Depression and heart disease: evidence of a link, and its therapeutic implications

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

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

COVID-19 lockdown: Impact on college students' lives

Objective: In light of COVID-19, leaders issued stay-at-home orders, including closure of higher-education schools. Most students left campus, likely impacting their employment and social network. Leaders are making decisions about opening universities and modality of instruction. Understanding students' psychological, physiological, academic, and financial responses to the shut-down and reopening of campuses can help leaders make informed decisions. Participants: 654 students from a large western university enrolled during the pandemic shutdown. Methods: Students were invited via email to complete an online survey. Results: Students reported stress, depression, loneliness, lack of motivation, difficulty focusing on schoolwork, restless sleep, appetite changes, job loss concerns, and difficulties coping. Most wanted to return to campus and felt social/physical distancing was effective but were mixed in terms of testing or masks. Conclusions: Moving to remote learning created physical and psychological stress. Students want to return to campus but do not want to take risk-reducing measures.

Association between level of depression and coronary heart disease, stroke risk and all-cause and cardiovascular mortality: Data from the 2005-2018 National Health and Nutrition Examination Survey

Research on the association between level of depression and coronary heart disease (CHD), stroke risk, and all-cause and cardiovascular mortality is lacking in large-scale or population-based studies incorporating cardiovascular disease (CVD) endpoints. We aim to assess the relationship between the level of a person's depression and their risk of CHD, stroke, and all-cause and cardiovascular mortality. Utilizing data from the United States National Health and Nutrition Examination Survey (NHANES), multicycle cross-sectional design and mortality linkage studies were conducted. The study sample included 30918 participants aged 20-85 years old during the 2005-2018 period. Depression was assessed using the nine-item Patient Health Questionnaire (PHQ-9), with scores of 5, 10, 15, and 20 being the cut-off points for mild, moderate, moderately severe, and severe depression, respectively. A series of weighted logistic regression analyses and Cox proportional hazards models were utilized to examine the relationship between the level of depression with the risk of CHD, stroke, all-cause, and cardiovascular mortality. Trend analyses were conducted by entering the level of depression as a continuous variable and rerunning the corresponding regression models. Weighted logistic regression models consistently indicated a statistically significant association between the level of depression and increased risk of CHD and stroke, and those linear trend tests were statistically significant (P for trend < 0.001). Furthermore, weighted Cox regression analyses consistently indicated that participants who had a more severe degree of depression were at a higher risk of all-cause death, and trend analyses suggested similar results (P for trend < 0.001). Another weighted Cox regression analysis also consistently indicated that except for severe depression, the hazard of cardiovascular death was increased with each additional level increase of depression. Our study confirmed that the level of depression was strongly associated with CHD, stroke, and all-cause and cardiovascular mortality, even after accounting for other factors that could impact risk, including variables of age, gender, ethnicity, income, education, body mass index (BMI), marital, and smoking status.

Association between Ultraviolet B Exposure Levels and Depression in Taiwanese Adults: A Nested Case-Control Study

Depression is a common mental disorder that affects more than 264 million people worldwide. Anxiety, diabetes, Alzheimer's disease, myocardial infarction, and cancer, among other disorders, are known to increase the risk of depression. Exposure to ultraviolet B (UVB) can cause human serotonin levels to increase. The vitamin D pathway is one mechanism through which ultraviolet light absorbed through the skin can affect mood; however, UVB exposure is known to increase the risk of cancer. In this study, we explored the effects of prolonged exposure to UVB on depression. Data were retrieved from the Taiwan National Health Insurance Research Database for 2008 to 2013. Each patient with depression was matched 1:4 with a comparison patient by sex and age (±5 years); thus, the study included 23,579 patients with depression and 94,316 healthy controls for comparison. The patients had been exposed to UVB for at least 1 year to observe the cumulative effect of UVB exposure. Based on the World Health Organization UV index, we divided the observation period data into five UV levels: low, moderate, high, very high, and extreme. A multivariate Poisson regression model was used to assess the risk of depression according to UVB exposure level, adjusting for sex, age, income, urbanization level, month, and comorbidities. The results revealed that the incidence rate ratio (IRR) for patients with depression was 0.889 for moderate levels (95% CI 0.835-0.947), 1.134 for high levels (95% CI: 1.022-1.260), 1.711 for very high levels (95% CI: 1.505-1.945), and 2.785 for extreme levels (95% CI: 2.439-3.180) when compared to low levels. Moderate levels of UVB lowered the risk of depression, while high levels of UVB gradually increased the risk. We propose that UVB at normal concentrations can effectively improve depression. However, exposure to high concentrations of UVB damage DNA results in physical diseases such as skin cancer, which increase the risk of depression.

Behavioral pathway to a broken heart: The link between adverse childhood experiences, depression, physical exercise and cardiovascular health

BACKGROUND AND AIM

Adverse childhood experiences (ACEs) are a major risk factor for unfavorable behavioral, mental and health outcomes later in life. However, the precise pathway via which ACEs convey these risks, in particular regarding health outcomes such as cardiovascular disease, remains unknown. Here, we combined psychiatric and cardiac methods to investigate the pathway via which childhood adversities may lead to adult adverse cardiovascular health, with a focus on epicardial adipose tissue (EAT) as a risk marker.

METHODS

210 adult congenital heart disease outpatients (mean age 35.5 y, 43% female) completed a thorough cardiac and psychiatric evaluation. Psychiatric measurements included an expert interview, the childhood trauma questionnaire (CTQ), Beck's depression inventory II (BDI-II), quality of life and the global scale of functioning, amongst others. All patients completed a full cardiac workup including EAT assessment using echocardiography. We then computed bootstrapping mediation models using ACEs as a predictor, depression and physical activity as mediators and EAT as dependent variable in PROCESS.

RESULTS

CTQ scores had a significant indirect effect on EAT via a serial mediation of BDI and physical activity [a^*b2^*d = 0.0260, 95% BCa CI [0.0047, 0.0619]].

CONCLUSION

Using mediation analyses, we show that adverse childhood events are linked to increased depressive symptoms, which are linked to decreased physical activity, which in turn are linked to a higher amount of epicardial adipose tissue. While other pathways most certainly exist and replication is needed, this suggests a meaningful pathway via which ACEs lead to adverse cardiovascular health, with several potential targets for health interventions across time.

