Somatic and sociodemographic predictors of depression outcome among depressed patients with coronary artery disease - a secondary analysis of the SPIRR-CAD study

BACKGROUND

Depressive symptoms are common in patients with coronary artery disease (CAD) and are associated with an unfavourable outcome. Establishing prognostic patient profiles prior to the beginning of mental health care may facilitate higher efficacy of targeted interventions. The aim of the current study was to identify sociodemographic and somatic predictors of depression outcome among depressed patients with CAD.

METHODS

Based on the dataset of the multicentre SPIRR-CAD randomised controlled trial (n = 570 patients with CAD and ≥ 8 points on the Hospital Anxiety and Depression Scale (HADS)), 141 potential sociodemographic and somatic predictors of the change in the HADS-D depression score from baseline to 18-month-follow-up were derived in two different ways. We screened for univariable association with response, using either analysis of (co)variance or logistic regression, respectively, both adjusted for baseline HADS-D value and treatment group. To guard against overfitting, multivariable association was evaluated by a linear or binomial (generalised) linear model with lasso regularisation, a machine learning approach. Outcome measures were the change in continuous HADS-D depression scores, as well as three established binary criteria. The Charlson Comorbidity Index (CCI) was calculated to assess possible influences of comorbidities on our results and was also entered in our machine learning approach.

RESULTS

Higher age (p = 0.002), unknown previous myocardial infarction (p = 0.013), and a higher heart rate variability during numeracy tests (p = .020) were univariably associated with a favourable depression outcome, whereas hyperuricemia (p ≤ 0.003), higher triglycerides (p = 0.014), NYHA class III (p ≤ 0.028), state after resuscitation (p ≤ 0.042), intake of thyroid hormones (p = 0.007), antidiabetic drugs (p = 0.015), analgesic drugs (p = 0.027), beta blockers (p = 0.035), uric acid drugs (p ≤ 0.039), and anticholinergic drugs (p = 0.045) were associated with an adverse effect on the HADS-D depression score. In all analyses, no significant differences between study arms could be found and physical comorbidities also had no significant influence on our results.

CONCLUSION

Our findings may contribute to identification of somatic and sociodemographic predictors of depression outcome in patients with CAD. The unexpected effects of specific medication require further clarification and further research is needed to establish a causal association between depression outcome and our predictors.

TRIAL REGISTRATION

www.clinicaltrials.gov   NCT00705965 (registered 27th of June, 2008). www.isrctn.com   ISRCTN76240576 (registered 27th of March, 2008).

Perceived Stress Levels in Adult Patients With Uveitis

Background: The aim of this study was to examine perceived stress levels in adult patients with uveitis. Patients and Methods: One hundred seventy-three adult consecutive uveitis patients (age range 18 to 85 years) were analyzed in a cross-sectional design for their perceived stress, according to the Perceived Stress Questionnaire (PSQ). Stress levels were classified into normal stress, moderate stress, and high stress. Results: In the majority of uveitis patients a normal stress level (82%) within the last 2 years was detected. In a subgroup analysis, perceived stress of the patients with active uveitis compared with patients with non-active uveitis was significantly higher within the last 2 years (n=80 active/n = 45 non-active; p = 0.005). Conclusions: Overall 18% of the uveitis patient had raised perceived stress, similar to the general population but patients with active uveitis were significantly more stressed. Therefore, consideration of stress levels may be important in the therapy of uveitis patients.

Mental Disorders in People Affected by Thalidomide

BACKGROUND

More than 50 years after the withdrawal of thalidomide from the market, subsequent orthopedic damages and psychosocial impairments dominate the complaints of thalidomide-affected individuals. The aim of the study was to determine the prevalence of mental disorders in this group.

METHODS

A total of 193 thalidomide-affected individuals from North Rhine-Westphalia (mean age 50.5 years, 56.5% women) underwent personal and comprehensive psychodiagnostic testing, which was based on the Structured Clinical Interview for DSM-IV disorders (SCID-I & SCID-II) and self-reporting questionnaires.

