Depression screening and patient outcomes in cardiovascular care: a systematic review

The role of adverse childhood experiences in cardiovascular disease risk: a review with emphasis on plausible mechanisms

Childhood adversity, characterized by abuse, neglect, and household dysfunction, is a problem that exerts a significant impact on individuals, families, and society. Growing evidence suggests that adverse childhood experiences (ACEs) are associated with health decline in adulthood, including cardiovascular disease (CVD). In the current review, we first provide an overview of the association between ACEs and CVD risk, with updates on the latest epidemiological evidence. Second, we briefly review plausible pathways by which ACEs could influence CVD risk, including traditional risk factors and novel mechanisms. Finally, we highlight the potential implications of ACEs in clinical and public health. Information gleaned from this review should help physicians and researchers in better understanding potential long-term consequences of ACEs and considering adapting current strategies in treatment or intervention for patients with ACEs.

Collaborative care for depression symptoms in an outpatient cardiology setting: A randomized clinical trial

BACKGROUND

Depression is a risk factor for morbidity and mortality in patients with coronary heart disease. Finding effective methods for identifying and treating depression in these patients is a high priority. The purpose of this study was to determine whether collaborative care (CC) for patients who screen positive for depression during an outpatient cardiology visit results in greater improvement in depression symptoms and better medical outcomes than seen in patients who screen positive for depression but receive only usual care (UC).

METHODS

Two hundred-one patients seen in an outpatient cardiology clinic who screened positive for depression during an outpatient visit were randomized to receive either CC or UC. Recommendations for depression treatment and ongoing support and monitoring of depression symptoms were provided to CC patients and their primary care physicians (PCPs) for up to 6months.

RESULTS

There were no differences between the arms in mean Beck Depression Inventory-II scores(CC, 15.9; UC, 17.4; p=.45) or in depression remission rates(CC, 32.5%; UC, 26.2%; p=0.34) after 6months, or in the number of hospitalizations after 12months (p=0.73). There were fewer deaths among the CC (1/100) than UC patients (8/101) (p=0.03).

CONCLUSIONS

This trial did not show that CC produces better depression outcomes than UC. Screening led to a higher rate of depression treatment than was expected in the UC group, and delays in obtaining depression treatment from PCPs may have reduced treatment effectiveness for the CC patients. A different strategy for depression treatment following screening in outpatient cardiology services is needed.

The association of depressive symptoms with cardiovascular and all-cause mortality in Central and Eastern Europe: Prospective results of the HAPIEE study

Background

Studies in western populations have shown a positive association between depression and cardiovascular disease (CVD) and all-cause mortality. The association with depressive symptoms seems to be graded, rather than limited to the presence versus the absence of depression. Evidence from populations with potentially different patterns of confounders helps to address the consistency of these findings. The objective of the study was to investigate the association between depressive symptoms and all-cause and CVD mortality in populations of Central and Eastern Europe.

Study design

This was a prospective cohort study.

Methods

A total of 24,542 participants aged 45–69 years, randomly selected from populations of Novosibirsk (Russia), Krakow (Poland) and six Czech towns, were included. Depressive symptoms, assessed by the 20-item Center for Epidemiologic Studies Depression (CES-D) scale, were used as both continuous and categorical variables. Data on deaths were obtained from local or national death registers. Associations between depression and mortality were assessed using Cox proportional hazards models.

Results

Over a median of 7 years, 2091 deaths from all causes and 850 CVD deaths occurred in the cohorts. There was a graded association between CES-D score and mortality; the hazard ratio (HR) of CVD mortality for a 1 SD increase in CES-D was 1.20 (95% confidence interval (CI): 1.16–1.24) in men and 1.23 (95% CI: 1.12–1.35) in women; for all-cause mortality, the HRs were 1.13 (95% CI: 1.09–1.18) and 1.17 (95% CI: 1.10–1.25), respectively. The results were similar across countries.

Conclusions

Depressive symptoms predicted CVD and all-cause mortality independently of a wide range of potential confounders. The association followed a gradient and increased mortality risks were associated with scores below the cut-offs that are commonly used to define ‘depression’.