Portal Vein Thrombosis Is Associated with an Increased Incidence of Depression and Anxiety Disorders

Portal vein thrombosis (PVT) is a severe disease that adversely affects patients' well-being. Data on the influence of PVT on the occurrence of depression or anxiety disorders are lacking. This study aimed to explore the impact of PVT on the incidence of depression and anxiety disorders diagnoses in a large German primary care cohort over a ten-year period. Patients with PVT were matched to non-PVT individuals by age, sex, yearly consultation frequency, index year and comorbidities in a 1:5 ratio. The primary outcome of the study was the incidence of depression and anxiety disorders. The relationship between PVT and both depression and anxiety disorders was investigated using Cox regression models. We compared 547 patients with PVT with 2735 matched individuals without PVT. Within 5 years of the index date, 17.4% of patients with PVT and 9.3% of non-PVT individuals were diagnosed with depression (p < 0.001). Anxiety disorders were diagnosed in 5.5% and 3.0% of patients with PVT and non-PVT individuals, respectively (p = 0.002). On regression analyses, PVT was positively associated with incident depression (HR 2.01, 95% CI 1.53-2.64, p < 0.001) as well as anxiety disorders (HR 2.16, 95% CI 1.35-3.46, p = 0.001). Regarding depression, this association remained significant in women as well as in men. There was no association between PVT and the incidence of anxiety disorders in women. In conclusion, PVT is associated with the development of depression and anxiety disorders. However, further prospective studies are needed to confirm our findings before definitive recommendations can be made.

Depression and the use of antidepressants in cardiovascular diseases from a cardiologist’s perspective

Introduction: Cardiovascular diseases, especially coronary heart disease or heart failure, are often chronic.

Aim and method: The aim of this study was to review the literature on the prevalence of depressive disorders and the use of antidepressants in cardiovascular disease. For this purpose, articles available in PubMed and Google Scholar databases were used.

Results: About one in five patients with cardiovascular disease suffers from major depressive disorder. Psychosocial stress, depression and anxiety, are associated with poorer prognosis and make it more difficult for patients to make positive lifestyle changes and comply with medical recommendations. Conversely, depressive symptoms are associated with an increased risk of cardiovascular incidents. Regarding pharmacotherapy, selective serotonin reuptake inhibitors (SSRIs) are considered safe drugs, while tricyclic antidepressants are not recommended. In the treatment of depression and cardiovascular diseases, supplementation or a diet rich in omega-3 fatty acids is worth mentioning.

Conclusions: The above literature review highlights the need for a multidirectional approach that is essential to diagnose, understand and then treat these, often comorbid, conditions of cardiovascular disease and depression.

Clinical outcomes and survival analysis in patients with psycho-cardiological disease: a retrospective analysis of 132 cases

Objectives

The deleterious effects of psychological problems on coronary heart disease (CHD) are not satisfactorily explained. We explored influential factors associated with mortality in psycho-cardiological disease in a Chinese sample.

Methods

Of 7460 cardiac patients, we selected 132 patients with CHD and mental illness. Follow-up was conducted via telephone. We analyzed clinical characteristics, clinical outcomes, and survival.

Results

The clinical detection rate of psycho-cardiological disease in the overall patient population was 1.8%. Of these, 113 patients completed follow-up; 18 died owing to cardiovascular diseases during follow-up. Kaplan–Meier analysis showed dysphagia, limb function, self-care ability, percutaneous coronary intervention, low-density lipoprotein, total cholesterol, pro-brain natriuretic peptide and high-sensitivity (hs) troponin T had significant associations with cumulative survival. Cox regression analysis showed total cholesterol (hazard ratio [HR]: 2.765, 95% confidence interval [CI]: 1.001–7.641), hs troponin T (HR: 4.668, 95% CI: 1.293–16.854), and percutaneous coronary intervention (HR: 3.619, 95% CI: 1.383–9.474) were independently associated with cumulative survival.

Conclusions

The clinical detection rate of psycho-cardiological disease was far lower than expected. Normal total cholesterol and hs troponin T were associated with reduced cardiovascular disease mortality over 2 years. Percutaneous coronary intervention is a prognostic risk factor in patients with psycho-cardiological disease.

Factors Differentiating Rural and Urban Population in Determining Anxiety and Depression in Patients with Chronic Cardiovascular Disease: A Pilot Study

The aim of this cross-sectional study was to analyze selected variables differentiating rural from urban populations, as well as identify potentially increased levels of depression and anxiety in patients with chronic cardiovascular disease. The study was carried out in 193 patients. The study used the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS), the Health Behavior Inventory Questionnaire (HBI), the WHOQOL-BREF Quality of Life Questionnaire, and the Hospital Anxiety and Depression Scale-Modified Version (HADS-M). Spearman's rank correlation coefficient test and logistic regression were used for analyses. In rural patients, we observed a relationship between anxiety and age (1/OR = 1.04; 95% CI: 0.91-0.99), the assessment of satisfied needs (1/OR = 293.86; 95% CI: 0.00001-0.56), and quality of life (QoL) in physical (OR = 1.56; 95% CI: 1.11-2.33), social (1/OR = 1.53; 95% CI: 0.04-0.94), and environmental domains (OR = 1.67; 95% CI: 1.06-3.00), as well as between depression and QoL in physical (1/OR = 1.39; 95% CI: 0.50-0.97) and psychological (OR = 1.37; 95% CI: 1.01-1.93) domains. In city patients, we observed a relationship between the drug and Qol in the physical (1/OR = 1.25; 95% CI: 0.62-0.98) and psychological (OR = 1.49; 95% CI: 1.13) domains. Younger patients living in a rural area with a lower assessment of met needs, a higher level of QoL in physical and environmental domains, and a lower social domain, as well as patients living in a city with a lower QoL in the physical domain and a higher psychological domain, have a greater chance of developing anxiety and depressive disorders.

Aqueous extract of pomegranate enriched in ellagitannins prevents anxiety-like behavior and metabolic changes induced by cafeteria diet in an animal model of menopause

Women around menopause are vulnerable to present psychiatric and metabolic disorders; thus, therapies that contribute to treat both pathologies are required. Previous reports showed that an aqueous extract of pomegranate (Punica granatum), enriched in ellagitannins, exerts an antidepressant-like effect in ovariectomized rats. We analyze whether this aqueous extract of P. granatum (AE-PG) prevents the anxiety-like behavior induced by a cafeteria diet (CAF) in middle-aged ovariectomized rats at the same time that it prevents an increase in body weight, glucose, lipids, and the changes on mRNA expression of the peroxisome proliferator-activated receptor-gamma (PPAR-γ) in the liver. Also, the effects of AE-PG on the protein levels of PPAR-γphospho-PPAR-γ, extracellular signal-regulated protein kinase (ERK1/2) and phospho-ERK1/2 were measured in the hippocampus and amygdala. CAF induced anxiety-like behavior, augmented lipids and glucose blood levels, body weight, visceral fat, insulin resistance, and decreased mRNA expression of PPAR-γ in the liver. In rats fed with the CAF, AE-PG prevented the anxiety-like behavior, reduced body weight, lowered lipid levels, reduced insulin resistance, and increased PPAR-γ mRNA expression in the liver. In the hippocampus, ERK1/2 but not PPAR-γ protein levels were decreased by CAF, while AE-PG prevented these effects. In the amygdala, CAF increased the phosphorylation of PPARγ, and AE-PG prevented it. In contrast, AE-PG rescued the decreased ERK1/2 protein level in the hippocampus caused by CAF. In conclusion, AE-PG treatment prevented anxiogenic and metabolic effects induced by CAF, and its effects appear to be mediated by ERK1/2 and PPARγ depending on the brain area studied.

