Prevalence, Risk Factors and Intervention for Depression and Anxiety in Pulmonary Hypertension: A Systematic Review and Meta-analysis

Depression in Pulmonary Hypertension: A Systematic Review of Clinical Outcomes, Treatment Interactions, and Emerging Technologies

Background: Pulmonary hypertension (PH) is characterized by elevated pulmonary artery pressure, often leading to right heart failure and poor prognosis. Depression, a common comorbidity in PH, significantly affects the quality of life. However, mechanistic insights into the bidirectional relationship between PH and depression and specific treatment interactions remain scarce. Objective: The object was to examine the clinical and therapeutic implications of depression in PH, focusing on its impact on patient outcomes and cost efficiency. Methods: A systematic review of Medline and Google Scholar was conducted to identify studies on depression in PH, emphasizing evidence-based interventions, clinical outcomes, and cost efficiency. Special consideration was given to potential drug interactions between PH medications and depression treatments and to the role of emerging technologies in managing PH-related depression. Results: While depression reduces the quality of life and exacerbates disease severity in PH, depression treatment improves outcomes, particularly when tailored to PH-targeted therapies, considering potential drug-drug interactions. Emerging technologies, including telemedicine, offer innovative approaches to manage depression in PH, enhancing access to care and improving adherence to treatment regimens. Conclusions: Depression in PH must no longer be neglected and should be acknowledged as both a critical comorbidity and a significant driver of disease progression. Interdisciplinary treatment approaches are necessary, considering potential pharmacological interactions and incorporating emerging technologies like telemedicine to improve patient care. Further research is needed to assess the long-term outcomes of depression treatment in different groups of PH.

A novel analysis of interoceptive underpinnings of anxious psychopathology in COVID-19 survivors

INTRODUCTION

SARS-CoV-2 affects brain, body, and their interchange. We investigated interoceptive mechanisms in COVID-19 survivors focusing on their potential link with psychopathology and inflammatory biomarkers.

METHODS

We assessed interoceptive accuracy (IAc) and time-perceiving (TA) skills of 57 COVID-19 survivors one month after hospital discharge through, respectively, a heartbeats perception task and a time duration task. Each participant was assessed about his interoceptive awareness (IAw) through Multidimensional Assessment of Interoceptive Awareness questionnaire (MAIA) and then, screened for post-traumatic (Impact of Events Scale - IES-R), anxious (State-Trait Anxiety Inventory - STAI-Y1) and depressive (Zung Self-Rating Depression Scale - ZSDS; Beck Depression Inventory - BDI-13) symptoms. Biomarkers of inflammation (platelet count, PC; mean platelet volume, MPV and systemic immune-inflammation index, SII) were obtained in a subsample of 40 survivors by a blood sampling conducted at admission and discharge time from the hospital. Correlational, GLM, GLMZ, and mediation analyses were performed.

RESULTS

IAc did not correlate with TA confirming the reliability of interoceptive measure. IAc positively predicts MAIA's Trusting subscale and negatively predicts anxious psychopathology which fully mediates the effect of IAc on Trusting.PC at hospital admission predicts anxiety at one month after recovery. Again, a higher decrease of SII during hospitalization predicts higher IAc skill and lower anxiety state at one month. The link between SII change and anxiety is fully mediated by IAc.

CONCLUSIONS

Our results unveil a potential key role of interoception and brain-body interchange in the exacerbation and maintenance of anxiety psychopathology in COVID-19 survivors.

Update to: self-help cognitive behavioural therapy for anxiety in pulmonary hypertension

Since being published in 2021 in ERJ Open Research, a self-help resource has been made widely available to adults with PH in the UK via PHA UK. This is an update on the continued impact of the intervention hearing from services users and PHA UK. https://bit.ly/3YLHIHm.

Mental health status and quality of life among Thai people after the COVID-19 outbreak: a cross-sectional study