Methodological quality of meta-analyses of the diagnostic accuracy of depression screening tools

OBJECTIVE

Concerns have been raised that primary studies of diagnostic accuracy of depression screening tools may exaggerate estimates of accuracy and that this could also influence the results of meta-analyses. No studies, however, have evaluated the quality of meta-analyses of depression screening tools. Our objective was to evaluate the quality of meta-analyses of the diagnostic accuracy of depression screening tools.

METHODS

We searched MEDLINE and PsycINFO from January 1, 2005 through March 13, 2016 for recent meta-analyses in any language on the diagnostic accuracy of depression screening tools. Two reviewers independently assessed methodological quality using the AMSTAR tool with appropriate adaptations made for studies of diagnostic test accuracy.

RESULTS

We identified 21 eligible meta-analyses. The majority provided a list of included studies (100%), included a comprehensive literature search (95%) and assessed risk of bias of included studies (71%). Meta-analyses less consistently included non-published evidence (38%), listed excluded studies (33%), incorporated risk of bias findings into conclusions (33%), and assessed selective cutoff reporting (29%). Meta-analyses rarely reported that duplicate study selection or data extraction occurred (14%), mentioned 'a priori' protocols (10%), or reported on conflicts of interest (0%) or funding sources (0%) of primary studies. Only 6 of 21 included meta-analyses complied with at least 7 of 14 adapted AMSTAR items.

CONCLUSIONS

The methodological quality of most meta-analyses of the diagnostic test accuracy of depression screening tools is suboptimal. Improving quality will reduce the risk of inaccurate estimates of accuracy and inappropriate inferences.

Combining training in knowledge translation with quality improvement reduced 30-day heart failure readmissions in a community hospital: a case study

RATIONALE, AIMS AND OBJECTIVES

Training programmes in evidence-based practice (EBP) frequently fail to translate their content into practice change and care improvement. We linked multidisciplinary training in EBP to an initiative to decrease 30-day readmissions among patients admitted to a community teaching hospital for heart failure (HF).

METHODS

Hospital staff reflecting all services and disciplines relevant to care of patients with HF attended a 3-day innovative capacity building conference in evidence-based health care over a 3-year period beginning in 2009. The team, facilitated by a conference faculty member, applied a knowledge-to-action model taught at the conference. We reviewed published research, profiled our population and practice experience, developed a three-phase protocol and implemented it in late 2010. We tracked readmission rates, adverse clinical outcomes and programme cost.

RESULTS

The protocol emphasized patient education, medication reconciliation and transition to community-based care. Senior administration approved a full-time nurse HF coordinator. Thirty-day HF readmissions decreased from 23.1% to 16.4% (adjusted OR = 0.64, 95% CI = 0.42-0.97) during the year following implementation. Corresponding rates in another hospital serving the same population but not part of the programme were 22.3% and 20.2% (adjusted OR = 0.87, 95% CI = 0.71-1.08). Adherence to mandated HF quality measures improved. Following a start-up cost of $15 000 US, programme expenses balanced potential savings from decreased HF readmissions.

CONCLUSION

Training of a multidisciplinary hospital team in use of a knowledge translation model, combined with ongoing facilitation, led to implementation of a budget neutral programme that decreased HF readmissions.

Anxiety and new onset of cardiovascular disease: critical review and meta-analysis

BACKGROUND

Anxiety has been associated with new-onset cardiovascular disease (CVD), but the quality of this relationship is unclear. Only if anxiety is a causal, independent cardiovascular risk factor might it be a target for CVD prevention.

AIMS

To determine and examine the independent association and causality between anxiety and incident CVD.

METHOD

PubMed, EMBASE and PsycINFO databases were searched up to October 2013. A review of Hill's criteria for causality and random effects meta-analysis were conducted of prospective, population-based studies examining anxiety and incident CVD in people free from CVD at baseline.

RESULTS

The meta-analysis comprised 37 papers (n = 1 565 699). The follow-up ranged from 1 to 24 years. Anxiety was associated with a 52% increased incidence of CVD (hazard ratio = 1.52, 95% CI 1.36-1.71). The risk seemed independent of traditional risk factors and depression. The evaluation of Hill's criteria largely argued in favour of causality.