Inflammation as the Common Biological Link Between Depression and Cardiovascular Diseases: Can Carnosine Exert a Protective Role?

Several epidemiological studies have clearly shown the high co-morbidity between depression and Cardiovascular Diseases (CVD). Different studies have been conducted to identify the common pathophysiological events of these diseases such as the overactivation of the hypothalamic- pituitary-adrenal axis and, most importantly, the dysregulation of immune system which causes a chronic pro-inflammatory status. The biological link between depression, inflammation, and CVD can be related to high levels of pro-inflammatory cytokines, such as IL-1β, TNF-α, and IL-6, released by macrophages which play a central role in the pathophysiology of both depression and CVD. Pro-inflammatory cytokines interfere with many of the pathophysiological mechanisms relevant to depression by upregulating the rate-limiting enzymes in the metabolic pathway of tryptophan and altering serotonin metabolism. These cytokines also increase the risk to develop CVD, because activation of macrophages under this pro-inflammatory status is closely associated with endothelial dysfunction and oxidative stress, a preamble to atherosclerosis and atherothrombosis. Carnosine (β-alanyl-L-histidine) is an endogenous dipeptide which exerts a strong antiinflammatory activity on macrophages by suppressing reactive species and pro-inflammatory cytokines production and altering pro-inflammatory/anti-inflammatory macrophage polarization. This dipeptide exhibits antioxidant properties scavenging reactive species and preventing oxidative stress-induced pathologies such as CVD. In the present review we will discuss the role of oxidative stress and chronic inflammation as common pathophysiological events both in depression and CVD and the preclinical and clinical evidence on the protective effect of carnosine in both diseases as well as the therapeutic potential of this dipeptide in depressed patients with a high co-morbidity of cardiovascular diseases.

Depression and Cardiovascular Disorders in the Elderly

The world's older population continues to grow at an unprecedented rate. This trend amplifies the necessity of improving the care of older patients with chronic health problems. Of those with chronic health problems, those with cardiovascular diseases and depression are particularly challenging due to the multifaceted nature of these conditions. This review discusses the significance of this aging trend and ways to better care for this particular population.

Inflammatory properties of diet mediate the effect of depressive symptoms on Framingham risk score in men and women: Results from the National Health and Nutrition Examination Survey (2007-2014)

Depression is common in patients with cardiovascular disease (CVD) and associated with inflammation. Inflammation contributes to the development of CVD and can be modulated by diet. However, the role of inflammatory properties of diet in the relationship between depressive symptoms and CVD risk is not well understood. We hypothesized that the inflammatory properties of diet mediate the relationship between depressive symptoms and CVD risk in men and women. Cross-sectional data collected by the National Health and Nutrition Examination Survey (2007-2014) were used for the study. Depressive symptoms scores, inflammatory properties of diet, and CVD risk were measured by the Patient Health Questionnaire-9 (PHQ-9), the Dietary Inflammatory Index (DII), and the Framingham risk score (FRS), respectively. Generalized linear models were used for the mediation analysis. There were significant differences in the proportions of men and women in the depressed group (PHQ-9 ≥ 10; 5.24 ± 0.65% vs 9.36 ± 0.87%, P < .001) and high CVD risk group (FRS >20%; 16.47 ± 0.79% vs 6.03 ± 0.32%, P < .001). The DII partially mediated the relationship between depressive symptoms and CVD risk in men (indirect effect: 0.06, P = .010) but fully mediated the relationship between depressive symptoms and CVD risk in women (indirect effect: 0.10, P < .001). These findings confirmed our hypothesis that inflammatory properties of diet at least partially mediate the relationship between depressive symptoms and CVD risk in men and women. Our findings suggest that interventions designed to reduce depressive symptoms should contain strategies to reduce pro-inflammatory and increase anti-inflammatory properties of diet to decrease CVD risk.

Gender differences in associations of depressive symptoms and anxiety with inflammatory markers in patients with non-obstructive coronary artery disease

OBJECTIVE

The aim of this study was to examine gender differences of the associations between depressive symptoms and anxiety with inflammatory markers in patients with non-obstructive coronary artery disease (NOCAD).

METHODS

Depressive symptoms and anxiety (Beck Depression Inventory BDI and Hospital Anxiety and Depression Scale HADS) were examined in 524 patients with NOCAD (52% women, mean age 64 ± 9 years) as part of the TweeSteden Mild Stenosis (TWIST) observational cohort study. Blood samples were analyzed for neutrophil gelatinase-associated lipocalin (NGAL) levels, high-sensitive C-reactive protein (hsCRP), and leukocyte differentiation. Multivariate analysis for the inflammatory markers with main effects of depressive symptoms or anxiety, gender, and their interactions were observed.

RESULTS

Women had elevated levels of hsCRP, and a lower monocyte and eosinophil count than men, with small to medium effect sizes (range η_(p)² = 0.019-0.047). After Holm-Bonferroni correction depressive symptoms according to the BDI were associated with an overall elevated hsCRP level explaining 2.4% of the hsCRP variance. A significant positive association between BDI cognitive symptoms with elevated hsCRP level was observed in men (R² = 0.045), but not in women (R² < 0.001). Adjustment for age, body mass index, smoking, and physical activity attenuated this finding.

CONCLUSION

Small associations of inflammatory markers with depressive symptoms and anxiety were confounded by lifestyle factors, predominantly smoking. The interacting roles of gender, smoking, and psychological factors on inflammatory markers may point toward different behavioral and inflammatory pathways for women and men with NOCAD, which remains to be further explored.

OBSERVATIONAL COHORT REGISTRATION

ClinicalTrials.gov identifier: NCT01788241.

Impact of depression and/or anxiety on patients with percutaneous coronary interventions after acute coronary syndrome: a protocol for a real-world prospective cohort study

INTRODUCTION

Acute coronary syndrome (ACS) is one of the leading causes of death. Depression and/or anxiety after ACS is common. Studies from developed countries have reported that the occurrence of anxiety or depression after ACS might increase the risk of cardiovascular events and mortality. However, the results varied, and are limited in developing countries. Therefore, well designed large-scale real-world study is needed to make further clarification. The main objective of this study is to evaluate whether depression or anxiety could affect the prognosis of patients with percutaneous coronary intervention (PCI) post-ACS.