The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on individuals' mental health and well-being worldwide. This study investigated the prevalences of and association between mental health and quality of life (QOL) in Thailand after the COVID-19 outbreak. A cross-sectional study was conducted among Thai individuals aged ≥ 20 years across all regions. Descriptive statistics, chi-square tests, and multiple logistic regression analyses were performed to examine the association between mental health and QOL. A total of 1,133 participants (mean age: 35.1 ± 17.2 years) completed the survey. The prevalence of depression with PHQ-9 instrument was 19.4%. Depression was significantly associated with those who have had family members die from COVID-19 infection (adjusted odds ratio [AOR] 2.27, 95% confidence interval [CI] [1.13-4.52]). The percentages of depression, anxiety, and stress with DASS-21 instrument were 32.4%, 45.4%, and 24.1%, respectively. Smokers and alcohol consumption had approximately 1.5-time higher risk of stress compared with non-smokers and no alcohol consumption (AOR = 1.50, 95% CI [1.01-2.24], AOR = 1.48, 95% CI [1.09-2.02], respectively). An association was observed between socioeconomic factors such as job and income loss and mental health outcomes. Depression, anxiety, and stress were significantly negatively associated with QOL. This study demonstrates a strong association between mental health and QOL among Thai people after the COVID-19 outbreak. The findings underscore the need for interventions targeting lifestyles, including those addressing alcohol consumption and smoking, especially among those who have had family members die from COVID-19 infection and mental health support services that can address depression, anxiety, and stress to improve the overall well-being of the population.

Exploring the patient perspective in pulmonary hypertension

The global impacts of pulmonary hypertension (PH) were formally recognised in 1973 at the 1st World Health Organization meeting dedicated to primary pulmonary hypertension, held in Geneva. Investigations into disease pathogenesis and classification led to the development of numerous therapies over the ensuing decades. While the impacts of the disease have been lessened due to treatments, the symptoms and adverse effects of PH and its therapies on patients' wellbeing and mental health remain significant. As such, there is a critical need to enhance understanding of the challenges patients face on a global scale with respect to care access, multidimensional patient support and advocacy. In addition, thoughtful analysis of the potential benefits and utilisation of mechanisms for the incorporation of patient-reported outcomes into diagnosis and treatment plans is needed. A summary of these areas is included here. We present a report of global surveys of patient and provider experiences and challenges regarding care access and discuss possible solutions. Also addressed is the current state of PH patient associations around the world. Potential ways to enhance patient associations and enable them to provide the utmost support are discussed. A summary of relevant patient-reported outcome measures to assess health-related quality of life in PH is presented, with suggestions regarding incorporation of these tools in patient care and research. Finally, information on how current global threats such as pandemics, climate change and armed conflict may impact PH patients is offered, along with insights as to how they may be mitigated with advanced contingency planning.

Causal association of depression, anxiety, cognitive performance, the brain cortical structure with pulmonary arterial hypertension: A Mendelian randomization study

BACKGROUND

Patients with pulmonary arterial hypertension (PAH) often present with anxiety, depression and cognitive deterioration. Structural changes in the cerebral cortex in PAH patients have also been reported in observational studies.

METHODS

PAH genome-wide association (GWAS) including 162,962 European individuals was used to assess genetically determined PAH. GWAS summary statistics were obtained for cognitive performance, depression, anxiety and alterations in cortical thickness (TH) or surface area (SA) of the brain cortex, respectively. Two-sample Mendelian randomization (MR) was performed. Finally, sensitivity analyses including Cochran's Q test, MR-Egger intercept test, leave-one-out analyses, and funnel plot was performed.

RESULTS

PAH had no causal relationship with depression, anxiety, and cognitive performance. At the global level, PAH was not associated with SA or TH of the brain cortex; at the functional regional level, PAH increased TH of insula (P = 0.015), pars triangularis (P = 0.037) and pars opercularis (P = 0.010) without global weighted. After global weighted, PAH increased TH of insula (P = 0.004), pars triangularis (P = 0.032), pars opercularis (P = 0.007) and rostral middle frontal gyrus (P = 0.022) while reducing TH of inferior parietal (P = 0.004), superior parietal (P = 0.031) and lateral occipital gyrus (P = 0.033). No heterogeneity and pleiotropy were detected.

LIMITATIONS

The enrolled patients were all European and the causal relationship between PAH and the structure of the cerebral cortex in other populations remains unknown.

CONCLUSION

Causal relationship between PAH and the brain cortical structure was implied, thus providing novel insights into the PAH associated neuropsychiatric symptoms.

