiac rehabilitation. The common preventative and management modalities used for depression following cardiac surgery include preoperative and peri-operative education, cardiac rehabilitation, cognitive behavioral therapy, religion/prayer/spirituality, biobehavioral feedback, anti-depressant medications, and statins.

Conclusion

This contemporary review explores the pathophysiological mechanisms leading to depression following cardiac surgery and the current management modalities. Further studies on the preventative and management strategies for postoperative depression in the cardiac surgery patient population are warranted.

Prevalence and Predictors of Suicidal Ideation in Patients Following Cardiac Surgery

BACKGROUND

Patient-reported outcomes (PROs) which demand special attention and immediate help are referred to as PROs alert. Suicidal ideation (SI) is one of the PROs alerts which are insufficiently investigated. The aim was to assess the prevalence and risk factors for SI in patients following cardiac surgery.

METHODS

A total of 190 patients (mean age: 66.09, SD = 10.19; 57 women) were assessed at three months following cardiac surgery. SI was identified using the Patient Health Qustionnaire-9 (PHQ-9) question. The Hospital Anxiety and Depression Scale-Modified was used to assess anxiety, depression, and irritability. Additionally, self-perceived health improvement and level of hope were assessed using the Likert scale. Dyspnea and chest pain were assessed using a visual analogue scale.

RESULTS

SI was observed in 14.7% of participants. Patients experiencing SI had significantly higher levels of depression, anxiety, irritability, dyspnea and chest pain. They perceived the surgery to be less effective and had lower levels of hope. No significant relationships were found regarding age, sex, employment status, myocardial infarction, heart failure, operation mode, type of procedure, extracorporal circulation, hospital stay and postsurgical complications. Logistic regression revealed female sex (B = 2.363), higher anxiety level (B = 0.451) and older age (B = 0.062) to be risk factors for SI. The total variance explained by the model was 46%.

CONCLUSIONS

Assessing suicidality and negative emotions with special emphasis on anxiety simultaneously with somatic complaints is vital to address PROs alerts and improve care for patients following cardiac surgery. In-depth evaluation and psychological care are recommended in case of positive screening.

Severity of psychological distress over five years differs as a function of sex and presence of coronary artery disease

BACKGROUND

Psychological distress is more prevalent and severe among patients with coronary artery disease (CAD) compared to healthy individuals. Little is known regarding its time course, and whether these differences extend to individuals with non-cardiovascular (CV) illnesses. This study examined the presence, severity, and time course of psychological distress in men and women with CAD and those of similarly aged individuals suffering from non-CV conditions.

METHODS

1229 individuals (61% men; mean_age = 60.4 ± 7.0 years) with stable CAD or non-CV illnesses reported on social support, hostility, stress, anxiety and depression at baseline as well as 4.8 ± 0.8 years later. Analyses involved mixed (Sex*CAD status*Time) repeated measures analyses (controlling for relevant covariates), as well as Chi-square and McNemar analyses.

RESULTS

Women with CAD reported more symptoms of depression compared to other participants at both evaluations (p's < 0.01), and reported more symptoms of anxiety and stress compared to others at T1 (p's < 0.05). At T2, perceived stress remained significantly greater among women with CAD compared to men (p's < 0.01), though differences in anxiety were no longer significant. Men reported more hostility than women (p = 0.001). CAD women fell within the clinical range for depression (p < 0.001), anxiety (p = 0.001), and stress (p = 0.030) more frequently compared to others at T1, and for depression (p = 0.009) and stress (p = 0.002) at T2.

CONCLUSIONS

The evolution of patient distress differed as a function of the measure examined, their sex, and/or CV status. While psychological distress was prevalent among these patients with diverse health conditions, women with CAD were particularly and chronically vulnerable.

Return to work after coronary artery bypass grafting and aortic valve replacement surgery: A scoping review

BACKGROUND

Coronary artery bypass grafting surgery and aortic valve replacement surgery are essential treatment options for people suffering from angina pectoris or aortic valve disease. Surgery aims to prolong life expectancy, improve quality of life, and facilitate participation in society for the individuals afflicted. The aim of this review was to explore the literature on work participation in patients following coronary artery bypass grafting or aortic valve replacement surgery, and to identify demographic and clinical characteristics associated with returning to work.

METHODS

A scoping review framework of Arksey and O'Malley was chosen. Four electronic databases: Medline, CINAHL, Embase, and Google Scholar were searched for studies in English, Swedish, Danish or Norwegian between January 1988 and January 2020. A blinded selection of articles was performed. The data were then charted and summarized by descriptive numerical analyses and categorized into themes.

RESULTS

Forty-five out of 432 articles were included in the final full-text analysis. Absence from work following coronary artery bypass graft grafting or aortic valve replacement surgery lasted on average 30 weeks, whereas 34% of the patients never returned to work. Being female, suffering from pre-existing depression, having limited secondary education, or low income were associated with decreased return to work rates. Previous employment was a decisive factor for returning to work after surgery. Data on return to work after aortic valve replacement were scarce.

CONCLUSIONS

A significant number of patients never return to work following coronary artery bypass grafting or aortic valve surgery, and the time interval until work return is longer than expected. Failure to resume work represents a threat to the patients' finances and quality of life. Nurses are in a unique position to assess work-related issues and have an active part in the multi-disciplinary facilitation of tailored occupational counselling after cardiac surgery.

Clinical, Surgical, and Sociopsychological Factors and Depression After Cardiothoracic Surgery

BACKGROUND

Depression is highly prevalent in cardiac surgical patients and is associated with mortality. The objectives of the study were to evaluate depression scores longitudinally pre- and postoperatively and to examine the association between postoperative depression scores and clinical, surgical, and sociopsychological factors.

METHODS

Depression scores were assessed using the Center for Epidemiological Study of Depression (CES-D) in 100 cardiac surgical patients who underwent cardiac surgery preoperatively, during hospitalization, and at 2 and 6 week after discharge. Clinical, surgical, and sociopsychological predictors of depression scores were recorded.

RESULTS

The average depression scores significantly increased from preoperative levels (14.9 ± 1.07) to during hospitalization (21.5 ± 1.05) and decreased at both 2 weeks (15.8 ± 1.07) and 6 weeks after discharge (14.0 ± 1.06), as compared with scores during hospitalization (P < .001). The percentage of patients who scored CES-D > 16 increased significantly from preoperative (39%) to hospitalization (71%) and decreased gradually at 2 weeks (45%) and 6 weeks (37%) after discharge (P < .001). Significant predictors of high postoperative CES-D scores were female gender, ejection fraction < 50%, and high preoperative CES-D scores.

CONCLUSIONS

High depression scores after cardiac surgery suggest that perioperative screening and management of depression after surgery are necessary and may improve outcomes of these patients who are at high risk for depression. Further understanding of the factors that contribute to high depression scores is required to facilitate clinical intervention.