METHOD AND ANALYSIS

The study is a prospective, multicentre, cohort study, which will be performed at 12 large hospitals in northwest China and led by the First Affiliated Hospital of Xi'an Jiaotong University. A total of 5000 patients with PCI post-ACS will be enrolled and followed up for 2 years. Their depression and anxiety status will be evaluated with the Patient Health Questionnaire-9 or Generalised Anxiety Disorder-7 Assessment scales during the follow-up. A Cox proportional hazard model will be used to determine if depression/anxiety after PCI increase the risk of cardiovascular events. The impact of antidepression or antianxiety treatment on the cardiac prognosis will be explored as well among the patients with ACS who received the treatment after PCI.

ETHICS AND DISSEMINATION

This study has been approved by the ethics committee of the First Affiliated Hospital of Xi'an Jiaotong University (approval number: XJTU1AF2016LSL-036). The results will be published in research articles or conference papers.

TRIAL REGISTRATION NUMBER

NCT03057691.

Depressive symptoms and sleep problems as risk factors for heart disease: a prospective community study

AIMS

The goals of the present study were to examine the associations between depressive symptoms, sleep problems and the risk of developing heart disease in a Canadian community sample.

METHODS

Baseline data were from the CARTaGENE study, a community health survey of adults aged 40-69 years in Quebec, Canada. Incidence of heart disease was examined in N = 33 455 participants by linking survey data with administrative health insurance data. Incident heart disease was identified using the World Health Organization's International Classification of Diseases, 9th or 10th edition (ICD-9 and ICD-10) diagnostic codes for heart disease. Sleep problems were assessed with diagnostic codes for sleep disorders within the 2 years preceding the baseline assessment. Average sleep duration was assessed by self-report. Depressive symptoms were assessed with the nine-item Patient Health Questionnaire.

RESULTS

In total, 2448 (7.3%) participants developed heart disease over an average follow-up period of 4.6 years. Compared to those without depressive symptoms and with no sleep disorders, those with elevated depressive symptoms and a sleep disorder (HR = 2.60, 95% CI 1.83-3.69), those with depressive symptoms alone (HR = 1.40, 95% CI 1.25-1.57) and those with sleep disorders alone (HR = 1.33, 95% CI 1.03-1.73) were more likely to develop heart disease. Test of additive interaction suggested a synergistic interaction between depressive symptoms and sleep disorders (synergy index = 2.17 [95% CI 1.01-4.64]). When sleep duration was considered, those with long sleep duration and elevated depressive symptoms were more likely to develop heart disease than those with long sleep alone (HR = 1.77, 95% CI 1.37-2.28; and HR = 1.16, 95% CI 0.99-1.36, respectively).

CONCLUSIONS

Depression and diagnosed sleep disorders or long sleep duration are independent risk factors for heart disease and are associated with a stronger risk of heart disease when occurring together.

The Influence of Sex on Cardiac Physiology and Cardiovascular Diseases

Cardiovascular disease (CVD) is the leading cause of death world-wide. Most of treatment strategies were based on studies conducted on male patients. Studies have shown that significant differences exist between the two sexes in the development of CVD. There are certain differences between men and women in the structure and physiological functions of the heart such as left ventricular mass index, resting heart rate, and contractile function. Accordingly, the pathological features of the heart such as the extend of hypertrophy, fibrosis, and remodeling are also different. In addition, different genders also affect clinical symptoms, responses to treatment and prognosis in the development of CVD. Therefore, it is important to take these differences into consideration when design treatment options for men and women.

Estrogen, Stress, and Depression: Cognitive and Biological Interactions

This article reviews the interactions of estrogen changes and psychosocial stress in contributing to vulnerability to major depressive disorder (MDD) in women. Estrogen modulates brain networks and processes related to changes in stress response, cognition, and emotional dysregulation that are core characteristics of MDD. Synergistic effects of estrogen on cognitive and emotional function, particularly during psychosocial stress, may underlie the association of ovarian hormone fluctuation and depression in women. We propose a model of estrogen effects on multiple brain systems that interface with stress-related emotional and cognitive processes implicated in MDD and discuss possible mechanisms through which reproductive events and changes in estrogen may contribute to MDD risk in women with other concurrent risk factors.

A journey through chaos and calmness: experiences of mindfulness training in patients with depressive symptoms after a recent coronary event - a qualitative diary content analysis

Background

Psychological distress with symptoms of depression and anxiety is common and unrecognized in patients with coronary artery disease (CAD). Efforts have been made to treat psychological distress in CAD with both conventional methods, such as antidepressant drugs and psychotherapy, and non-conventional methods, such as stress management courses. However, studies focusing on the experiences of mindfulness training in this population are still scarce. Therefore, the aim of this study was to explore immediate experiences of mindfulness practice among CAD patients with depressive symptoms.

Methods

A qualitative content analysis of diary entries, written immediately after practice sessions and continuously during an 8-week long Mindfulness Based Stress Reduction course (MBSR), was applied.

Results

Twelve respondents participated in the study. The main category: a journey through chaos and calmness captured the participants’ concurrent experiences of challenges and rewards over time. This journey appears to reflect a progressive development culminating in the harvesting of the fruits of practice at the end of the mindfulness training. Descriptions of various challenging facets of mindfulness practice – both physical and psychological - commonly occurred during the whole course, although distressing experiences were more predominant during the first half. Furthermore, the diary entries showed a wide variety of ways of dealing with these struggles, including both constructive and less constructive strategies of facing difficult experiences. As the weeks passed, participants more frequently described an enhanced ability to concentrate, relax and deal with distractions. They also developed their capacity to observe the content of their mind and described how the practice began to yield rewards in the form of well-being and a sense of mastery.

Conclusions

Introducing MBSR in the aftermath of a cardiac event, when depressive symptoms are present, is a complex and delicate challenge in clinical practice. More nuanced information about what to expect as well as the addition of motivational support and skillful guidance during the course should be given in accordance with the participants’ experiences and needs.

Trial registration

The trial was retrospectively registered in clinicaltrials.gov (registration number: NCT03340948).

Electronic supplementary material

The online version of this article (10.1186/s40359-018-0252-1) contains supplementary material, which is available to authorized users.

Depression and Cardiovascular Disorders in the Elderly

The world's older population continues to grow at an unprecedented rate. This trend amplifies the necessity of improving the care of older patients with chronic health problems. Of those with chronic health problems, those with cardiovascular diseases and depression are particularly challenging due to the multifaceted nature of these conditions. This review discusses the significance of this aging trend and ways to better care for this particular population.

A Survey of Coping Strategies With Stress in Patients With Acute Myocardial Infarction and Individuals Without a History of Fixed Myocardial Infarction

Background

This study aimed at investigating the coping strategies with stress in patients with acute myocardial infarction (MI) and individuals without a history of fixed MI and cardiovascular disorders.