Exploratory and confirmatory factor analysis of emPHasis-10: The health-related quality-of-life measure in pulmonary hypertension

The emPHasis-10 is a health-related quality of life (HRQoL) unidimensional measure developed specifically for adults with pulmonary hypertension. The tool has excellent psychometric properties and is well used in research and clinical settings. Its factor structure has not been examined, which may help to identity a complimentary approach to using the measure to examine patient functioning. We performed an exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) on a data set collected from 263 adults with PH recruited from a community setting. The EFA suggested the emPHasis-10 consists of three underlying latent variables, which based on the loading of items, were termed "fatigue" (Items 3, 4, and 5), "independence" (Items 7, 8, 9, and 10), and "breathlessness" (Items 1, 2, and 6). All factors were found to have good internal consistency. "Independence" accounted for most of the variance (29%), followed by "breathlessness" (22%) and "fatigue" (19%). The CFA looked to confirm the fit of a three-factor model. A higher-order model was found to be the best fit consisting of HRQoL as a superordinate factor, for which the association between this factor and the 10 items was mediated through the three latent factors. Further analyses were performed testing the validity of the latent variables revealing all were significantly correlated with self-reported measures of depression, anxiety, health-anxiety, and dyspnea. Our analyses support the emPHasis-10 as a measure of HRQoL, while also proposing the clinical utility of examining the three emergent factors, which could be used to glean additional insight into the respondent's functioning and inform care.

'Fear, uncertain, tired…...' psychological distress among pulmonary hypertension patients: a qualitative interview study

BACKGROUND

Patient-centered health care for patients with pulmonary hypertension (PH) is important and requires an understanding of patient experiences. However, there is a lack of approaches to examine what's the effects and how the disease impact patients' psychological well-beings.

METHODS

We conducted qualitative interviews with PH patient representatives to understand patient psychological experiences and inform patient-centered research and care. Participants were chosen from a tertiary hospital located in northwest China. 20 patients with PH who be treated at the hospital (13 participants were women, aged 18-74 years) were strategically selected and individually interviewed. We used qualitative analysis to identify themes relating to existential psychological distress that would clarify the nature of such concerns.

RESULTS

We found that patients experience tremendous psychological distress throughout the treatment process. Four categories that describe patients' psychological experiences emerged: burden of PH treatment, fear and uncertainty about the disease, frustration in social and family role, and lack of recognition of the condition.

CONCLUSIONS

Existential concerns are salient in PH and involve the experience of loss and disruptions to the sense of self and relationships. Healthcare practitioners must work more in collaboration to detect patients' need for support and to develop the patient's own skills to manage daily life. The PH teams should tailor interventions to provide emotional, informational and instrumental support and guidance to patients.

The mediating effect of sleep disturbance on the association between hypertension and depression: a national data analysis

BACKGROUND

Sleep disturbance is a common among people with hypertension. However, the mediating role of sleep disturbance in the association between hypertension and depression remains unclear. This study aims to investigate the mediating role of sleep disturbance in the association between hypertension and depression.

MATERIALS AND METHODS

This was cross-sectional study. The data were derived from the Indonesian Family Life Survey Fifth Wave (2014-2015). We include a total of 19,138 adults' participants with age range from 18 to 65 years old who completed response on the variable of hypertension, sleep disturbance, and depression. The mediating model analysis was processed using the PROCESS macro ins SPSS from Hayes model.

RESULTS

Depression was reported by 22% of total respondents. The group with hypertension showed a substantially higher prevalence of depression than non-hypertension group (P < 0.001). Hypertension had a significant overall effect on depression (β = 0.682; 95%CI 0.489 to 0.875, P < 0.001). The direct effect of hypertension on depression was significant (β = 0.418; 95%CI 0.244 to 0.592, P < 0.001) and the indirect effect that mediated by sleep disturbance was also significant (β = 0.264, 95%CI 0.174 to 0.356, P < 0.001). It is worth noting that sleep disturbance partially mediated the association between hypertension and depression.

CONCLUSION

The findings of this study indicated that sleep disturbance contributed to the etiology of depression and hypertension in adult populations. Nurses should be involved in managing sleep disturbances, such as using behavioral therapy, as it may serve as both a treatment and primary prevention measure for depression and hypertension.

End-of-Life and Palliative Care Issues for Patients Living with Pulmonary Arterial Hypertension: Barriers and Opportunities

Pulmonary arterial hypertension (PAH) is a progressive, incurable disease that results in significant symptom burden, health care utilization, and eventually premature death. Despite the advancements made in treatment and management strategies, survival has remained poor. End-of-life care is a challenging issue in management of PAH, especially when patients are in younger age group. End-of-life care revolves around symptom palliation and reducing psychosocial disease burden for a dying patient and entails advanced care planning that are often challenging. Thus, support from palliative care specialist becomes extremely important in these patients. Early introduction to palliative care in patients with high symptom burden and psychosocial suffering is suggested. Despite of the benefits of an early intervention, palliative care remains underutilized in patients with PAH, and this significantly raises issues around end-of-life care in PAH. In this review, we will discuss the opportunities offered and the existing barriers in addressing high symptom burden and end-of-life care issues. We will focus on the current evidence, identify areas for future research, and provide a call-to-action for better guidance to PAH specialists in making timely, appropriate interventions that can help mitigate end-of-life care issues.