CONCLUSIONS

Anxiety may be of interest for CVD prevention. Future research should examine biological and behavioural underpinnings of the association in order to identify targets for intervention.

Depression and postoperative complications: an overview

BACKGROUND

The interaction of depression and anesthesia and surgery may result in significant increases in morbidity and mortality of patients. Major depressive disorder is a frequent complication of surgery, which may lead to further morbidity and mortality.

LITERATURE SEARCH

Several electronic data bases, including PubMed, were searched pairing "depression" with surgery, postoperative complications, postoperative cognitive impairment, cognition disorder, intensive care unit, mild cognitive impairment and Alzheimer's disease.

REVIEW OF THE LITERATURE

The suppression of the immune system in depressive disorders may expose the patients to increased rates of postoperative infections and increased mortality from cancer. Depression is commonly associated with cognitive impairment, which may be exacerbated postoperatively. There is evidence that acute postoperative pain causes depression and depression lowers the threshold for pain. Depression is also a strong predictor and correlate of chronic post-surgical pain. Many studies have identified depression as an independent risk factor for development of postoperative delirium, which may be a cause for a long and incomplete recovery after surgery. Depression is also frequent in intensive care unit patients and is associated with a lower health-related quality of life and increased mortality. Depression and anxiety have been widely reported soon after coronary artery bypass surgery and remain evident one year after surgery. They may increase the likelihood for new coronary artery events, further hospitalizations and increased mortality. Morbidly obese patients who undergo bariatric surgery have an increased risk of depression. Postoperative depression may also be associated with less weight loss at one year and longer. The extent of preoperative depression in patients scheduled for lumbar discectomy is a predictor of functional outcome and patient's dissatisfaction, especially after revision surgery. General postoperative mortality is increased.

CONCLUSIONS

Depression is a frequent cause of morbidity in surgery patients suffering from a wide range of conditions. Depression may be identified through the use of Patient Health Questionnaire-9 or similar instruments. Counseling interventions may be useful in ameliorating depression, but should be subject to clinical trials.

Diagnostic accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for detecting major depression in pregnant and postnatal women: protocol for a systematic review and individual patient data meta-analyses

INTRODUCTION

Studies of the diagnostic accuracy of depression screening tools often used data-driven methods to select optimal cut-offs. Typically, these studies report results from a small range of cut-off points around whatever cut-off score is identified as most accurate. When published data are combined in meta-analyses, estimates of accuracy for different cut-off points may be based on data from different studies, rather than data from all studies for each cut-off point. Thus, traditional meta-analyses may exaggerate accuracy estimates. Individual patient data (IPD) meta-analyses synthesise data from all studies for each cut-off score to obtain accuracy estimates. The 10-item Edinburgh Postnatal Depression Scale (EPDS) is commonly recommended for depression screening in the perinatal period. The primary objective of this IPD meta-analysis is to determine the diagnostic accuracy of the EPDS to detect major depression among women during pregnancy and in the postpartum period across all potentially relevant cut-off scores, accounting for patient factors that may influence accuracy (age, pregnancy vs postpartum).

METHODS AND ANALYSIS

Data sources will include Medline, Medline In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science. Studies that include a diagnosis of major depression based on a validated structured or semistructured clinical interview administered within 2 weeks of (before or after) the administration of the EPDS will be included. Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects meta-analysis will be conducted for the full range of plausible cut-off values. Analyses will evaluate data from pregnancy and the postpartum period separately, as well as combining data from all women in a single model.

ETHICS AND DISSEMINATION

This study does not require ethics approval. Dissemination will include journal articles and presentations to policymakers, healthcare providers and researchers.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2015:CRD42015024785.

Psychosocial interventions for patients with coronary heart disease and depression: A systematic review and meta-analysis

INTRODUCTION

Depression is common in patients with coronary heart disease, and together these conditions significantly affect health outcomes. Impaired social support is also considered an important predictor of coronary heart disease prognosis and, as there is a complex interplay between social isolation and depression, interventions to address both may be required. This review aimed to assess the effectiveness of psychosocial interventions addressing both depression and social support for people with coronary heart disease and depression.