Is Belonging to a Religious Organization Enough? Differences in Religious Affiliation Versus Self-ratings of Spirituality on Behavioral and Psychological Variables in Individuals with Heart Failure

In the United States, heart failure (HF) affects approximately 6.5 million adults. While studies show that individuals with HF often suffer from adverse symptoms such as depression and anxiety, studies also show that these symptoms can be at least partially offset by the presence of spiritual wellbeing. In a sample of 327 men and women with AHA/ACC classification Stage B HF, we found that more spirituality in patients was associated with better clinically-related symptoms such as depressed mood and anxiety, emotional variables (affect, anger), well-being (optimism, satisfaction with life), and physical health-related outcomes (fatigue, sleep quality). These patients also showed better self-efficacy to maintain cardiac function. Simply belonging to a religious organization independent of spiritualty, however, was not a reliable predictor of health-related benefits. In fact, we observed instances of belonging to a religious organization unaccompanied by parallel spiritual ratings, which appeared counterproductive.

Use of serotonin reuptake inhibitors is not associated with increased bleeding after CABG

OBJECTIVES

Selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs) are the most commonly prescribed antidepressants worldwide. Studies suggest that SSRI/SNRIs can increase bleeding following different surgical procedures, including open heart surgery, but results are conflicting. The objective of this study was to analyse their effects on bleeding after coronary artery bypass grafting (CABG).

METHODS

Of 1237 patients that underwent CABG in Iceland in 2007-2016, 97 (7.8%) used SSRIs/SNRIs preoperatively and were compared to a reference group (n = 1140). Bleeding was assessed using 24-h chest-tube output, number of RBC units transfused and reoperation for bleeding. Thirty-day mortality rates and incidence of complications were also compared.

RESULTS

The two groups were comparable with respect to preoperative and operative variables, with the exception of BMI being significantly higher in the SSRI/SNRI group (30.2 vs. 28.3 kg/m², p < 0.001). No significant differences were observed between groups in 24-h chest-tube output [815 (SSRI/SNRI) vs. 877 ml (reference), p = 0.26], number of RBC units transfused (2.2 vs. 2.2, p = 0.99) or the rate of reoperation for bleeding (4.1% vs. 6.0%, p = 0.61). The incidences of complications and 30-day mortality rate were also similar.

CONCLUSIONS

Using three different criteria, preoperative use of SSRIs/SNRIs was not shown to increase bleeding after CABG. Furthermore, short-term complications as well as 30-day mortality rates did not differ from those of controls. Thus, temporary cessation of SSRI/SNRI treatment prior to CABG to decrease the risk of bleeding is unwarranted.

Effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery: a systematic review

REVIEW OBJECTIVE

The objective of this review was to investigate the effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery on patients' health-related quality of life and hospital readmission.

INTRODUCTION

Coronary heart disease is a major cause of death and disability worldwide, putting a great strain on healthcare resources. For the past two decades, population-wide primary prevention and individual healthcare approaches have resulted in a dramatic decline in overall cardiac mortality. Over the intervening years, surgical techniques in cardiology have also improved substantially. As a result, long-term outcomes in patients treated with coronary artery bypass graft surgery have established the treatment's effectiveness and survival benefit. Furthermore, participating in cardiac rehabilitation following coronary artery bypass graft surgery has also demonstrated a significant decrease in all-cause cardiac mortality in these patients.

INCLUSION CRITERIA

This review included studies with participants aged 18 years and over, post coronary artery bypass graft surgery that evaluated nurse-led cardiac rehabilitation (CR) programs compared with usual care or other forms of CR. The outcomes of interest were the health-related quality of life and hospital readmissions following coronary artery bypass graft surgery and measured using validated scales. Randomized controlled trials reported in English between 2000 to June 2017 were considered for inclusion.

METHODS

The search strategy aimed to find both published and unpublished studies using a three-step search strategy. An initial search of MEDLINE, CINAHL and Scopus was undertaken, followed by a search for unpublished studies including Dissertation Abstracts International, ProQuest Dissertations and Theses, Google Scholar, MedNar and ClinicalTrials.gov. Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal tools from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Quantitative data was extracted from papers included in the review using the standardized data extraction tool from JBI-SUMARI. No meta-analysis was undertaken due to heterogeneity of the outcome measures. All results were subject to double data entry. Effect sizes expressed as risk ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis.

RESULTS

Three trials involving 329 patients were included in the final review. The trials that investigated the effect of home based cardiac rehabilitation programs compared to usual care at six weeks, three months and six months follow-up demonstrated no statistically significant difference in health-related quality of life at any of the follow-up periods. However, one study demonstrated significantly higher scores related to health-related quality of life among those who received nurse-led home based cardiac rehabilitation (154.93 ± 4.6) compared to those who received usual care (134.20 ± 8.2) at two months follow-up. No trials were identified that compared the effectiveness of nurse-led cardiac rehabilitation programs following coronary artery bypass graft surgery on readmissions to hospital.

CONCLUSION

There is not enough evidence to support or discourage nurse-led cardiac rehabilitation programs on health-related quality of life in patients following coronary artery bypass graft surgery. However, the sparse data available suggests improvements in health-related quality of life at two months follow-up among those who received a nurse-led program. Further large-scale multicenter trials with standardized methodology are needed to determine the effect of nurse-led cardiac rehabilitation programs on health-related quality of life and rates of readmission to hospital following coronary artery bypass graft surgery.

Selective serotonin reuptake inhibitor use and outcomes following cardiac surgery-a systematic review

A high prevalence of depression is observed in patients undergoing cardiac surgery, and depression has been shown to be an independent predictor of morbidity and mortality in this patient population. Selective serotonin re-uptake inhibitors (SSRIs) are the first-line recommended therapy for depressive disorders, however due to their platelet inhibitory actions they have been associated with increased incidences of post-operative bleeding. This review has sought to address whether the use of SSRIs is associated with a higher rate of mortality, major adverse events or bleeding events following cardiac surgery. A retrospective literature search selected studies comparing the use of SSRIs with no SSRI use in patients undergoing cardiac surgery. Seven of the ten studies analysed reported no significant difference in mortality in SSRI users. Five of the seven studies reporting bleeding events demonstrated no significant difference in SSRI users. Three of the five studies reporting other significant morbidity demonstrated no significant difference in SSRI users. Our study demonstrates the safety of the use of SSRIs for the treatment of depressive disorders in patients undergoing cardiac surgery.

Sex-Based Differences in Discharge Disposition and Outcomes for ST-Segment Elevation Myocardial Infarction Patients Within a Regional Network

BACKGROUND

It is known that women with ST-segment elevation myocardial infarction (STEMI) have higher mortality in comparison to men. While the reasons for this sex-based difference are not completely understood, biologic differences and disparities in care have been implicated. Whether these differences persist within an urban, regional STEMI system of care with defined protocols is unclear. Our objective was to explore sex-related effects in outcomes in a large regional system of care.

MATERIALS AND METHODS

Data were drawn from a regional subset of the National Cardiovascular Data Registry for 33 hospitals in and around Dallas County, Texas from 2010 to 2015. We explored adjusted differences between women and men for discharge disposition, door to balloon (D2B), total ischemic time (TIS), length of stay, and in-hospital mortality rates.