RESULTS

Overall, the four-week prevalence of mental disorders was 47.2%. Multiple mental disorders were present in 45.1% among the 91 participants with diagnosed mental disorders. The most frequent diagnoses were unipolar depressive disorders (16.5%), somatoform disorders (14.0%), phobic disorders (12.4%), and alcohol-related disorders (6.2%). Immediate mental health care was indicated in 80.2% of participants with current mental disorders, but only 29.7% had used some form of psychosocial treatment in the 12 months preceding the study.

CONCLUSION

Mental disorders occur approximately twice as often (relative risk [RR]: 1.77; 95% confidence interval [1.49; 2.10]) in thalidomide-affected individuals as in the age-matched German population. Together with a very low rate of utilization of mental health care, this finding implies an underuse of psychosocial healthcare. The development of specialized psychosocial treatment services may remove barriers that impede access to the healthcare system.

Gender differences in psychosocial outcomes of psychotherapy trial in patients with depression and coronary artery disease

INTRODUCTION

The biological and psychosocial risk profile differs between women and men with coronary artery disease (CAD). Depressive symptoms and Vital Exhaustion (VE) predict an unfavourable course of CAD. The secondary analysis of the SPIRR-CAD trial offered the possibility to examine gender as exposure variable of the clinical and psychological situation at baseline and in a variety of psychosocial measures as outcomes.

METHODS

In this trial, 450 men (78.9%) and 120 women (21.1%) with CAD (age ≤ 75 y), with mild to moderate depression (scoring ≥8 on the HADS), were randomized to usual care with or without a stepwise psychotherapy intervention. Beside clinical measures exhaustion and other indicators of depressive symptoms were collected at baseline and 18-month follow up.

RESULTS

Men had more signs and symptoms of heart disease at baseline, whereas women had higher psychosocial burden (e.g. negative affect). Women were more likely to live alone, had lower educational levels and employment rates and higher levels of depression and exhaustion. The psychotherapy intervention differed as a function of gender: In women, VE decreased from 29.4 ± 8.1 to 22.1 ± 11.7 in the intervention group (IG) and from 29.2 ± 8.2 to 25.1 ± 11.3 in the control group (CG). In men VE decreased from 23.3 + -10.8 to 21.2 ± 9.7 in the IG and from 23.6 ± 10.7 to 19.3 ± 11.3 in the CG (time x intervention x gender; F = 4.97; p = .026).

DISCUSSION

Women had a higher psychosocial burden than men. VE compared to other rating instruments of depressive symptoms suggested a stronger response to the intervention in women. VE may help to understand gender differences in psychotherapeutic treatment studies of CAD.

ISRCTN

76240576; clinicaltrials.gov.

Associations of NT-proBNP and parameters of mental health in depressed coronary artery disease patients

Natriuretic peptides (NP) are involved in the regulation of blood pressure and blood volume, and are elevated in patients with coronary artery disease (CAD). They are used as markers for illness severity, but their role in mental health is not well understood. Recently, A-type NP (ANP) has been associated with reduced anxiety in studies on cardiac patients; however, this study is the first to assess this effect for B-type NP (BNP) and for further dimensions of well-being and mental health. Depression, anxiety, and distress are more common in CAD patients than in the general population and are most likely not only influenced by psychological adaptation but also by neurobiological processes. We used baseline N-terminal proBNP (NT-proBNP) samples and psychometric assessments of 529 at least mildly depressed (Hospital Anxiety and Depression Scale, depression score ≥ 8) CAD patients from the multicenter Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease (SPIRR-CAD) trial. Psychosocial status was assessed using standardized self-rating questionnaires on anxiety, depression, coping with illness, vital exhaustion, type D personality, and quality of life. Separate linear regression models for each psychometric scale revealed significant negative correlations of NT-proBNP with anxiety, depression, vital exhaustion, depressive coping, and negative affectivity. Moreover, patients with higher levels of NT-proBNP experienced less bodily pain and had a better self-rated mental health, despite worse physical functioning. Linear regression adjusted for age, sex, and physical functioning (Short Form Health Survey [SF-36]) revealed NT-proBNP to be a significant predictor for all tested measures of the patients' psychosocial status. These results indicate that NT-proBNP is not only positively associated with greater disease severity in mildly to moderately depressed CAD patients but also with better psychosocial status and mental well-being. Possible mechanisms of this effect are discussed.