METHODS

PRISMA guidelines were used to search major health databases to identify randomised controlled trials that evaluated psychosocial interventions compared with usual care in patients with coronary heart disease and depression; the primary outcome was depressive symptoms and secondary outcomes were mortality (all-cause and cardiac), myocardial infarction, revascularisation, anxiety, social support and quality of life. Data, when suitable, were pooled using a random-effects meta-analysis model.

RESULTS

Five studies (n=1358 participants) were eligible and included. The psychosocial intervention group had significantly lower levels of depressive symptoms (standardised mean difference (SMD) -0.15, 95% confidence interval (CI) -0.27 to -0.03; P=0.02) and higher levels of social support (SMD 0.17; 95% CI 0.04 to 0.30; P=0.01) but no differences were found for mortality (all-cause and cardiac), myocardial infarction, revascularisation, anxiety or quality of life.

CONCLUSIONS

Psychosocial interventions for patients with coronary heart disease and depression result in modest reductions in depressive symptoms and improvements in social support. However, caution is warranted in view of the small number of studies included in the review and potential heterogeneity in outcomes and in differences in treatment.

Discrepancies between physician's perception of depression in HIV patients and self-reported CES-D-20 assessment: the DHIVA study

Depression in HIV/AIDS patients affects adherence and disease progression and often goes unnoticed. DHIVA is a cross-sectional epidemiologic survey, investigating the prevalence of depression in people living with HIV through use of a validated self-administered scale (CES-D-20), as well and the degree of concordance between the physician's perception and patients' reports. A total of 690 HIV-infected patients attending 24 centers across Italy were enrolled. Concordance was calculated by K statistics. Association between depression and subject characteristics were evaluated through univariate and multivariate logistic models (OR and 95%CI). The prevalence of depressive symptoms was 48.8% from patient's questionnaires and 49.5% from physicians' reports, with a low/fair concordance (K = .38, p < .001). CES-D-20 found severe depression in 22.5% of the patients vs 4% identified by physicians. 135/155 (87%) of the severely depressed patients (according to CES-D-20) were considered as non or mildly/moderately depressed by physicians. Risk of severe depression was associated with unemployment (p < .001), previous depression (p < .001), treatment failure (p = .001), and former smoking status (p = .018). Depression is frequent in HIV-infected patients in the HAART era, with significant discrepancy between physician perception and the self-reported CES-D-20 results. Screening should be mandatory in all HIV patients.

Prevention of depression in patients with acute coronary syndrome (DECARD) randomized trial: effects on and by self-reported health

AIM

Escitalopram may prevent depression following acute coronary syndrome. We sought to estimate the effects of escitalopram on self-reported health and to identify subgroups with higher efficacy.

METHODS

This is a secondary analysis of a 12-month double-blind clinical trial randomizing non-depressed acute coronary syndrome patients to escitalopram (n = 120) or matching placebo (n = 120). The main outcomes were mean scores on Short Form 36 Health Survey (SF-36) domains, and diagnosis of depression was adjusted for baseline SF-36 scores.

RESULTS

Escitalopram did not yield different SF-36 trajectories on any scale compared with placebo (P > 0.28). Efficacy of escitalopram may have been better among those scoring at least the normative score on general health perceptions (hazard ratio (HR) for depression 0.17 (95% confidence interval 0.02-1.42) ) or social functioning (HR = 0.12 (0.02-0.99) ) than in the full sample of patients (HR = 0.20 (0.04-0.90) ), although not statistically significant.

CONCLUSIONS

The SF-36 may be too broad an outcome measure in trials or treatments that seek to prevent depression following acute coronary syndrome. The SF-36 may, however, indicate who is more likely to benefit from treatment.

The effects of anti-depressants on depression symptom scores at 12 months follow-up in patients with cardiometabolic disease: Results from a large primary care cohort

Background:

Evidence on the long-term usefulness of anti-depressants in managing depression in cardiometabolic disease is limited.