RESULTS

Multivariate regressions to control for confounding factors, including age, D2B, and TIS, were significantly prolonged in women compared to men (D2B 58 vs. 54 minutes; TIS 206 vs. 178 minutes; both p < 0.001). Length of stay was 0.45 median days longer. Women were also much less likely to survive at discharge than men [odds ratio (OR): 0.63; 95% confidence interval (CI): 0.52-0.76]. Most notably, they were much less likely to be discharged to home than men (88% vs. 92%, p < 0.001).

CONCLUSIONS

In this study, we found that sex-based disparities persist for both cardiovascular outcomes and discharge disposition, even in a modern regionalized system of care.

Does Gender Influence the Likelihood or Types of Complications Following Cardiac Surgery?

Over 410,000 cardiac surgeries are performed in American women each year. Women having coronary artery bypass graft (CABG) and valve surgery do so at an older age and with more cardiovascular risk factors than men. Women's smaller body size may also increase risk by increasing the technical difficulty of surgical procedures. Female CABG patients appear to have higher perioperative mortality and cardiac morbidity, although studies of neurologic outcomes in female CABG patients have produced equivocal findings. Women undergoing CABG tend to consume more hospital resources than men do in terms of blood transfusion, mechanical ventilation, and length of intensive care unit and overall hospital stay. With regard to valve surgery, women appear to have worse outcomes than men if the surgery is combined with a CABG operation. Women and men undergoing isolated aortic valve surgery have similar mortality, but little is known about gender differences in mitral and tricuspid valve surgery outcomes. Women who require heart transplantation tend to have idiopathic cardiomyopathy rather than the ischemic cardiomyopathy that is more common in male heart transplant candidates. Although female heart transplant recipients seem to have a stronger immunologic response after transplantation, which manifests in more frequent acute rejection episodes, it is not clear whether this increases women's mortality risk. Men appear to have a greater incidence of posttransplant vasculopathy than women. Further research is needed to identify risk factors for perioperative morbidity and mortality in women undergoing cardiac surgery and to develop medical interventions to mitigate these risks.

Psychological burden in inpatient relatives: the forgotten side of medical management

BACKGROUND

The burden of the hospital experience is a broad issue that has been evaluated in a particular context of intensive care unit (ICU). It is likely, however, that the load is heavy on families even in other hospital wards and not just in the ICU. The present study was designed to assess the prevalence of anxiety and depression in family members of patients admitted in a general medicine department, and to identify associated factors with those symptoms.

METHODS

Patients' and relatives' socio-demographic data and information pertaining to the patients' health characteristics were collected. Family members completed the Arabic version of Hospital Anxiety and Depression Scale (HADS). Associations between anxiety or depression and covariates of interest were investigated using generalized estimating equations, for univariate and multivariate logistic regression analysis.

RESULTS

The prevalence of anxiety (55.6%) and depression (41.1%) in family members remains high. The multivariate model identified three groups of factors associated with these symptoms: (i) Patient related: a short length of hospital stay is associated with depression (OR 1.04, 95% CI 1.01-1.08; P = 0.02); (ii) Family related: rural residence is associated with depression (OR 2.56, 95% CI 1.01-6.74; P = 0.04), and female gender is associated with anxiety and depression (OR 2.60, 95% CI 1.41-4.81; P = 0.002), (OR 3.04, 95% CI 1.62-5.70; P = 0.01), respectively; and (iii) Caregiver related: short length of visit (OR 1.08, 95% CI 1.03-1.13; P = 0.002) is associated with anxiety, admission to a share room (OR 2.56, 95% CI 1.25-5.23; P = 0.01) is associated with depression and a need for more information is associated with anxiety and depression (OR 1.78, 95% CI 1.02-3.10; P = 0.04),(OR 1.77, 95% CI 1.01-3.11; P = 0.04), respectively.

CONCLUSION

The prevalence of symptoms of anxiety and depression in family members remains high at the end of acute health care. It is hoped that improving the provision of information will decrease the risk of psychological distress.

Psychometric properties of the cardiac depression scale in patients with coronary heart disease

BACKGROUND

This study examined the psychometric properties of the Cardiac Depression Scale (CDS) in a sample of coronary heart disease (CHD) patients.

METHODS

A total of 152 patients were diagnosed with coronary heart disease and were administered the CDS along with the Beck Depression Inventory- 2 (BDI-2) and the State Trait Anxiety Inventory (STAI) 3.5-months after cardiac hospitalization.

RESULTS

The CDS's factorial composition in the current sample was similar to that observed in the original scale. Varimax-rotated principal-components analyses extracted six factors, corresponding to mood, anhedonia, cognition, fear, sleep and suicide. Reliability analyses yielded internal consistency α - coefficients for the six subscales ranging from 0.62 to 0.82. The CDS showed strong concurrent validity with the BDI-II (r = 0.64). More patients were classified as severely depressed using the CDS. Both the CDS and the BDI-2 displayed significantly strong correlations with the STAI (r = 0.61 and r = 0.64), respectively.

CONCLUSIONS

These findings encourage the use of the CDS for measuring the range of depressive symptoms in those with CHD 3.5 months after cardiac hospitalization.

Depression in patients with cardiovascular disease

It has been widely suggested that depression negatively affects patients with cardiovascular disease. There are several pathophysiological mechanisms as well as behavioral processes linking depression and cardiac events. Improvements in nursing and medical care have prolonged survival of this patient population; however, this beneficial outcome has led to increased prevalence of depression. Since mortality rates in chronic heart failure patients remain extremely high, it might be as equally important to screen for depression and there are several valid and reliable screening tools that healthcare personnel could easily employ to identify patients at greater risk. Consultation should be provided by a multidisciplinary team, consisting of cardiologists, psychiatrists, and hospital or community nurses so as to carefully plan, execute, and evaluate medical intervention and implement lifestyle changes. We aim to systematically review the existing knowledge regarding current definitions, prognostic implications, pathophysiological mechanisms, and current and future treatment options in patients with depression and cardiovascular disease, specifically those with heart failure.

Overlap of genetic influences in phenotypes classically categorized as psychiatric vs medical disorders

Psychiatric disorders have traditionally been segregated from medical disorders in terms of drugs, treatment, insurance coverage and training of clinicians. This segregation is consistent with the long-standing observation that there are inherent differences between psychiatric disorders (diseases relating to thoughts, feelings and behavior) and medical disorders (diseases relating to physical processes). However, these differences are growing less distinct as we improve our understanding of the roles of epistasis and pleiotropy in medical genetics. Both psychiatric and medical disorders are predisposed in part by genetic variation, and psychiatric disorders tend to be comorbid with medical disorders. One hypothesis on this interaction posits that certain combinations of genetic variants (epistasis) influence psychiatric disorders due to their impact on the brain, but the associated genes are also expressed in other tissues so the same groups of variants influence medical disorders (pleiotropy). The observation that psychiatric and medical disorders may interact is not novel. Equally, both epistasis and pleiotropy are fundamental concepts in medical genetics. However, we are just beginning to understand how genetic variation can influence both psychiatric and medical disorders. In our recent work, we have discovered gene networks significantly associated with psychiatric and substance use disorders. Invariably, these networks are also significantly associated with medical disorders. Recognizing how genetic variation can influence both psychiatric and medical disorders will help us to understand the etiology of the individual and comorbid disease phenotypes, predict and minimize side effects in drug and other treatments, and help to reduce stigma associated with psychiatric disorders.