[Comorbid Mental Disorders in Gastroenterology and Hepatology: Prevalence and Psychosocial Needs in Tertiary Care]

BACKGROUND

In the field of gastroenterology and hepatology, associations and interactions with comorbid mental disorders are often described, but there is currently a lack of methodologically high-quality studies on prevalence and the need for care. The aim of the study was to take account of this shortcoming.

METHODS

Prospective, monocentric, cross-sectional study of a representative sample of inpatients at a university hospital. A total of 308 participants were examined for the presence of 8 frequent psychological syndromes with a validated questionnaire (PHQ-D). In addition, 63 participants were examined for the presence of mental disorders according to ICD-10 with a diagnostic interview (SKID-I) that covers a wider range of diagnoses. The need for psychosocial care was raised from the perspective of internal medicine practitioners and psychosomatic experts.

RESULTS

The prevalence for at least 1 mental syndrome in the questionnaire sample (PHQ-D excl. PHQ-15) was 39.6%, in 23.8% of whom more than one syndrome was present. The most frequent were depressive and anxiety syndromes. There were significant differences in the various subgroups (sex, type and severity of the somatic disease). The 4-week prevalence for any mental disorder in the interview sample (SKID-I) was 52.4%. Affective and somatoform disorders as well as adaptation disorders were dominant. The need for psychosocial care was reported in 23.1% by the practitioners and in 30.2% by the experts.

CONCLUSIONS

Patients with gastroenterological-hepatological tertiary care have a high prevalence of treatment-related psychological syndromes or disorders. In comparison with the reference data of the Robert Koch Institute on the 12-month prevalence of mental disorders among the general population in Germany, the proportion of current mental disorders is almost twice as high (52.7 vs. 27.1%, p<0.001). To cover the need for care, the provision of psychosomatic liaison services and the strengthening of psychosomatic basic care in gastroenterology/hepatology should be established.

Socioeconomic factors in coronary artery disease - Results from the SPIRR-CAD study

Low socio-economic status (SES) has been associated with an increased coronary risk in Western countries. All stress experiences are more pronounced in low SES patients with stress emanating from problems with family, job, or money. The SPIRR-CAD study offered an excellent opportunity to examine these risk factors in German speaking mildly and medium depressed patients. In the SPIRR CAD study, a German multi centre randomized clinical trial of 450 male and 120 female coronary patients, we examined the standard and psychosocial risk factor profiles in relation to SES, as assessed by educational level. All differences in risk factors between low and high SES were in the inverse direction. Of standard risk factors, only smoking was socially graded and more common in low SES. Of psychosocial factors and emotions, exhaustion showed the strongest and most consistent inverse social gradient, but also anger, anxiety and depression were socially graded. The findings suggest that in German patients, as in other national groups, social gradients in CHD risk are considerable. They can be ascribed to both psychosocial and to standard risk factors. In the present two years follow-up, the prospective significance of psychological and social risk factors was analyzed showing that emotional factors played an important role, in that low and high SES patients differed in the expected direction. However, the differences were not statistically significant and therefore firm conclusions from follow up were not possible.

TRIAL REGISTRATION

ISRCTN 76240576; NCT00705965.

Perceived Psychotherapist's Empathy and Therapy Motivation as Determinants of Long-Term Therapy Success-Results of a Cohort Study of Short Term Psychodynamic Inpatient Psychotherapy

