A Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease (SPIRR-CAD): Results of an Observer-Blinded, Multicenter, Randomized Trial in Depressed Patients With Coronary Artery Disease

Prevalence of mental disorders among depressed coronary patients with and without Type D personality. Results of the multi-center SPIRR-CAD trial

OBJECTIVE

Type D personality, as with formal mental disorders, is linked to increased mortality in coronary heart disease (CHD). Our aim was to determine the prevalence of mental disorders among depressed CHD patients with and without Type D personality.

METHODS

Depressive symptoms (HADS, HAM-D), Type D personality (DS-14) and mental disorders based on DSM-IV (SCID I and II) were assessed. Results were calculated by Kruskal-Wallis tests, Fisher's exact tests and logistic regression analyses.

RESULTS

570 CHD patients were included (age 59.2±9.5years; male 78.9%, HADS-D depression 10.4±2.5; HAM-D 11.3±6.6; Type D 60.1%). 84.8% of patients with Type D personality and 79.3% of non-Type D patients suffered from at least one mental disorder (p=0.092), while 41.8% of Type D positives and 27.8% of Type D negatives had at least two mental disorders (p=0.001). Patients with Type D personality significantly more often had social phobia [odds ratio (95% confidence interval): 3.79 (1.1 to 13.12); p=0.035], dysthymia [1.78 (1.12 to 2.84); p=0.015], compulsive [2.25 (1.04 to 4.86); p=0.038] or avoidant [8.95 (2.08 to 38.49); p=0.003] personality disorder.

CONCLUSIONS

Type D personality among depressed CHD patients is associated with more complex and enduring mental disorders. This implies higher treatment demands.

TRIAL REGISTRATION

ISRCTN 76240576; NCT00705965.

Utilization of Mental Health Care, Treatment Patterns, and Course of Psychosocial Functioning in Northern German Coronary Artery Disease Patients with Depressive and/or Anxiety Disorders

BACKGROUND

Comorbid mental disorders in patients with coronary artery disease (CAD) are common and associated with adverse somatic outcomes. However, data on utilization rates of mental health care and treatment efficiency are scarce and inconsistent, which we tried to remedy with the present preliminary study on Northern German CAD patients.

METHOD

A total of 514 German CAD patients, as diagnosed by cardiac catheterization, were assessed using the Mini International Neuropsychiatric Interview and the Global Assessment of Functioning (GAF) scale.

RESULTS

Global utilization of mental health care since onset of CAD was 21.0%. Depressive disorders, younger age, and lower GAF at onset of CAD were associated with higher utilization rates, while anxiety disorders and gender were not. Lower GAF at onset of CAD, female gender, and psychotherapy was positively associated with higher gains in GAF, while younger age and anxiety disorders were negatively associated.

CONCLUSION

The majority of CAD patients with comorbid depression reported to have received mental health treatment and seemed to have benefited from it. However, we found preliminary evidence of insufficiencies in the diagnosis and treatment of anxiety disorders in CAD patients. Further studies, preferably prospective and with representative samples, are needed to corroborate or falsify these findings and explore possible further mediators of health-care utilization by CAD patients such as race, ethnicity, and socioeconomic status.

Collaborative Care and Related Interventions in Patients With Heart Disease: An Update and New Directions

BACKGROUND

Psychiatric disorders, such as depression, are very common in cardiac patients and are independently linked to adverse cardiac outcomes, including mortality. Collaborative care and other integrated care models have been used successfully to manage psychiatric conditions in patients with heart disease, with beneficial effects on function and other outcomes. Novel programs using remote delivery of mental health interventions and promotion of psychological well-being may play an increasingly large role in supporting cardiovascular health.

METHODS

We review prior studies of standard and expanded integrated care programs among patients with cardiac disease, examine contemporary intervention delivery methods (e.g., Internet or mobile phone) that could be adapted for these programs, and outline mental health-related interventions to promote healthy behaviors and overall recovery across all cardiac patients.

RESULTS

Standard integrated care models for mental health disorders are effective at improving mood, anxiety, and function in patients with heart disease. Novel, "blended" collaborative care models may have even greater promise in improving cardiac outcomes, and interfacing with cardiac patients via mobile applications, text messages, and video visits may provide additional benefit. A variety of newer interventions using stress management, mindfulness, or positive psychology have shown promising effects on mental health, health behaviors, and overall cardiac outcomes.