New frontiers in cardiovascular behavioral medicine: comparative effectiveness of exercise and medication in treating depression

Exercise, considered a mainstay of cardiac rehabilitation, has been shown to reduce cardiac risk factors such as hyperlipidemia and hypertension. Growing evidence also suggests that exercise has beneficial effects on mental health, which is relevant for cardiac patients because of the prognostic significance of depression in patients with coronary heart disease (CHD). Depression has been associated with increased mortality and nonfatal cardiac events in patients with CHD; it is also associated with worse outcomes in patients who undergo coronary artery bypass graft surgery and those who have heart failure. The standard therapy for depression is pharmacologic treatment, often with second-generation antidepressants such as selective serotonin reuptake inhibitors. Despite their widespread use, antidepressants have only modest effects on depression for many patients compared with placebo controls. Exercise therapy, already an established component of cardiac rehabilitation, has potential efficacy as a treatment for depression in cardiac disease patients. Randomized controlled trials are needed to determine the clinical effects of exercise in this population and to compare the effects of exercise with those of antidepressants.

Causal attributions among patients undergoing coronary artery bypass surgery: gender aspects and relation to depressive symptomatology

Causal attributions made by patients for their coronary heart disease may contribute to gender differences in emotional adjustment. The purpose of this study was to determine gender differences in causal attributions and to analyze the associations between causal attributions and depressive symptomatology in patients undergoing coronary artery bypass graft (CABG) surgery. Nine hundred and seventy-nine patients (mean age 66.8 years, 19.9% women) completed a modified version of the Illness Perception Questionnaire (IPQ) and the depression module of the Patient Health Questionnaire (PHQ-9) 1-3 days before CABG-surgery and 1 year after surgery. Men were more likely to name their health behavior (men: 40.2%, women: 26.9%, P < .001) as a cause of disease, whereas women were more likely to cite destiny (women: 34.7%, men: 25.7%, P = .012). Regression analyses showed cross-sectional and longitudinal associations of attributions with depressive symptomatology which were independent of gender, sociodemographic and clinical variables. Attribution to personality and stress were associated with an increase in depressive symptomatology. Causal attributions may present a valuable approach for identifying patients at risk for depression and the implementation of targeted interventions.

Trajectories and predictors of anxiety and depression in women during the 12 months following an acute cardiac event

OBJECTIVES

Many previous investigations of the recovery of emotional well-being, particularly the resolution of depression, following an acute cardiac event assume that all patients follow a similar, linear trajectory. However, it is possible that there are different groups of patients who follow different trajectories. This study tested for multiple trajectories of anxiety and depression and identified the characteristics of patients most at risk for persistent or worsening anxiety and depression in the 12 months following their cardiac event.

METHOD

A consecutive sample of 226 women was interviewed following either acute myocardial infarction (AMI) or coronary artery bypass graft surgery (CABGS). The Hospital Anxiety and Depression Scale were administered on four occasions over 12 months. Growth curve and growth mixture modelling were used to identify trajectories of change and univariate tests were employed to establish predictors of each trajectory.

RESULTS

Most women began with relatively low levels of anxiety and/or depression that improved over the 12 month period (84% women showed this trajectory for anxiety, 89% for depression). A smaller group began with relatively high levels of anxiety and/or depression that worsened over time (16% for anxiety, 11% for depression). Patients in the latter group were more likely to report high levels of loneliness, have a first language other than English, perceive their cardiac disease as more severe (anxiety group only) and have diabetes (depression group only). Trajectories were non-linear, with most change occurring in the initial 2-month period.

CONCLUSION

Growth modelling techniques highlight that change in anxiety and depression following an acute event follows neither a single nor linear trajectory. Most women showed early resolution of anxiety and depression following their event, indicative of a normal bereavement or adjustment response. A minority of women reported worsening anxiety and/or depression in the year following their cardiac event, particularly those who lacked social support or were from non-English speaking backgrounds. Intervention studies to explore support options for these women are warranted, both prior to and following their event.

Treatment of depression after coronary artery bypass surgery: a randomized controlled trial

CONTEXT

There has been little research on the treatment of depression after coronary artery bypass surgery.

OBJECTIVE

To test the efficacy of 2 nonpharmacological interventions for depression after coronary artery bypass surgery compared with usual care.

DESIGN

A 12-week, randomized, single-blind clinical trial with outcome evaluations at 3, 6, and 9 months.

SETTING

Outpatient research clinic at Washington University School of Medicine, St Louis, Missouri.

PATIENTS

One hundred twenty-three patients who met the DSM-IV criteria for major or minor depression within 1 year after surgery.

INTERVENTION

Twelve weeks of cognitive behavior therapy or supportive stress management. Approximately half of the participants were taking nonstudy antidepressant medications.

MAIN OUTCOME MEASURE

Remission of depression, defined as a score of less than 7 on the 17-item Hamilton Rating Scale for Depression.

RESULTS

Remission of depression occurred by 3 months in a higher proportion of patients in the cognitive behavior therapy (71%) and supportive stress-management (57%) arms than in the usual care group (33%) (chi(2)(2) = 12.22, P = .002). Covariate-adjusted Hamilton scores were lower in the cognitive behavior therapy (mean [standard error], 5.5 [1.0]) and the supportive stress-management (7.8 [1.0]) arms than in the usual care arm (10.7 [1.0]) at 3 months. The differences narrowed at 6 months, but the remission rates differed again at 9 months (73%, 57%, and 35%, respectively; chi(2)(2) = 12.02, P = .003). Cognitive behavior therapy was superior to usual care at most points on secondary measures of depression, anxiety, hopelessness, stress, and quality of life. Supportive stress management was superior to usual care only on some of the measures.

CONCLUSIONS

Both cognitive behavior therapy and supportive stress management are efficacious for treating depression after coronary artery bypass surgery, relative to usual care. Cognitive behavior therapy had greater and more durable effects than supportive stress management on depression and several secondary psychological outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00042198.

The Bypassing the Blues treatment protocol: stepped collaborative care for treating post-CABG depression

OBJECTIVE

To present the design of the Bypassing the Blues (BtB) study to examine the impact of a collaborative care strategy for treating depression among patients with cardiac disease. Coronary artery bypass graft (CABG) surgery is one of the most common and costly medical procedures performed in the US. Up to half of post-CABG patients report depressive symptoms, and they are more likely to experience poorer health-related quality of life (HRQoL), worse functional status, continued chest pains, and higher risk of cardiovascular morbidity independent of cardiac status, medical comorbidity, and the extent of bypass surgery.