Objective: Outcome predictors and determinants for treatment outcome of inpatient psychotherapy will be assessed in a follow-up-study. Sociodemographic factors and the level of depressiveness at admission, the perceived psychotherapist's empathy rated by patients and the therapy motivation as possible moderators of treatment outcome (reduction of depressive symptoms) are analyzed. Methods: In a cohort study, the outcome of inpatient multimodal psychotherapy was examined with Beck-Depression-Inventory (BDI) at admission (T1), discharge (T2) and at follow-up (1-3 years after treatment) (T3). Inclusion criteria were: Inpatient psychotherapy between 2007 and 2010 with a duration of at least 1 week and complete data set. The influence on therapy success of (1) sociodemographic factors, (2) the perceived psychotherapist's empathy rated by patients using the Consultation and Relational Empathy Measure (CARE), and (3) the therapy motivation of the patients rated by therapists are examined by means of correlation analysis, distribution comparisons and subsequently logistic regression. Results: Ninety-two (64 females, average age 39 yrs.) of 182 eligible patients participated in the follow-up survey. Duration of inpatient psychotherapy lasted 8.7 weeks ± 3.6 [min. 1, max. 33 weeks]. The perceived psychotherapist's empathy, therapy motivation, education level and depression at baseline had a significant impact on therapy success. Gender, age, and partnership were not significant. The length between discharge and follow-up had no influence on the results. Based on these variables a multiple logistic regression explained 42% of the variation (goodness-of-fit). Conclusion: Due to the shown relevance of the psychotherapist's empathy perceived by patients and the therapy motivation of patients for therapy success, both factors should be considered already at the beginning of the therapy. Consequently, they should be recognized in the context of postgraduate training and education.

[Report from an ongoing research project: The Cologne Research and Development Network (CoRe-Net) and the value-based approach to healthcare]

With the BMBF's funding program "Structural Development in Health Services Research" the Cologne Research and Development Network CoRe-Net is being set up by various partners from both clinical practice and health services research. The network focuses on the further development of healthcare according to the concept of learning organizations. On the basis of three research projects, the Cologne network CoRe-Net aims to establish itself in a sustainable manner and analyze healthcare delivery for two vulnerable patient groups. The two groups include a) deceased patients in Cologne and b) people suffering from heart disease and an associated mental comorbidity. The Cologne network CoRe-Net is based on M.E. Porter's value-based healthcare approach.

The Diagnosis of Chronic Coronary Heart Disease

BACKGROUND

Chronic coronary heart disease (CHD) and acute myocardial infarction are endemic conditions. In Germany, an estimated 900 000 cardiac catheterizations were performed in the year 2014, and a percutaneous intervention was carried out in 40% of these procedures. It would be desirable to lessen the number of invasive diagnostic procedures while preserving the reliability of diagnosis. In this article, we present the updated recommendations of the German National Care Guideline for Chronic CHD with regard to diagnostic evaluation.

METHODS

Updated recommendations for the diagnostic evaluation of chronic CHD were developed on the basis of existing guidelines and a systematic literature review and approved by a formal consensus process.

RESULTS

8-11% of patients with chest pain who present to a general practitioner and 20-25% of those who present to a cardiologist have chronic CHD. General practitioners should estimate the probability of CHD with the Marburg Heart Score. Specialists can use detailed tables for determining the pre-test probability of CHD; if this lies in the range of 15% to 85%, then non-invasive tests should be primarily used for evaluation and treatment planning. If the pretest probability is less than 15%, other potential causes should be ruled out first. If it is over 85%, the presence of CHD should be presumed and treatment planning should be initiated. Coronary angiography is needed only if therapeutic implications are expected (revascularization). Psychosocial risk factors for the development and course of CHD and the patient's quality of life should be regularly assessed as well.

CONCLUSION

Non-invasive testing and invasive coronary angiography should be used only if their findings are expected to have therapeutic implications. Psychosocial risk factors, the quality of life, and adherence to treatment are important components of these patients' diagnostic evaluation and long-term care.