A systematic review of psychological interventions in adults with pulmonary hypertension: Is the evidence-base disproportionate to the problem?

INTRODUCTION

Our understanding of the psychological impact of living with pulmonary hypertension (PH) is growing, particularly for how anxiety and depression present in this group. There is evidence for the use of psychological interventions in other chronic lung conditions; however, trials focusing on adults with PH have yet to be subject to a systematic review.

METHODS

We systematically searched four databases for evidence examining the effectiveness of psychological interventions for adults with PH. A narrative approach has been used to present findings.

RESULTS

Overall, 186 unique articles were identified of which four were suitable. Data was gathered from 143 individuals. Cognitive behavioural therapy (CBT), metacognitive therapy (MCT) or counselling were investigated. All three studies reported a significant reduction in anxiety and depression, and some secondary outcomes were also associated with change.

DISCUSSION

The evidence supporting the use of psychological therapies for adults with PH is promising, although limited. There is an urgent need for more research in this area to better understand how we can support this clinical group.

Can self-compassion help us better understand the impact of pulmonary hypertension on those with the condition and their carers? A cross-sectional analysis

Pulmonary hypertension (PH) can have a multifaced impact both on the affected individual and close family members. However there are relatively few studies that have sought to identify potential protective factors. Individual differences in ability to be self-compassionate are known to be implicated in adjustment in other long-term conditions and are now featuring in the provision of care for a number of conditions. This is a cross-sectional study that investigated the relationship between self-compassion, demographic, PH-related information, and measures of psychosocial functioning in adults with PH (n = 65) and caregivers (n = 29). Individuals with PH and caregivers of someone with PH completed self-report measures on demographic and clinical factors, anxiety, depression, self-compassion, and in those with PH, health-related quality of life, and in carers, caregiver burden. Data were analyzed using hierarchical regression analyses. Surprisingly, participants with PH and caregivers did not significantly differ on rates of depression (p = 0.19) or anxiety (p = 0.57) with both scoring relatively high. Components of self-compassion were associated with psychological functioning in both individuals and caregivers. Greater self-compassion was associated with fewer symptoms of anxiety and depression, and greater health-related quality of life in individuals with PH and lower burden in caregivers. More specifically, multiple regression analyses revealed after controlling for age, gender, and duration of PH, self-compassion was a significant predictor of anxiety and depression in people with PH, and of anxiety and caregiver burden in carers. These findings add to the evidence base indicating that there can be a range of burdens experienced by both people living with PH and their wider families. Further, this study uniquely suggests that psychological and supportive interventions that seek to build self-compassion may be useful to develop and test in this clinical group.

Cognitive and behavioral processes predict anxiety and depression in patients with pulmonary hypertension

Emotional and psychological difficulties cannot fully be explained by disease-related factors in people with pulmonary hypertension (PH). This study examined the relationship between anxiety, depression, demographic, objective and subjective PH factors, and self-reported cognitive and behavioral processes, which have been associated with mood in clinical and nonclinical samples. This is a secondary analysis of baseline data from 77 adults with PH who took part in a randomized controlled trial of a self-help intervention targeting anxiety in PH. Participants completed self-report measures including: demographic (age, gender, ethnicity, education, employment) and clinical questionnaire (PH diagnosis, functional class, years since diagnosis), depression (PHQ-9), anxiety (GAD-7), health-related quality of life (emPHAsis-10), dyspnea (D12), and cognitive and behavioral processes (CBP-Q) scale. Data were analyzed using correlational and regression analyses. Overall, 70% and 63% of participants scored above the clinical cut off for anxiety and depression, respectively. Demographics were not associated with anxiety or depression. PH-related factors were correlated with depression but not anxiety. A multiple regression analysis suggested dyspnea and cognitive processes significantly predicted anxiety whereas behavioral processes were not a unique predictor. In contrast, dyspnea and behavioral processes predicted depression whereas cognitive processes did not. While a body of evidence exists demonstrating people with PH are more likely to experience anxiety and depression, less is known about factors that cause and maintain these disorders. Findings highlight the significance of subjective factors that could be a target for screening and psychological treatments for emotional difficulties, such as cognitive behavioral therapy.