Aim:

We examined the effects of anti-depressant prescribing on depressive symptoms at 12 months follow-up in patients with cardiometabolic disease and a positive depression screening result at baseline.

Design and Setting:

We retrospectively reviewed routine UK primary care data for patients with coronary heart disease, diabetes and previous stroke for the year 2008–2009. 35,537 patients with one of the three above diseases underwent depression screening using the Hospital Anxiety and Depression Scale (HADS-D). Of 7080 patients with a positive screening result (HADS-D ≥ 8), 3933 (55.5%) patients had a repeat HADS-D recorded at 12 months follow-up.

Methods:

We compared the change in HADS-D at follow-up and remission rate in those who were prescribed anti-depressants (n = 223) against those who were not (n = 3710).

Results:

The mean change in HADS-D from baseline, for the nonprescribed group was similar to the reduction observed in patients who were continuously prescribed (n = 93) with anti-depressants during follow-up. Patients who were prescribed intermittently (n = 72) or only one (n = 58) prescription during follow-up had a lower reduction in HADS-D compared to the nonprescribed group. There was no difference in remission rates between continuously prescribed and the nonprescribed group, but remission was lower in patients prescribed intermittently and single prescription.

Conclusion:

Improvement in depressive symptoms in patients with cardiometabolic disease at 12 months was not any better in patients prescribed with anti-depressants compared to the nonprescribed group. The role of anti-depressants in the management of depression in cardiometabolic disease merits further investigation.

The Patient Centered Assessment Method (PCAM): integrating the social dimensions of health into primary care

BACKGROUND

Social dimensions of health are known to contribute to what is often termed "patient complexity," which is particularly common among patients with multimorbidity. Health-care professionals require tools to help them identify and manage these aspects of patient needs.

OBJECTIVES

To examine: (i) the Patient Centered Assessment Method (PCAM), a tool for assessing patient complexity in ways that are sensitive to the biopsychosocial dimensions of health, in primary care settings in Scotland; (ii) the impact of the PCAM on referral patterns and its perceived value; and (iii) the PCAM's perceived applicability for use in a complex patient population.

DESIGN

Two studies are described: (i) a mixed-methods prospective cohort study of the implementation of the PCAM in primary care clinics; and (ii) a qualitative exploratory study that evaluated the value of the PCAM in a complex patient population.

RESULTS

Use of the PCAM did not impact patient satisfaction or perception of practitioners' empathy, but it did increase both the number of onward referrals per referred patient (9-12%) and the proportion of referrals to non-medical services addressing psychological, social, and lifestyle needs. Nurses valued the PCAM, particularly its ability to help them address psychological and social domains of patients' lives, and found it to be highly relevant for use in populations with known high complexity.

CONCLUSIONS

The PCAM represents a feasible approach for assessing patient needs with consideration to the social dimensions of health, and allows practitioners to refer patients to a broader range of services to address patient complexity.

Psychological resources are associated with reduced incidence of coronary heart disease. An 8-year follow-up of a community-based Swedish sample

BACKGROUND

A large number of studies have provided clear evidence for a link between the risk of coronary heart disease and psychological risk factors. Much less attention has been given to the potential protective effect of psychological resources.

PURPOSE

The major aim of this study was to investigate the independent association between psychological resources and incidence of coronary heart disease (CHD) in an 8-year follow-up study of a Swedish community-based cohort.

METHODS

The cohort consisted of 484 men and 497 women, aged 45-69 years at baseline. The incidence of first-time major event of CHD was analysed in relation to baseline levels of psychological resources, including mastery, self-esteem, and sense of coherence as well as psychological risk factors including cynicism and hostile affect, vital exhaustion, hopelessness, and depressive symptoms. In Cox proportional hazard models, adjustments were made for age, sex, eight traditional cardiovascular risk factors, and depressive symptoms.