Methods

This case-control crossover study was conducted from March 2015 to February 2016 on 220 patients with acute MI (MI patients) as case group and 220 patients without any history of MI and cardiovascular diseases as the control group using availability sampling method. To collect the required data, demographic information questionnaire, Holms-Raheh life stress inventory, perceived stress questionnaire, and coping inventory for stressful situations (CISS) were applied.

Results

On the basis of our findings, 118 patients (53.6%) with MI used emotion-focused coping strategy. Ninety-seven patients (82.2%) with MI who used emotion-focused coping strategy had negative perceived stress. Additionally, 71 patients (60.2%) with MI who had used emotion-focused coping strategy suffered from very high level of stress.

Conclusion

The most MI patients had very high level of stress while most people in control group had high level of stress. Most MI patients that had very high level of stress cope with it in emotion-focused coping strategy and it proves that people with higher levels of stress are more likely to use inefficient coping strategies.

Prophylactic antidepressant treatment following acute coronary syndrome: A systematic review of randomized controlled trials

Major depressive disorder is significantly increased in patients following acute coronary syndrome resulting in twofold increased mortality compared with patients without depression. The depression diagnosis is often missed leading to considerable undertreatment. This systematic review assesses the current evidence of primary prophylactic treatment of depression in patients after acute coronary syndrome. The study protocol was prospectively registered at PROSPERO (registration number CRD42015025587). A systematic review were conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Embase, PsychINFO, CINAHL, and Cochran Library was searched. Two independent reviewers screened the records. The inclusion criteria were randomized controlled trials on adult patients with acute coronary syndrome treated prophylactically with an antidepressant intervention of any kind. A validated assessment tool should measure depression and depressive symptoms. Languages were limited to articles written in English. Six articles were included. Four studies utilized different components of case and disease management, health coaching, or relaxational audiotapes as intervention compared with usual care or with no formal program of rehabilitation. None of the studies showed any significant prophylactic effect against depression. One study with a program of health education and counselling and another study with a pharmacological antidepressant showed significant prophylactic effect on depression and depressive symptoms. All six included studies were associated with high risk of bias. There is not strong evidence of the effects of any type of routine antidepressant prophylaxis in patients following acute coronary syndrome. Further high quality studies are warranted.

Lifestyle Modification in Secondary Prevention: Beyond Pharmacotherapy

Despite significant advances in medical technology and pharmacology, cardiovascular disease (CVD) remains a major contributor to health care expenses and the leading cause of death in the United States. Patients with established CVD and their health care providers are challenged with achieving cardiovascular risk reduction to decrease the likelihood of recurrent cardiovascular events. This "secondary prevention" can be achieved, in part, through adherence to prescribed pharmacotherapies that favorably modify major coronary risk factors (ie, hypertension, hypercholesterolemia, diabetes, and obesity). However, lifestyle modification can also be helpful in this regard, providing independent and additive benefits to the associated reductions in cardiovascular morbidity and mortality. Accordingly, physicians and other health care providers should routinely counsel their coronary patients to engage in structured exercise and increased lifestyle physical activity, consume a heart-healthy diet, quit smoking and avoid secondhand smoke, and purposefully address psychosocial stressors that may elevate cardiovascular risk. These lifestyle interventions, either as an adjunct to medication therapy or independently in those patients where medications may be poorly tolerated, cost prohibitive, or ineffective, can significantly decrease cardiovascular mortality and the risk of recurrent cardiac events.

The effect of MElatonin on Depressive symptoms, Anxiety, CIrcadian and Sleep disturbances in patients after acute coronary syndrome (MEDACIS): study protocol for a randomized controlled trial

BACKGROUND

Depression following acute coronary syndrome (ACS) constitutes a serious and debilitating problem. Approximately one in five patients will develop significant depression following ACS and less severe depressive symptoms are even more frequent. Furthermore, anxiety symptoms and sleep-wake disturbances are frequent. The objective of the MEDACIS trial is to investigate whether prophylactic treatment with melatonin has a preventive effect on depression, depressive and anxiety symptoms, sleep, and circadian disturbances following ACS.

METHODS/DESIGN

"The effect of MElatonin and Depressive symptoms, Anxiety, CIrcadian and Sleep disturbances in patients after acute coronary syndrome" trial (MEDACIS) is a multicenter, double-blinded, placebo-controlled, randomized clinical trial. A total of 240 patients with ACS and no depressive symptoms will be included in the trial for treatment with either 25 mg melatonin or placebo for a 12-week period. Development and severity of depressive symptoms will be evaluated using Major Depression Inventory every 2 weeks with the purpose of investigating the potential preventive effect of melatonin on depressive symptoms.

DISCUSSION

Previously, only selective serotonin reuptake inhibitors (SSRIs) have been investigated in a primary preventive setup in patients following ACS. However, SSRIs are associated with several side effects. An ideal intervention would constitute the highest degree of prevention of depressive symptoms with the lowest risk of side effects. In this regard, melatonin may have advantages due to its low toxicity as well as its proven anxiolytic and hypnotic effects.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT02451293 . Registered on 12 May 2015. EudraCT nr. 2015-002116-32.

Seasonal variations in mood and behavior associate with common chronic diseases and symptoms in a population-based study

The purpose of this study was to assess how seasonality is associated with some of the most common non-communicable diseases (NCDs) in the general Finnish population. The global seasonality score (GSS) was used to measure the magnitude of seasonality in 4689 participants, in addition to which they reported the extent to which the seasonal variations in mood and behavior were experienced as a problem. Regression models and the odds ratios were adopted to analyze the associations adjusted for a range of covariates. Seventy percent of the participants had seasonal variations in sleep duration, social activity, mood, or energy level, and forty percent those in weight and appetite. Angina pectoris and depression were significantly associated with seasonality throughout the analysis. Hypertension, high cholesterol levels, diabetes, other (than rheumatoid) joint diseases and other (than depressive) psychological illnesses were significantly associated with experiencing a problem due to the seasonal variations, with an increase in the GSS, and with seasonal affective disorder and its subsyndromal form. The co-occurrence of the seasonal variations in mood and behavior with certain common NCDs warrants future research to have insights into the etiology and potentially shared pathways and mechanisms of action.

Functional decline and herpes zoster in older people: an interplay of multiple factors

Herpes zoster is a frequent painful infectious disease whose incidence and severity increase with age. In older people, there is a strong bidirectional link between herpes zoster and functional decline, which refers to a decrement in ability to perform activities of daily living due to ageing and disabilities. However, the exact nature of such link remains poorly established. Based on the opinion from a multidisciplinary group of experts, we here propose a new model to account for the interplay between infection, somatic/psychiatric comorbidity, coping skills, polypharmacy, and age, which may account for the functional decline related to herpes zoster in older patients. This model integrates the risk of decompensation of underlying disease; the risk of pain becoming chronic (e.g. postherpetic neuralgia); the risk of herpes zoster non-pain complications; the detrimental impact of herpes zoster on quality of life, functioning, and mood; the therapeutic difficulties due to multimorbidity, polypharmacy, and ageing; and the role of stressful life events in the infection itself and comorbid depression. This model underlines the importance of early treatment, strengthening coping, and vaccine prevention.