METHODS

BtB was designed to enroll 450 post-CABG patients from eight Pittsburgh-area hospitals including: (1) 300 patients who expressed mood symptoms preceding discharge and at 2 weeks post hospitalization (Patient Health Questionnaire (PHQ-9) >or=10); and (2) 150 patients who served as nondepressed controls (PHQ-9 <5). Depressed patients were randomized to either an 8-month course of nurse-delivered telephone-based collaborative care supervised by a psychiatrist and primary care expert, or to their physicians' "usual care." The primary hypothesis will test whether the intervention can produce an effect size of >or=0.5 improvement in HRQoL at 8 months post CABG, as measured by the SF-36 Mental Component Summary score. Secondary hypotheses will examine the impact of our intervention on mood symptoms, cardiovascular morbidity, employment, health services utilization, and treatment costs.

RESULTS

Not applicable.

CONCLUSIONS

This effectiveness trial will provide crucial information on the impact of a widely generalizable evidence-based collaborative care strategy for treating depressed patients with cardiac disease.

Family members of critically ill cancer patients: assessing the symptoms of anxiety and depression

OBJECTIVE

To determine prevalence and factors associated with symptoms of anxiety and depression in family members of critically ill cancer patients.

DESIGN

Prospective cohort study.

SETTING

A 23-bed intensive care unit in a tertiary cancer centre.

PATIENTS AND PARTICIPANTS

Three hundred consecutive families of cancer patients with length of stay >72 h in ICU.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The Hospital Anxiety and Depression Scale questionnaire and critical care family needs inventory were completed by family members. Prevalence of anxiety and depression in family members was 71 and 50.3%, respectively. Regarding the patients' disease, family depression was correlated with presence of metastasis, whereas hematological malignancies correlated with family' anxiety. Anxiety was independently associated with one patient-related factor (prolonged mechanical ventilation) and two family-related factors (catholic religion and gender). Factors associated with symptoms of depression included one patient-related factor (presence of metastasis) and one family-related factor (gender).

CONCLUSIONS

Present findings demonstrated a high prevalence of anxiety and depression in critically ill cancer patients' family members during an intensive care unit stay.

Private prayer and quality of life in cardiac patients: pathways of cognitive coping and social support

Despite the growing evidence linking faith with health and well-being, national leaders noted the need to explore the mechanism underlying these linkages. The goal of this prospective study was to investigate the psychosocial mechanisms involved in the preoperative use of private prayer for coping and the effects of such act on short-term quality of life (SPQOL) in 294 patients following open-heart surgery. Using established instruments, three interviews were conducted with middle-aged and older patients (average age 62) at two weeks and two days preoperatively, then 36 days postoperatively. The endpoints were assessed with levels of distress (e.g., depression and anxiety) and fatigue symptoms. Structural equation modeling was used to test a theoretical model. The final model showed the indirect influence of using prayer for coping on SPQOL through the mediation of cognitive coping and perceived social support. However, this mediation was not observed for behavioral, anger, and avoidant coping. Psychosocial factors may explain the potential role of using prayer for coping on short-term postoperative quality of life.

Dimensions of social support and depression in patients at increased psychosocial risk recovering from myocardial infarction

BACKGROUND

There is considerable evidence that depression and low social support are associated with increased morbidity and mortality for patients with coronary heart disease (CHD). However, there is a lack of consensus regarding the measurement of social support and its relation to depression.

PURPOSE

The primary purpose of the present study was to identify key dimensions of existing social support and depression measures for patients with CHD using factor analysis.

METHOD

Seven hundred-five patients with a recent acute myocardial infarction and either depression, low social support, or both, completed measures of several types of social support and depression. Exploratory and confirmatory factor analysis were used to examine the underlying dimensions of the existing social support and depression measures, and to compare theoretically plausible models specifying the relation between the social support and depression factors.

RESULTS

Confirmatory factor analysis indicated that an approach in which smaller facets of depression are measured (somatic, cognitive/affective, anxious) and social support (perceived emotional support from intimate relationships; perceived tangible support from peripheral contacts; and the number of children, relatives, and friends in a patient's support network), may be the most optimal way to measure social support and depression in this population RMSEA = 0.05; CFI = 0.81; TLI = 0.88).

CONCLUSION

Efforts to identify patients at increased psychosocial risk may be improved by screening for these subcomponents of social support and depression.

Relationship of genetic variability and depressive symptoms to adverse events after coronary artery bypass graft surgery

OBJECTIVE

To assess genetic variability in two serotonin-related gene polymorphisms (MAOA-uVNTR and 5HTTLPR) and their relationships to depression and adverse cardiac events in a sample of patients undergoing coronary artery bypass surgery.

METHODS

A total of 427 coronary artery bypass graft (CABG) patients were genotyped for two polymorphisms and assessed for depressive symptoms at three time points, in accordance with the Center for Epidemiological Studies-Depression (CES-D): preoperative baseline; 6 months postoperative; and 1 year postoperative. Logistic regression was used to assess the association between depressive symptoms (CES-D = >16), genotype differences, and cardiac events. Because MAOA-uVNTR is sex-linked, males and females were analyzed separately for this polymorphism; sexes were combined for the 5HTTLPR analysis.

RESULTS

Depressed patients were more likely than nondepressed patients to have a new cardiac event within 2 years of surgery (p < .0001); depressed patients who carry the long (L) allele of the 5HTTLPR polymorphism were more likely than the short/short (S/S carriers to have an event (p = .0002). Genetic associations with 6-month and 1-year postoperative depressive symptoms do not survive adjustment for baseline depressive symptoms.

CONCLUSIONS

A serotonin-related gene polymorphism--5HTTLPR--was associated with adverse cardiac events post CABG, in combination with depressive symptoms. Because depressed patients with the L allele of the 5HTTLPR polymorphism were more likely to have an event compared with the S/S carriers, combining genetic and psychiatric profiling may prove useful in identifying patients at the highest risk for adverse outcomes post CABG.

Psychosocial mediators of the relationship between race/ethnicity and depressive symptoms in Latino and white patients with coronary artery disease

BACKGROUND

The high prevalence of depressive symptoms in patients with coronary artery disease has been well documented. However, little is known about the prevalence and correlates of depressive symptoms in Latino patients with coronary artery disease.

PURPOSE

Among Latino and white patients who had percutaneous transluminal coronary angioplasty (PTCA), this study examined whether differences in the prevalence of depressive symptoms exist and the degree to which psychosocial factors (years of education, employment status, stressful life events, emotional social support) explained any differences.

METHODS

Using a cross-sectional design, closed-format questionnaires were used to obtain clinical and psychosocial history. The definition of high depressive symptoms was based on a score of > or =16 on the Center for Epidemiologic Studies Depression Scale (CES-D).

RESULTS

Compared to whites (n=492), Latinos (n=59) were younger, and a greater proportion were female, but fewer completed high school and fewer were employed (P<0.05). More Latinos reported experiencing > or =2 recent stressful life events, but fewer reported having emotional social support (P<0.05). There was a significant association between race/ethnicity and depressive symptoms (OR=2.3, 95% CI: 1.3-4.5). In multivariate analyses, the significance of this association diminished when psychosocial variables were added to the model.