CONCLUSIONS

Further study of novel applications of collaborative care and related interventions is warranted given the potential of these programs to increase the reach and effect of mental health interventions in patients with heart disease.

[Bio-psycho-socio or psychotherapeutic medicine - actual development of psychosomatics in clinical practice]

In Germany a model of Psychosomatic Medicine has developed, which integrated several psychotherapeutic methods in clinical practice. The concept, which focused on disease mechanisms in the human body and the interaction between diseased individuals and their environment became a basic psychosomatic research strategy and was imlemented in medical care. In this paper the result of a psychosomatic development in clinical health care and research and possible deficiences are described. Perspectives of development and future tasks of Psychosomatic Medicine will be reviewed.

Validity of the European Society of Cardiology's Psychosocial Screening Interview in Patients With Coronary Artery Disease-The THORESCI Study

OBJECTIVE

The aim of the study was to examine the validity of the European Society of Cardiology (ESC) psychosocial screening instrument.

METHODS

A total of 508 acute (67%) or elective (33%) percutaneous coronary intervention patients (mean [standard deviation]age = 63 [10] years, 81% male) completed the ESC screening interview and established questionnaires for psychosocial risk markers, that is, depression (Patient Health Questionnaire 9), anxiety (Generalized Anxiety Disorder Questionnaire 7), type D personality (Type D Scale 14), hostility (Cook-Medley Hostility Scale 7), and marital/work stress (Maudsley Marital Quality Questionnaire 6, Effort-Reward Imbalance Scale) during or close after hospital admission. At 1-year follow-up, angina and cardiopulmonary symptoms were assessed.

RESULTS

Prevalence estimates of psychosocial factors based on the ESC screener were as follows: depression (18%), anxiety (33%), negative affectivity (11%), social inhibition (41%), work stress (17%), marital stress (2%), and hostility (38%). Analysis of correspondence with validated questionnaires revealed fair to moderate agreement (depression [κ = .39], anxiety [κ = .23], type D personality [κ = .21]), regardless of percutaneous coronary intervention indication. For work and marital stress, there was poor to fair performance (κ range = .04-.24); agreement for hostility was poor (κ = -.27). A positive ESC screen for depression, anxious tension, and type D personality was associated with more angina and cardiopulmonary symptoms at follow-up (odds ratios ranging between 1.85 (95% confidence interval = 0.84-4.08) and 8.01 (95% confidence interval = 2.35-27.35).

CONCLUSIONS

The ESC screener contributes to the search for a multidimensional and easy-to-use psychosocial screening instrument for cardiac patients. Although the screener, in its current form, may not be sufficiently valid to reliably detect all predefined psychosocial factors, screening scores for depression and anxiety might be useful in clinical practice. Our findings can be used for further refinement and validation of the screener.

Explaining heterogeneity in the predictive value of Type D personality for cardiac events and mortality

BACKGROUND

Type D personality has been associated with adverse outcomes in patients with coronary artery disease (CAD). However, large heterogeneity exists between Type D studies, including some studies reporting null-findings.

OBJECTIVES

The aim of this study was to examine i) choice of endpoint and ii) age as two study characteristics that may partly explain this large heterogeneity in the Type D associated prognostic effect.

METHODS

We used four existing data cohorts of 1503 CAD patients (89% male, mean age=57.2±9.1) with baseline measures of Type D and endpoints >5years follow-up: major adverse cardiac events (MACE), cardiac death/MI, and non-cardiac death. Patients were classified in 4 age categories: <50y, 50-59y, 60-69y and ≥70y. Multiple logistic regression models included age, sex, and clinical covariates.

RESULTS

At follow-up, there were 295 events, including 116 cardiac death/MI, and 37 non-cardiac deaths. Both continuous and categorical measures of Type D predicted adverse events. Type D was independently associated with MACE (OR=1.82; 95%CI 1.33-2.50) and cardiac death/MI (OR=2.49; 95%CI 1.55-3.99). However, Type D was not associated with non-cardiac death (OR=1.23; 95%CI 0.57-2.69). Regarding age, Type D consistently predicted MACE in the lower age groups (all ORs≥2.20, all ps≤.004), but not in patients aged ≥70y (OR=1.43, p=.57).

CONCLUSIONS

Choice of endpoint and age modulated the risk conferred by Type D personality. Type D was associated with an increased risk of cardiac events, but not with non-cardiac death, or with events in patients aged ≥70y. Research on psychosocial risk in CAD should account for different sources of heterogeneity in study characteristics.