Insufficient glucocorticoid signaling and elevated inflammation in coronary heart disease patients with comorbid depression

Coronary heart disease (CHD) and depression are very common and often co-existing disorders. In addition to psychological and social morbidity, depression exacerbates adverse cardiac outcomes in CHD patients. Inflammation has been proposed as one of the mechanisms involved in the association between these two debilitating diseases. Therefore, the present study aimed to evaluate inflammatory responses as well as to investigate the pathophysiological mechanisms underlying the putative inflammatory activation in CHD patients with and without depression, by assessing the function of two important biological factors regulating inflammation, the hypothalamus-pituitary-adrenal (HPA) axis and the glucocorticoid receptor (GR). Eighty-three CHD patients with (n=28) and without (n=55) comorbid depression were recruited from primary care services in South London. Depression status was assessed by means of Clinical Interview Schedule Revised for diagnosis of depression, and Beck Depression Inventory for the presence of depressive symptoms. Serum C-reactive protein (CRP), plasma vascular endothelial growth factor (VEGF), and plasma and salivary cortisol were measured using commercially available ELISA kits. Gene expression of GR and interleukin-6 (IL-6) were conducted via qPCR. GR sensitivity was evaluated in vitro in isolated peripheral blood mononuclear cells using the dexamethasone inhibition of lipopolysaccharide-stimulated IL-6 levels. Serum levels of kynurenine pathway metabolites were measured using high performance liquid chromatography. Our results show that CHD patients with depression had higher levels of CRP, IL-6 gene expression, and VEGF compared with CHD non-depressed, as well as lower plasma and saliva cortisol levels. The CHD depressed group also exhibited a reduction in GR expression and sensitivity. Finally, tryptophan levels were significantly lower in patients with depression, who also showed an increased kynurenine/tryptophan ratio. In conclusion, CHD patients with depression had elevated levels of inflammation in the context of HPA axis hypoactivity, GR resistance, and increased activation of the kynurenine pathway. Reduced cortisol bioavailability and attenuated glucocorticoid responsiveness due to decreased expression and sensitivity of GR may lead to insufficient glucocorticoid signaling and thus elevation of inflammation in these patients.

The interface of depression and cardiovascular disease: therapeutic implications

Patients with major depression are at an increased risk for developing cardiovascular disease, respond more poorly to treatment, and exhibit worse outcomes, including increased morbidity and mortality. This article reviews the relationship between depression and heart disease, with an emphasis on epidemiology, biological substrates that likely underlie this relationship, and implications for treatment.

Association between concomitant psychiatric drug use, and patients' beliefs about and persistence with chronic cardiovascular medication

OBJECTIVE

Psychiatric disorders are associated with an increased risk of cardiovascular diseases and may result in additional risk of non-adherence. No data on the influence of concomitant psychiatric drug use on patients' beliefs and persistence related to cardiovascular medication are available. The objective of this study was to assess to what extent the use of concomitant psychiatric drugs is associated with patients' beliefs about and persistence with chronic cardiovascular medication.

METHODS

An observational study in patients using cardiovascular medication was conducted. A mailed questionnaire containing socio-demographical questions and a measure of beliefs about medication (Beliefs about Medicines Questionnaire - specific) was sent to patients selected from fifteen participating pharmacies. Persistence was evaluated based on pharmacy records.

RESULTS

Of the 1547 included patients, 551 responded to key questions in the questionnaire and were included for beliefs about medication analysis. In concomitant users of psychiatric drugs significantly higher necessity (17.0 vs. 16.0) and higher concerns (14.3 vs. 13.3), as well as higher proportion of ambivalent (34.5% vs. 25.6%) and lower proportion of indifferent patients (24.1% vs. 33.0%) were found compared with non-users (p < 0.05). 65.2% (n = 1009) of patients were persistent on all their cardiovascular drugs. There was no significant association between concomitant use of psychiatric drugs and non-persistence (OR = 1.2; 95% CI 0.9-1.5).

CONCLUSION

Concomitant use of psychiatric drugs was found to be associated with increased beliefs about the necessity of and concerns about cardiovascular medication. Clinicians caring for cardiovascular patients should give additional attention to identifying patients' beliefs about medication among those concomitantly using psychiatric drugs.

Sex differences in platelet reactivity and cardiovascular and psychological response to mental stress in patients with stable ischemic heart disease: insights from the REMIT study

BACKGROUND

Although emotional stress is associated with ischemic heart disease (IHD) and related clinical events, sex-specific differences in the psychobiological response to mental stress have not been clearly identified.

OBJECTIVES

We aimed to study the differential psychological and cardiovascular responses to mental stress between male and female patients with stable IHD.

METHODS

Patients with stable IHD enrolled in the REMIT (Responses of Mental Stress-Induced Myocardial Ischemia to Escitalopram) study underwent psychometric assessments, transthoracic echocardiography, and platelet aggregation studies at baseline and after 3 mental stress tasks. Mental stress-induced myocardial ischemia (MSIMI) was defined as the development or worsening of regional wall motion abnormality, reduction of left ventricular ejection fraction (LVEF) ≥8% by transthoracic echocardiography, and/or ischemic ST-segment change on electrocardiogram during 1 or more of the 3 mental stress tasks.

RESULTS

In the 310 participants with known IHD (18% women, 82% men), most baseline characteristics were similar between women and men (including heart rate, blood pressure, and LVEF), although women were more likely to be nonwhite, living alone (p < 0.001), and unmarried (p < 0.001); they also had higher baseline depression and anxiety (p < 0.05). At rest, women had heightened platelet aggregation responses to serotonin (p = 0.007) and epinephrine (p = 0.004) compared with men. Following mental stress, women had more MSIMI (57% vs. 41%; p < 0.04), expressed more negative (p = 0.02) and less positive emotion (p < 0.001), and demonstrated higher collagen-stimulated platelet aggregation responses (p = 0.04) than men. Men were more likely than women to show changes in traditional physiological measures, such as blood pressure (p < 0.05) and double product.

CONCLUSIONS

In this exploratory analysis, we identified clear, measurable, and differential responses to mental stress in women and men. Further studies should test the association of sex differences in cardiovascular and platelet reactivity in response to mental stress and long-term outcomes. (Responses of Myocardial Ischemia to Escitalopram Treatment [REMIT]; NCT00574847).