CONCLUSIONS

In this study, education, employment, stressful life events and emotional social support partially explained the observed racial/ethnic differences in depressive symptoms.

Interpreting studies of cognitive function following cardiac surgery: a guide for surgical teams

Patients with coronary disease and related health care providers are faced with confusing and often conflicting information with regards to the neurocognitive impact of different strategies for coronary revascularization. Studies involving the measurement of postoperative cognitive deficit (POCD) have significant limitations that may ultimately impact on their interpretation and clinical relevance. In this review, we have described the origin of these tests and delineated the rationale for the design of testing that is commonly used in cardiac surgery patients. In general, neurocognitive tests assess domains of memory/new learning, psychomotor speed/dexterity and attentional capacity/mental control. Pre- and post-intervention tests in each domain can be evaluated either by the measurement of mean change scores (Group Comparison Model) for the entire group as continuous data, or by using categorical or continuous data to examine patterns of individual decline (Individual Comparison Model). This latter approach requires a specific definition of what constitutes a decline, which can be criticized as being arbitrary. There are limitations to each of these approaches that necessitate that critical information in trial design is available to the reviewer to facilitate interpretation. For example, the impact of factors such as test/re-test reliability and practice effect can be mitigated by the use of an appropriately chosen control population. Liberal parlance of neurocognitive outcome as a rationale for therapeutic choice must be tempered by wise interpretation of these tests. It is only through the understanding of their limitations and the implications of trial design that we can translate these results to provide the best therapeutic options for our patients in unbiased manner.

Longitudinal Risk Factors for Adverse Psychological Functioning Six Months after Coronary Artery Bypass Graft Surgery

This research aimed to identify modifiable risk factors for poor psychological functioning six months post-operatively, using a chronic illness model to explain the relationships between risk factors. Consecutive elective CABG patients ( N = 119) completed self-report measures including optimism, illness representations, self-rated health, social support, coping methods, depression, anxiety and PTSD symptomatology in a repeated measures design. Poor pre-operative psychological functioning was the strongest psychological risk factor for adverse psychological functioning six months post-operatively. Longitudinal support for the chronic illness model examined was limited. Further research to identify modifiable risk factors and pre-operative psychopathology screening to determine individuals at-risk of poor psychological outcome is recommended.

Physical, psychological and social recovery patterns after coronary artery bypass graft surgery: A prospective repeated measures questionnaire survey

AIM

This study examined the physical, psychological and social recovery patterns of Hong Kong Chinese patients who have undergone CABG surgery over a period of six months.

BACKGROUND

Recovery from coronary artery bypass graft (CABG) surgery is a dynamic process and the associated physical, psychological and social effects could lead to failure to recuperate leading to hospital re-admission and morbidity.

DESIGN

A prospective repeated measures design was used for this research. Patients were interviewed in person 5 days before surgery and at 1 week after discharge, and by telephone at 3 and 6 months after discharge. Physical recovery dimension was assessed by three categories of the Sickness Impact Profile (ambulation, sleep-rest, body movement and care). Social recovery dimension was assessed by three categories of the Sickness Impact Profile (SIP) (home management, social interaction, and recreation and pastimes). Psychological recovery was assessed using the Centre for Epidemiologic Studies-Depression (CES-D).

RESULTS

Sixty-eight patients participated in this research. The mean physical SIP-dimension score and depression level at discharge was the highest then gradually decreased at 6 months after CABG. The SIP-physical and SIP-social and depression level differed significantly across the four-assessment time within-group. There were no gender differences in physical and social recovery and depression levels. Patients who had poorer physical and social recovery had more depression at one week and three months after CABG surgery.

CONCLUSION

Patients should be prepared for discharge after CABG surgery. Cultural factors may have influenced the similar recovery patterns between genders. These factors contributing to early recovery must be further examined.

RELEVANCE TO CLINICAL PRACTICE

Because of the large number of patients who undergo CABG worldwide, and because of healthcare cost related to this intervention, it is important for both patients and healthcare providers to have realistic expectations about the recovery process and to recognise deviations from the norm. The results provided some insights into the Hong Kong Chinese patients' recovery from CABG surgery that would guide the development of culturally appropriate pre-operative and discharge teaching for this group of patients.

Relation of depression, natural killer cell function, and infections after coronary artery bypass in women

BACKGROUND

After hospital discharge for coronary artery bypass grafting (CABG), infection is a common cause of morbidity. Although depression has been associated with immune dysfunction, its role in post-CABG infection is unknown.

AIMS

The purpose of this study was to: 1) compare natural killer cell cytotoxicity (NKCC) and post-hospitalization infections in depressed and non-depressed women after CABG; and 2) test whether NKCC mediated the relationship between post-discharge depression and infections.

METHODS

Sixty-seven women recovering from CABG were assessed for depression prior to hospital discharge and followed for six months. Major depression was identified by a structured clinical interview. Infections were identified by patient report using the Modified Health Review and by medical chart audit.

RESULTS

Compared to non-depressed women after CABG, women with major depression had reduced NKCC, more all-cause infections, and more self-reported illnesses. Although NKCC did not mediate the relationship between depression and wound (i.e. incisional) infections after CABG, it did mediate the relationship between depression and non-wound infections, including pneumonias and upper respiratory infections.

CONCLUSIONS

For the first six months after CABG, women with major depression are at increased risk for infections. Natural killer cell cytotoxicity may be related to this phenomenon, particularly to non-wound infections.

Influence of patient-related and surgery-related risk factors on cognitive performance, emotional state, and convalescence after cardiac surgery

BACKGROUND

Cardiac surgery may account for complications such as cognitive impairment, depression, and delay of convalescence. This study investigated the influence of different risk factors on cognitive performance, emotional state, and convalescence.

METHODS

We included 83 patients undergoing cardiac surgery who had no indication of postoperative delirium. Psychometric testing was performed 1 day before and 7 days after surgery. Neuron-specific enolase (NSE) levels were measured 1 day before and 36 h after surgery.

RESULTS

Depression score increased after surgery, but patients showed no clinically significant depression. Postoperative cognitive performance correlated with postoperative depression level and preoperative cognitive performance. Forty-three percent of patients showed postoperative decline. Older patients exhibited a higher postoperative increase in NSE concentrations. Patients undergoing coronary artery bypass grafts or combined procedures exhibited more medical risk factors than those undergoing valve surgery alone. The number of bypass grafts was associated with time of hospitalization, and the number of patient-related risk factors correlated with stay in intensive care unit.

CONCLUSIONS

For elderly patients undergoing cardiac surgery, older age, total preexisting medical risk factors, and surgery duration seem to be the most important factors influencing cognitive outcome and convalescence. Results show that, also for patients without postoperative delirium, medical risk factors and intraoperative parameters can result in delay of convalescence.