RESULTS

A total of 56 CHD events had occurred after the 8-year follow-up. After adjustment for age, sex, and eight traditional risk factors, a significantly decreased risk of CHD was found for mastery (HR 0.62 per SD, p = 0.003), self-esteem (HR 0.64, p = 0.004), and sense of coherence (HR 0.70, p = 0.031). An increased risk of CHD was found for vital exhaustion (HR 1.46, p = 0.014), hopelessness (HR 1.59, p = 0.003), and depressive symptoms (HR 1.45, p = 0.009). After further adjustment for depressive symptoms, significant associations remained for mastery (HR 0.67, p = 0.034), self-esteem (HR 0.69, p = 0.048), and hopelessness (HR 1.48, p = 0.023).

CONCLUSIONS

The psychological resources, mastery and self-esteem, showed robust protective effects on CHD, also after adjustment for established risk factors as well as depressive symptoms. In parallel, hopelessness was an independent risk factor for CHD. The results may have implications for novel approaches in preventive efforts.

A patient-centered perspective of treating depressive symptoms in chronic heart failure: What do patients prefer?

OBJECTIVE

To date, very little is known about the specific needs of patients with chronic heart failure (CHF) who must cope with depression. We therefore questioned CHF patients reporting depressive symptoms about their concerns and preferences regarding various psychosocial treatment options. After three-month, we determined how many patients had actually participated in a treatment.

METHODS

85 patients with CHF fulfilling the criteria of a depressive disorder according to the PHQ-9 were investigated. Data were analyzed using descriptive and frequency, as well as logistic regression analyses.

RESULTS

64.7% of the sample reported that they could envision adhering to supportive talks at longer intervals, whereas only 34.1% would accept an antidepressant. After three months, 24.7% of the patients had actually participated in a treatment. Generalized anxiety severity (GAD-7) was very closely associated with treatment preferences and treatment utilization: The higher the generalized anxiety severity, the more likely was the patients' disposition to begin an antidepressant and/or psychotherapy.

CONCLUSIONS

The most favoured treatment option was a low-threshold service with supportive talks.

PRACTICE IMPLICATIONS

Future studies investigating the improvement of patient-centred care in CHF patients should include measurements of generalized anxiety.

Comparative efficacy and safety of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors in older adults: a network meta-analysis

OBJECTIVES

To establish the comparative efficacy and safety of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors in older adults using the network meta-analysis approach.

DESIGN

Systematic review and network meta-analysis.

PARTICIPANTS

Individuals aged 60 and older.

MEASUREMENTS

Data on partial response (defined as at least 50% reduction in depression score from baseline) and safety (dizziness, vertigo, syncope, falls, loss of consciousness) were extracted. A Bayesian network meta-analysis was performed on the efficacy and safety outcomes, and relative risks (RRs) with 95% credible intervals (CrIs) were produced.

RESULTS

Fifteen randomized controlled trials were eligible for inclusion in the analysis. Citalopram, escitalopram, paroxetine, duloxetine, venlafaxine, fluoxetine, and sertraline were represented. Reporting on partial response and dizziness was sufficient to conduct a network meta-analysis. Reporting on other outcomes was sparse. For partial response, sertraline (RR=1.28), paroxetine (RR=1.48), and duloxetine (RR=1.62) were significantly better than placebo. The remaining interventions yielded RRs lower than 1.20. For dizziness, duloxetine (RR=3.18) and venlafaxine (RR=2.94) were statistically significantly worse than placebo. Compared with placebo, sertraline had the lowest RR for dizziness (1.14) and fluoxetine the second lowest (1.31). Citalopram, escitalopram, and paroxetine all had RRs between 1.4 and 1.7.

CONCLUSION

There was clear evidence of the effectiveness of sertraline, paroxetine, and duloxetine. There also appears to be a hierarchy of safety associated with the different antidepressants, although there appears to be a dearth of reporting of safety outcomes.