Lack of an association between a functional polymorphism in the neuropeptide Y gene promoter and the presence of coronary artery disease in an Iranian population

BACKGROUND/AIMS

Several genetic factors have been identified that may contribute to the risk of coronary artery disease (CAD). Variants of the neuropeptide Y (NPY) gene, whose products play an important role in regulating several physiological functions, have been associated with the risk of CAD in some populations. The purpose of this study was to investigate the relationship between the NPY gene rs16147 polymorphism and the presence of CAD in an Iranian population.

METHODS

DNA samples of 922 subjects, including 433 with angiographically defined CAD (CAD+), 196 without angiographically defined significant CAD (CAD-) and 293 controls, were genotyped using polymerase chain reaction based on the amplification-refractory mutation system. Logistic regression analyses were performed to assess the association of rs16147 genotypes with the presence of significant CAD.

RESULTS

Although logistic regression analysis indicated that the NPY polymorphism rs16147 was nominally associated with an increased risk of CAD (p < 0.05), after adjustment for confounding factors, there was no evidence for any significantly increased or decreased risk of CAD with this polymorphism. However, in stratified analyses, the C allele was significantly associated with a reduced risk of CAD in males and subjects who were <50 years of age.

CONCLUSIONS

This study suggests that the rs16147 polymorphism in the NPY gene may not be a potential contributor to the risk of CAD in an Iranian population.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Design and Methodology for the Korean Observational and Escitalopram Treatment Studies of Depression in Acute Coronary Syndrome: K-DEPACS and EsDEPACS

Depression is common after acute coronary syndrome (ACS), adversely affecting cardiac course and prognosis. There have been only a few evidence-based treatment options for depression in ACS. Accordingly, we planned the Korean Depression in ACS (K-DEPACS) study, which investigated depressive disorders in patients with ACS using a naturalistic prospective design, and the Escitalopram for DEPACS (EsDEPACS) trial, which assessed the efficacy and safety of escitalopram for treating major or minor depression in patients with ACS. Participants in the K-DEPACS study were consecutively recruited from patients with ACS who were recently hospitalized at Chonnam National University Hospital, Gwangju, South Korea. Diagnoses were confirmed by coronary angiography from 2005. Data on depressive and cardiovascular characteristics were obtained at 2 weeks, 3 months, 12 months, and every 6 months thereafter following the index ACS admission. The K-DEPACS participants who met the DSM-IV criteria for major or minor depressive disorder were randomly assigned to groups in the 24-week, double-blind, placebo-controlled EsDEPACS trial beginning in 2007. The outcome of treatments for depressive and other psychiatric symptoms, issues related to safety, including general adversity, and cardiovascular factors were assessed. The K-DEPACS study can significantly contribute to research on the complex relationships between depression and ACS. The results of the EsDEPACS trial provide an additional treatment option for clinicians treating these patients.

Disturbance of serotonergic neurotransmission in patients with postmyocardial infarction and depression

The objective of this study was to assess the hypothesis that patients who develop depression after myocardial infarction (MI) have a lower level of brain serotonergic neurotransmission through measurement of plasma free fraction of L-tryptophan and intensity-dependence auditory-evoked potentials (IDAEPs). A cross-sectional study was carried out in 74 adults after MI. Thirty-four patients suffered from depression and 40 patients did not demonstrate depressive symptoms. We measured the free fraction, bound and total plasma L-tryptophan, and neutral amino acids as well as recording IDAEPs. Patients who developed depression after MI showed a significantly lower level in the free fraction of L-tryptophan and in the ratios of free fraction of L-tryptophan/total L-tryptophan and free fraction of L-tryptophan/neutral amino acids. It is noteworthy that the slope of the amplitude/stimulus intensity functions (ASF slope) of the N1/P2 component was significantly higher post-MI in depressed patients. Higher ASF slope of the N1/P2 component associated with a low free fraction of L-tryptophan in plasma reflect a low brain serotonergic neurotransmission. These findings suggest an important deterioration of brain serotonergic activity as a pathophysiological mechanism in post-MI patients for the development of clinical depression. Therefore, we propose these biochemical and electrophysiological procedures as noninvasive clinical indicators of brain serotonergic activity in these patients.

Depressive symptoms and mental stress-induced myocardial ischemia in patients with coronary heart disease

OBJECTIVES

The aim of this study was to examine the associations between depressive symptoms and mental stress-induced myocardial ischemia (MSIMI) in patients with coronary heart disease (CHD).

METHODS

Adult patients with documented CHD were recruited for baseline mental stress and exercise stress screening testing as a part of the enrollment process of the Responses of Myocardial Ischemia to Escitalopram Treatment trial. Patients were administered the Beck Depression Inventory II and the Center for Epidemiologic Studies Depression Scale. After a 24-48-hour β-blocker withdrawal, participants completed three mental stress tests followed by a treadmill exercise test. Ischemia was defined as a) any development or worsening of any wall motion abnormality and b) reduction of left ventricular ejection fraction at least 8% by transthoracic echocardiography and/or ischemic ST-segment change by electrocardiography during stress testing. MSIMI was considered present when ischemia occurred in at least one mental test. Data were analyzed using logistic regression adjusting for age, sex, and resting left ventricular ejection fraction.

RESULTS

One hundred twenty-five (44.2%) of 283 patients were found to have MSIMI, and 93 (32.9%) had ESIMI. Unadjusted analysis showed that Beck Depression Inventory II scores were positively associated with the probability of MSIMI (odds ratio = 0.1.30: 95% confidence interval = 1.06-1.60, p = .013) and number of MSIMI-positive tasks (all p < .005). These associations were still significant after adjustment for covariates (p values <.05).

CONCLUSIONS

In patients with CHD, depressive symptoms were associated with a higher probability of MSIMI. These observations may enhance our understanding of the mechanisms contributing to the association of depressive symptoms to future cardiovascular events. Trial Registration Clinicaltrials.gov identifier: NCT00574847.

Spousal depression, anxiety, and suicide after myocardial infarction

AIMS

Death of a spouse from acute myocardial infarction (AMI) presents hardship, yet few studies have investigated the psychological consequences of fatal and non-fatal AMI on spouses.