Psychosocial mediation of religious coping styles: a study of short-term psychological distress following cardiac surgery

Although religiousness and religious coping styles are well-documented predictors of well-being, research on the mechanisms through which religious coping styles operate is sparse. This prospective study examined religious coping styles, hope, and social support as pathways of the influence of general religiousness (religious importance and involvement) on the reduced postoperative psychological distress of 309 cardiac patients. Results of structural equation modeling indicated that controlling for preoperative distress, gender, and education, religiousness contributed to positive religious coping, which in turn was associated with less distress via a path fully mediated by the secular factors of social support and hope. Furthermore, negative religious coping styles, although correlated at the bivariate level with preoperative distress but not with religiousness, were associated both directly and indirectly with greater post-operative distress via the same mediators.

Utility of Observer-Rated and Self-Report Instruments for Detecting Major Depression in Women After Cardiac Surgery: A Pilot Study

Background Major depression is common after coronary artery bypass graft surgery and is associated with increased mortality and morbidity. Clinicians have few practical options for detecting depression, especially in women, who are at higher risk for depression than men.

Objectives To evaluate the clinical utility of common self-report and observer-rated instruments for detection of major depression in women after coronary artery bypass graft surgery.

Methods In 66 women being discharged after coronary artery bypass graft surgery, 4 instruments were completed: the Hamilton Depression Rating Scale, Beck Depression Inventory, Beck Depression Inventory Short Form, and Beck Depression Inventory for Primary Care. For each instrument, receiver-operating-characteristic curves were analyzed, and positive and negative predictive values were calculated for cutoff points determined from the curves.

Results At hospital discharge, all 4 instruments yielded highly accurate curves. Compared with cutoffs suggested for patients without medical illness and hospitalized nonsurgical patients, identified cutoffs for screening were higher when all types of depressive symptoms (cognitive, affective, behavioral, somatic) were measured with the Hamilton Depression Rating Scale and the Beck Depression Inventory but lower when only cognitive and/or affective symptoms were measured with the 2 subscales of the Beck Depression Inventory.

Conclusions The Hamilton Depression Rating Scale and both subscales of the Beck Depression Inventory may be useful for detecting major depression in women shortly after coronary artery bypass graft surgery. Further study is warranted to confirm cutoffs in these patients.

Effects of a home-based intervention program on anxiety and depression 6 months after coronary artery bypass grafting: a randomized controlled trial

OBJECTIVE

The objective of this study was to evaluate the effects of a home-based intervention program (HBIP) on anxiety and depression 6 months after coronary artery bypass grafting (CABG).

METHODS

In a prospective randomized controlled trial, 203 elective CABG patients were included. An HBIP structured for respondents in the intervention group was performed 2 and 4 weeks after surgery. Anxiety and depression symptoms were measured by the Hospital Anxiety and Depression Scale (HADS) in both patient groups before surgery, 6 weeks after surgery, and 6 months after surgery.

RESULTS

A total of 185 patients completed the study: 93 patients in the intervention group and 92 patients in the control group. On 6-week and 6-month follow-ups, significant improvements in anxiety and depression symptoms were found in both groups. These improvements did not differ significantly between the groups. However, in a predefined subgroup of patients with anxiety and/or depression symptoms at baseline (n=65), improvement was significantly larger in the intervention group (n=29) than in the control group (n=36) after 6 months (P<.05).

CONCLUSIONS

Patients experiencing high levels of psychological distress before CABG surgery benefited from a structured informational and psychological HBIP. Implementation of psychological screens of patients scheduled for CABG might serve to identify patients experiencing anxiety and/or depression. These patients could then be targeted to receive individualized HBIP.

Differential effects of faith-based coping on physical and mental fatigue in middle-aged and older cardiac patients

PURPOSE

This analysis investigated the effect of faith-based coping used by cardiac patients undergoing surgery on physical and mental fatigue, symptoms which have significant prognostic implications for mortality. Particularly, we explored whether this faith effect is independent or explained by positive mediators.

METHODS

Two weeks preoperatively, 481 patients (male, 58%; mean age = 62 years) were recruited for three sequential interviews. Among them, 426 completed the second interview, and 335 completed the post-operative follow-up. Cross-clamp and bypass time were obtained from patients' charts. Plasma interlukin-6 (IL-6) was used as a correlate of age-associated diseases and frailty.

RESULTS

Hierarchical multiple regression analyses showed that pre-operative positive religious coping styles and optimism contributed to reduced physical fatigue, controlling for post-operatively confirmed prayer coping and such covariates as severe injury. Depression and lower-back problems contributed to mental fatigue. No potential mediators explained these effects.

CONCLUSION

Faith-based coping and optimism are independent predictors of physical fatigue.

Depression is associated with worse patency and recurrent leg symptoms after lower extremity revascularization

OBJECTIVES

Depression is associated with worse outcomes after coronary artery bypass surgery, but its association with the results after revascularization for symptomatic peripheral arterial disease (PAD) is unknown. This study assessed the association between depression and patency, recurrent symptoms, and limb salvage after revascularization for symptomatic PAD.

METHODS

Electronic medical records were retrospectively reviewed for all patients with symptomatic PAD who underwent intervention (open, endovascular, or combined) between January 2000 and October 2004. All patients were previously screened for depression, and treatment was initiated as indicated by the primary care physician or psychiatrist. Demographic data and outcomes were recorded using published guidelines. Outcomes of interest included primary patency of the revascularization (bypass graft or angioplasty/stented artery), assisted primary patency, secondary patency, recurrent symptomatic ipsilateral PAD, and major amputation. Follow-up was available for all patients (mean, 23.4 +/- 14.1 months).

RESULTS

Board-certified vascular surgeons performed all interventions. At the time of intervention, 78 (36.1%) of 216 patients had been diagnosed with depression. Compared with those without depression, depressed patients were younger (64.4 vs 69.1 years; P = .001), currently using tobacco (74.4% vs 51.4%; P = .001), and less likely to have hypertension (79.5% vs 89.9%; P = .03). No other significant differences were noted for cardiovascular risk factors or prevalent comorbidities. During follow-up, 50 patients (23.1%) had failing or failed revascularizations, and 24 (11%) had amputations. Those with depression at the time of the PAD intervention, compared at 24 months with patients without depression, had significantly worse primary patency (58.2% vs 79.8%; P = .02), primary assisted patency (59.5% vs 81.5%; P = .01), and secondary patency (60.2% vs 82.2%; P = .007). They also had a significantly increased risk of recurrent symptomatic PAD (33.7% vs 20.8%; P = .03) but not major amputation (13.8% vs 10.4%; P = .73). By multivariate analysis, patients with depression were at significantly increased risk for recurrent symptomatic PAD (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.03 to 3.02; P = .04) and failure of revascularization (HR, 2.18; 95% CI, 1.22 to 3.88; P < .01), but not major amputation.

CONCLUSIONS

Depression is common among patients undergoing intervention for symptomatic PAD. After intervention, patients with depression have worse outcomes for the affected leg. Prospective analysis is required to confirm these results.