The role of neutrophil gelatinase associated lipocalin (NGAL) as biological constituent linking depression and cardiovascular disease

Depression is more common in patients with cardiovascular disease than in the general population. Conversely, depression is a risk factor for developing cardiovascular disease. Comorbidity of these two pathologies worsens prognosis. Several mechanisms have been indicated in the link between cardiovascular disease and depression, including inflammation. Systemic inflammation can have long-lasting effects on the central nervous system, which could be associated with depression. NGAL is an inflammatory marker and elevated plasma levels are associated with both cardiovascular disease and depression. While patients with depression show elevated NGAL levels, in patients with comorbid heart failure, NGAL levels are significantly higher and associated with depression scores. Systemic inflammation evokes NGAL expression in the brain. This is considered a proinflammatory effect as it is involved in microglia activation and reactive astrocytosis. Animal studies support a direct link between NGAL and depression/anxiety associated behavior. In this review we focus on the role of NGAL in linking depression and cardiovascular disease.

Effects of depression screening on psychiatric outcomes in patients with acute coronary syndrome: Findings from the K-DEPACS and EsDEPACS studies

BACKGROUND

It has been controversial whether routine screening for depression should be recommended in all patients with acute coronary syndrome (ACS) due to lack of evidence for psychiatric as well as for cardiac outcomes. This study aimed to evaluate the result of screening for treatment and subsequent treatment of depression on one-year psychiatric outcomes in ACS.

METHODS

At baseline 1152 patients with recently developed ACS were screened with the Beck Depression Inventory (BDI) and depressive disorder diagnoses were applied according to DSM-IV criteria. Of the 446 patients with depressive disorder, 300 were randomized to a 24-week double-blind trial of escitalopram or placebo, while the remaining 146 received conventional medical treatment only (MTO) without randomization. Of all baseline participants, 828 were followed up one year later. Psychiatric outcomes included BDI, Hamilton Depression Rating Scale (HAMD), Montgomery Asberg Depression Rating Scale (MADRS), Social and Occupational Functioning Assessment Scale (SOFAS) and the World Health Organization Disability Assessment Schedule-12 (WHODAS-12).

RESULTS

BDI screen-positive ACS patients showed worse one-year outcomes on MADRS, SOFAS, and WHODAS scores (p-values<0.01) compared to BDI screen-negative patients. Escitalopram treatment was associated with beneficial effects compared to placebo and MTO on one-year outcomes on HAMD, MADRS and SOFAS (p-values<0.01). Of patients screening positive on the BDI, those with depressive disorder treated with escitalopram had similar outcomes to those without depressive disorder.

CONCLUSIONS

Routine screening of depressive symptom in ACS patients is helpful to plan further management. Moreover, successive accurate diagnosis of depressive disorder with appropriated treatment is effective at least for psychiatric outcomes.

Treatment of depression and anxiety with internet-based cognitive behavior therapy in patients with a recent myocardial infarction (U-CARE Heart): study protocol for a randomized controlled trial

Background

Major depression and depressive symptoms are common in patients with a recent myocardial infarction (MI), and depression is associated with adverse cardiovascular outcomes. Anxiety post-MI is less studied, but occurs commonly in patients with heart disease, and is also considered a risk factor for recurrence of cardiac events. Cognitive behavior therapy (CBT) is an established therapy for depression and anxiety disorders. To the best of our knowledge, there have not been any studies to determine if internet-based CBT (iCBT) can reduce the symptoms of depression and anxiety in patients with a recent MI. The main aim of the U-CARE Heart trial is to evaluate an iCBT intervention for patients with a recent MI.

Methods/design

This is a randomized, controlled, prospective study with a multicenter design. A total of 500 participants will be randomized at a 1:1 ratio, around two months after an acute MI, to either iCBT or to a control group. Both groups will receive an optimal standard of care according to guidelines. The intervention consists of a self-help program delivered via the internet with individual online support from a psychologist. Treatment duration is 14 weeks. The primary outcome is change in patients’ self-rated anxiety and depression symptoms from baseline to end of treatment. An internal pilot study was conducted indicating sufficient levels of study acceptability and engagement in treatment.

Discussion

The present study is designed to evaluate an iCBT intervention targeting symptoms of depression and anxiety in a post-MI population. If effective, iCBT has several advantages, and will potentially be implemented as an easily accessible treatment option added to modern standard of care.

Trial registration

This trial was registered with Clinicaltrials.gov (identifier: NCT01504191) on 19 December 2011.