METHODS AND RESULTS

Several Danish national registries were linked to identify individuals whose spouses had a fatal or non-fatal AMI. Married patients with fatal or non-fatal AMI (1997-2008) were matched with their counterparts dying or hospitalized with a non-AMI cause; incident use of antidepressants and benzodiazepines, incident depression care, and suicides were compared pre- and post-event using Poisson models. Overall, 16 506 spouses of individuals dying of AMI were matched with 49 518 spouses of individuals dying of a non-AMI cause. Similarly, 44 566 spouses of individuals with a non-fatal AMI were matched with 131 563 spouses of individuals with a non-fatal, non-AMI hospitalization. Those whose spouse died of AMI (compared with a non-AMI cause) had increased antidepressant and benzodiazepine use [peak incidence rate ratio (IRR) 5.7 vs. 3.3, and 46.4 vs. 13.0, respectively; P< 0.001]. Those whose spouse had a non-fatal AMI (compared with a non-AMI hospitalization) had increased risk for antidepressant and benzodiazepine initiation (IRR 1.5 vs. 1.1, and 6.7 vs. 1.3, respectively, P< 0.001). Spouses of fatal AMI patients also had an increased risk of depression and suicide. Male individuals whose spouse had a fatal or non-fatal AMI had a relatively higher increased risk of depression than female individuals.

CONCLUSION

Spouses of those who experience AMIs-both fatal and non-fatal-are at elevated risk for psychological consequences; therefore, the care needs of AMI patients and their spouses need to be considered.

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.

Responses of mental stress-induced myocardial ischemia to escitalopram treatment: background, design, and method for the Responses of Mental Stress Induced Myocardial Ischemia to Escitalopram Treatment trial

BACKGROUND

Mental stress-induced myocardial ischemia (MSIMI) is common in patients with clinically stable coronary heart disease (CHD) and is associated with poor outcomes. Depression is a risk factor of MSIMI. The REMIT trial investigates whether selective serotonin reuptake inhibitor (SSRI) treatment can improve MSIMI. The rationale and outline of the study are described.

METHOD

In this single-center randomized clinical trial, adult patients with clinically stable CHD are recruited for baseline mental and exercise stress testing assessed by echocardiography. In addition, psychometric questionnaires are administered, and blood samples are collected for platelet activity analysis. Patients who demonstrate MSIMI, defined by new abnormal wall motion, ejection fraction reduction ≥8%, and/or development of ischemic ST change in electrocardiogram during mental stress testing, are randomized at a 1:1 ratio to escitalopram or placebo for 6 weeks. Approximately 120 patients with MSIMI are enrolled in the trial. The stress testing, platelet activity assessment, and psychometric questionnaires are repeated at the end of the 6-week intervention. The hypothesis of the study is that SSRI treatment improves MSIMI via mood regulation and modification of platelet activity.

CONCLUSION

The REMIT study examines the effect of SSRI on MSIMI in vulnerable patients with CHD and probes some potential underlying mechanisms.

Long-term depression is a stroke risk factor

Kocer E, Kocer A, Degirmenci Y, Eryılmaz M. Long-term depression is a stroke risk factor.

Background and Aim: Only a few studies have evaluated depression prevalence in pre-stroke period in comparison to controls. We investigated this association based on a hospitalised stroke population.

Methods: One hundred and forty-eight stroke patients were evaluated. The presence of depression was compared with those of 100 healthy controls without stroke, from the same region. Depression was accepted as present or not present after history and clinical evaluation according to Diagnostic and Statistical Manual of Mental Disorders-IV. Socio-demographic variables, other stroke risk factors and the time of diagnosis of depression (how many year or month they got depression) were recorded.

Results: Gender and mean age of patients and controls were similar in comparison. Depression was diagnosed in 27 patients and 24 controls (p > 0.05). The time period passed after diagnosis of depression was longer in stroke patients in comparison to controls (p < 0.001).

Conclusions: The risk of stroke should be considered in elderly with long-term depression. This indicates that treatment of depression is another factor which should be considered in prevention of brain stroke.

Depression in vascular pathologies: the neurologist's point of view

The coexistence of depression and cardiovascular disease (CVD) is regularly discussed, and much debated. There is strong evidence that there are pathophysiological mechanisms, particularly endothelial dysfunction, altered platelet aggregation, and hyperactivation of the thrombosis cascade, which coexist with hypothalamic-pituitary-adrenocortical axis dysfunction, and link depression to CVD. Therefore, depression should not be automatically considered to be a consequence of life impairment due to myocardial infarction or major stroke. Probably, it should be considered as one of the many other stressful events, or "genetic reactions to life", which are risk factors for CVD development. This review will examine the significance of depression in clinical daily practice, its pathophysiology as a determinant in vascular events, and its real importance in, before, and after many CVD events.

Depression screening in patients with coronary heart disease: a critical evaluation of the AHA guidelines

OBJECTIVE

We lack evidence that routine screening for depression in patients with coronary heart disease (CHD) improves patient outcome. This lack has challenged the advisory issued by the American Heart Association (AHA) to routinely screen for depression in CHD patients. We assess the AHA advisory in the context of well-established criteria of screening for diseases.

METHODS

Using principles and criteria for screening developed by the World Health Organization and the United Kingdom National Screening Committee, we generated criteria pertinent to screening for depression in CHD patients. To find publications relevant to these criteria and clinical setting, we performed a broadly based literature search on "depression and CHD," supplemented by more focused literature searches.

RESULTS

Evidence for an association between depression and CHD is strong. Despite this, the AHA advisory has several limitations. It did not account for the complexity of the association between depression and CHD. It acknowledged there was no evidence that screening for depression leads to improved outcomes in cardiovascular populations but still recommended routine screening without providing an alternative evidence-based explanation. It ignored the paucity of literature about the safety and cost-effectiveness of routine screening for depression in CHD and failed to define the nature and extent of resources needed to implement such a program effectively.

CONCLUSION

We conclude that the AHA advisory is premature. We must first demonstrate the efficacy, safety, and cost-effectiveness of screening and define the resources necessary for its implementation and monitoring. Meanwhile, organizations representing cardiologists, psychiatrists, and general practitioners must coordinate efforts to manage depression and CHD through collaborative care, and work with the policy makers to develop the necessary infrastructure and services delivery system needed to optimize the outcome of depressed and at-risk-for-depression patients suffering from CHD.

Popular medicine and self-care in a Mexican migrant community: toward an explanation of an epidemiological paradox

While Hispanics are among the most economically disadvantaged groups in the United States, immigrants from Latin America have health profiles equal to or better than Americans of European descent. Research on this epidemiological paradox suggests that aspects of Hispanic culture prevent negative health outcomes associated with poverty, poor education, and barriers to professional care. However, little attention has been given to the ethnomedical beliefs and practices of any Hispanic subgroup. Here I present an ethnographic study of women's popular medicine in a Mexican migrant community in Athens, Georgia. Migrant women promote healthy behaviors, diagnose sick family members, and prescribe home remedies. These practices stem from long traditions of self-medication and family care, which have experienced less disruption by the biomedical profession than have other North American popular medical systems. Examining Mexican popular medicine within the context of scientific literature suggests that these self-care practices protect health and should be considered by investigators of the "Hispanic health paradox." The study also suggests that directing more attention to self-care will be fruitful for medical anthropology.