Messung der Therapeutenkompetenz in Psychotherapiegruppen

Zusammenfassung. Theoretischer Hintergrund: Methodisch betrachtet stellt die psychotherapeutische Kompetenz ein wichtiges Qualitätsmerkmal zur Überprüfung der Validität in Psychotherapiestudien dar. Bisher lag kein Instrument zur Erfassung der Psychotherapeutenkompetenz in Gruppentherapien vor. Fragestellung: Eignet sich die hier vorgestellte Adaptation der deutschsprachigen Version der Cognitive Therapy Scale (CTS-D-G) zur Erfassung der psychotherapeutischen Kompetenz in kognitiv-verhaltenstherapeutischen Gruppen? Methodik: Das Ratingsystem wurde anhand von 32 exemplarischen Videoaufzeichnungen von 7 Therapeut_innen und 68 Patient_innen aus 16 Therapiegruppen von zwei Ratern evaluiert. Die Evaluierung erfolgte im Rahmen einer randomisierten, kontrollierten Studie mit depressiven Diabetespatient_innen. Ergebnisse: Es konnten eine sehr gute Interraterreliabilität (r = .82) und eine hohe interne Konsistenz (Cronbach’s α = .96) nachgewiesen werden. Schlussfolgerung: Die Studie liefert erste Hinweise, dass die CTS-D-G zur Erfassung der psychotherapeutischen Kompetenz in verhaltenstherapeutischen Gruppentherapie geeignet ist.

Substantial improvement of primary cardiovascular prevention by a systematic score-based multimodal approach: A randomized trial: The PreFord-Study

Trial design Prospective randomized multicentre interventional study. Methods Individual cardiovascular risk assessment in Ford Company, Germany employees ( n = 4.196), using the European Society of Cardiology-Systematic Coronary Risk Evaluation (ESC-SCORE) for classification into three risk groups. Subjects assigned to ESC high-risk group (ESC-SCORE ≥ 5%), without a history of cardiovascular disease were eligible for randomization to a multimodal 15-week intervention programme (INT) or to usual care and followed up for 36 months. Objectives Evaluation of the long-term effects of a risk-adjusted multimodal intervention in high-risk subjects. Primary endpoint: reduction of ESC-SCORE in INT versus usual care. Secondary endpoints: composite of fatal and non-fatal cardiovascular events and time to first cardiovascular event.

STATISTICAL ANALYSIS

intention-to-treat and per-protocol analysis. Results Four hundred and forty-seven subjects were randomized to INT ( n = 224) or to usual care ( n = 223). After 36 months ESC-SCORE development favouring INT was observed (INT: 8.70% to 10.03% vs. usual care: 8.49% to 12.09%; p = 0.005; net difference: 18.50%). Moreover, a significant reduction in the composite cardiovascular events was observed: (INT: n = 11 vs. usual care: n = 27). Hazard ratio of intervention versus control was 0.51 (95% confidence interval 0.25-1.03; p = 0.062) in the intention-to-treat analysis and 0.41 (95% confidence interval 0.18-0.90; p = 0.026) in the per-protocol analysis, respectively. No intervention-related adverse events or side-effects were observed. Conclusions Our results demonstrate the efficiency of identifying cardiovascular high-risk subjects by the ESC-SCORE in order to enrol them to a risk adjusted primary prevention programme. This strategy resulted in a significant improvement of ESC-SCORE, as well as a reduction in predefined cardiovascular endpoints in the INT within 36 months. (ISRCTN 23536103.).

The prescription talk - an approach to teach patient-physician conversation about drug prescription to medical students

Background: Medication communication from physicians to patients often is poor, by this among others enhancing the risk of non-adherence. In this context, a neglect regarding the prescription talk has been complained. Aim of the project: In a newly developed elective medical students work on physician-patient conversations dealing with drug prescription. Essential aspects related to an effective and safe drug treatment are combined with steps of shared decision-making. Together with a tutor, students develop a (model) conversation guide that might be tailored according to individual needs and views. Description/Methods: In a one-week course 3rd-5th year medical students treat a paper case according to problem-based learning. This is accompanied by a one-hour lecture and literature provided on an online learning platform (ILIAS). During a workshop, aspects of drug treatment and patient participation are integrated into a guide for a prescription talk. At the end of the week the students are invited to apply the (if need be individualized) guide in a simulated physician-patient communication with an actor. The conversation is evaluated using a checklist based upon the (model) conversation guide. Results: Informal and formalized feedback indicate high acceptance and satisfaction of participants with this elective. The checklist turned out to be of acceptable to good reliability with mostly selective items. Portfolio entries and written evaluation suggest that participants' positions and attitudes are influenced.