Application of a chronic illness model as a means of understanding pre-operative psychological adjustment in coronary artery bypass graft patients

OBJECTIVES

To increase understanding of the factors associated with pre-operative psychological adjustment in coronary artery bypass graft (CABG) patients by assessing the utility of a chronic illness model developed by Scharloo, Kaptein, Weinman, Willems, and Rooijmans (2000).

DESIGN

A cross-sectional design was employed.

METHOD

Elective CABG patients (N=119) completed self-report measures of illness representation, self-rated health, social support, coping methods, and pre-operative adjustment (depression and post-traumatic stress disorder (PTSD) symptomatology) an average of 30 days prior to surgery. Hierarchical multiple regression was used to assess the mediational relationships proposed by the chronic illness model.

RESULTS

Five 3-variable mediational chains were assessed. In all instances, the results conformed to the relationships suggested by the chronic illness model where the strength of the relationship between the independent and dependent variables was reduced when the mediator variable was controlled. However, a significant reduction of this relationship was found in three of the five chains examined. The most rigorous support for the model occurred, where increased use of avoidance coping mediated the relationship between poorer self-rated health and increased PTSD symptomatology, and also where increased use of avoidance coping partially mediated the relationship between a more negative illness representation and increased PTSD symptomatology, and poorer self-rated health and increased depression.

CONCLUSIONS

The chronic illness model of Scharloo and colleagues shows potential in explaining pre-operative adjustment in CABG patients. Longitudinal examination of the model is recommended.

Effect of intense lifestyle modification and cardiac rehabilitation on psychosocial cardiovascular disease risk factors and quality of life

This study examined the effect of the Ornish Program for Reversing Heart Disease and cardiac rehabilitation (CR) on psychosocial risk factors and quality of life in patients with confirmed coronary artery disease. Participants had previously undergone a revascularization procedure. The 84 patients self-selected to participate in the Ornish Program for Reversing Heart Disease (n = 507 28), CR (n = 28), or a control group (n = 28). Twelve psychosocial risk factors and quality of life variables were collected from all three groups at baseline, 3 months, and 6 months. At 3 and 6 months, Ornish group participants demonstrated significant improvements in all 12 outcome measures. The rehabilitation group improved in 7 of the 12, and the control group showed significant improvements in 6 of the variables. Intensive lifestyle modification programs significantly affect psychosocial risk factors and quality of life.

Minor depression as a cardiac risk factor after coronary artery bypass surgery

A few studies have investigated the role of psychosocial variables on clinical outcomes in coronary artery bypass grafting patients. The aims of this prospective study were 1) to assess clinical and subclinical distress in a consecutive sample of patients who underwent coronary artery bypass grafting surgery at both a 1-month assessment and a 6- to 8-year follow-up visit; and 2) to investigate the relationship between psychological variables and coronary events. A consecutive series of 47 patients with recent coronary artery bypass grafting surgery was evaluated by means of observer-rated categories (both the Diagnostic and Statistical Manual [DSM] and the new Diagnostic Criteria for Psychosomatic Research [DCPR]), and self-rated scales such as the Psychosocial Index. Survival analysis was used to characterize the clinical course of patients at the 6- to 8-year follow-up. One month after surgery, at the first psychological assessment, 36% of patients received a psychiatric diagnosis, and almost half of the sample met the criteria for a DCPR cluster. At follow-up, only abnormal illness behavior scores varied significantly from those at the first evaluation. Among the variables examined as potential risk factors for coronary events, only minor depression attained statistical significance. Psychological evaluation of patients who underwent coronary artery bypass grafting surgery needs to incorporate both clinical (DSM) and subclinical (DCPR) methods of classification. Furthermore, the data suggest minor depression as a potential cardiac risk factor in coronary artery bypass grafting patients. The clinical approach to coronary artery bypass grafting patients should thus include not only major depressive symptoms but also minor depression.

Effects of mood state and psychosocial functioning on plasma Interleukin-6 in adult patients before cardiac surgery

OBJECTIVE

The purpose of this study was to examine the potential effect of mood states and psychosocial functioning during the waiting weeks prior to major cardiac surgery on the plasma Interleukin-6 (IL-6) levels in 236 patients immediately before their operation.

METHOD

The sample was recruited from patients at the cardiac clinic of the University of Michigan Medical Center (Ann Arbor). Two weeks before cardiac surgery, trained research assistants conducted a face-to-face interview with these middle-aged and older patients on their preoperative physical examination date at the clinic. Standardized instruments were used to assess mood states and psychosocial functioning. The blood samples of 236 patients, obtained on the morning of the operation, were analyzed for plasma IL-6.

RESULTS

In bivariate analysis, poor psychological functioning and anxiety, as well as bodily pain and body mass index (BMI), were correlated with plasma IL-6 (p < .05), but sociodemographics, chronic illness and use of psychotropic medications were not. When the effect of bodily pain and BMI were taken into account, partial correlation analysis showed that psychological functioning continued to be associated with plasma IL-6 (p < .05); the association of IL-6 with depression now became significant (p < .05), whereas that with anxiety became even more significant (p < .001).

CONCLUSIONS

Preoperative psychological disturbances during the waiting weeks before cardiac surgery may influence the plasma levels of IL-6 immediately prior to the procedure. The clinical implications of these findings remain to be determined.

Validation of the Cardiac Depression Scale in a cardiac rehabilitation population

OBJECTIVE

The current study was undertaken to provide further evidence supporting the reliability and validity of the Cardiac Depression Scale (CDS) in a population of cardiovascular patients.

METHODS

The CDS was administered to 627 consecutive ambulatory adult cardiac patients attending an outpatient Cardiac Rehabilitation program, and a subgroup also completed the Geriatric Depression Scale--Short Form (GDS-SF).

RESULTS

Factor analysis revealed six subscales accounting for 62% of scale variance. The CDS demonstrated high internal consistency (Cronbach's alpha=.92) and correlation coefficient with the GDS-SF of .77. Receiver operating characteristic curves suggested a CDS cutoff score of 100 to detect more severe depression, and 90 to detect mild to moderate depression.

CONCLUSION

These findings encourage the continued use and evaluation of the CDS for measuring symptoms of depressive affect in cardiac patients.

Depression, faith-based coping, and short-term postoperative global functioning in adult and older patients undergoing cardiac surgery

OBJECTIVES

This prospective study examined how preoperative depression and faith-based coping, assessed preoperatively and postoperatively, affected short-term postoperative global functioning (SPGF) following a major cardiac surgery.

METHODS

We recruited 481 patients (male, 58%; mean age=62 years, range=35-89) 2 weeks before surgery for three sequential psychosocial interviews using standardized instruments. Of them, 426 completed the second interview, and 335 completed the postoperative follow-up.

RESULTS

Multiple regression analyses showed that depression predicted poor SPGF, controlling for age, preoperative illness impact, and two noncardiac chronic conditions. Preoperative positive religious coping contributed to better SPGF, controlling for preoperative depression and other confounders. However, postoperatively assessed prayer coping was associated with poor SPGF.

CONCLUSION

Research should distinguish the longitudinal protection of generally adaptive faith-based coping styles from the increased usage of such coping for immediate distress, mobilized by crisis.