High sensitivity C reactive protein, fibrinogen levels and the onset of major depressive disorder in post-acute coronary syndrome

Background

Major depression disorder (MDD) is a common condition in patients suffering from acute coronary syndrome (ACS), and depression is a risk factor for mortality following an ACS. Growing evidence suggests that there is an intricate interplay between atherosclerosis, inflammation and depression. The aim of this study was to investigate the role of atherosclerosis-induced inflammation in the mediation of MDD.

Methods

87 patients without depression were recruited at the time of an ACS, evaluated at 3 and 7 days and followed at 1, 3 and 9 months for the occurrence of a MDD as assessed by structured interviews (MINI). At each time point, they were monitored for inflammatory markers (high sensitivity C Reactive Protein {hsCRP} and fibrinogen), cardiovascular risk factors and atherosclerosis burden. Association between possible predictive characteristics and depression was assessed using a multivariable logistic regression model.

Results

The overall incidence of MDD, in this population, was 28.7% [95% CI: 19.5 – 39.4] during the 9-month follow up period. Elevated hsCRP was not associated with depression onset after an ACS (adjusted OR: 1.07 [0.77 - 1.48]; p = 0.70), and similarly no association was found with fibrinogen. Furthermore, we found no association between hsCRP, fibrinogen or atherosclerosis burden at any time-point, and the occurrence of a MDD (or HDRS-17 and MADRS). The only factor associated with depression occurrence after an ACS was a previous personal history of depression (adjusted OR: 11.02 [2.74 to 44.34]; p = 0.0007).

Conclusions

The present study shows that after an ACS, patients treated with optimal medications could have a MDD independent of elevated hsCRP or fibrinogen levels. Personal history of depression may be a good marker to select patients who should be screened for depression after an ACS.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-015-0015-3) contains supplementary material, which is available to authorized users.

Performance of screening tools in detecting major depressive disorder among patients with coronary heart disease: a systematic review

BACKGROUND

Eligible studies published before 31 Dec 2013 were identified from the following databases: Ovid Medline, EMBASE, PsycINFO, Scopus, Cochrane Library, CINAHL Plus, and Web of Science.

MATERIAL AND METHODS

Eligible studies published before 31, Dec 2013 were identified from the following databases: Ovid Medline, EMBASE, psycINFO, Scopus, Cochrane Library, CINAHL Plus, and Web of Science.

RESULTS

Eight studies aiming to identify MDD in CHD patients were included, and there were 10 self-reporting questionnaires (such as PHQ-2, PHQ-9, PHQ categorical algorithm, HADS-D, BDI, BDI-II, BDI-II-cog, CES-D, SCL-90, 2 simple yes/no items) and 1 observer rating scale (Ham-D). For MDD alone, the sensitivity and specificity of various screening tools at the validity and optimal cut-off point varied from 0.34 [0.19, 0.52] to 0.96 [0.78, 1.00] and 0.69 [0.65, 0.73] to 0.97 [0.93, 0.99]. Results showed PHQ-9 (≥10), BDI-II (³14 or ≥16), and HADS-D (≥5 or ≥4) were widely used for screening MDD in CHD patients.

CONCLUSIONS

There is no consensus on the optimal screening tool for MDD in CHD patients. When evaluating the performance of a screening tool, balancing the high sensitivity and negative predictive value (NPV) between specificity and positive predictive value (PPV) for screening or diagnostic purpose should be considered. After screening, further diagnosis, appropriate management, and necessary referral may also improve cardiovascular outcomes.

Using a single screening question for depressive symptoms in patients with acute coronary syndrome

BACKGROUND

Despite the prevalence of depressive symptoms and increased risk for future cardiovascular events, depressive symptoms frequently go underrecognized in patients hospitalized for acute coronary syndrome (ACS). Identifying an effective approach to depressive symptom screening is imperative in this population.

OBJECTIVE

The purpose of this cross-sectional study was to explore the agreement between Beck Depression Inventory-II (BDI-II) scores and a single screening question for depressive symptoms in 1122 patients hospitalized for ACS.

METHODS

Independent-samples t tests and χ tests were used to compare the groups with BDI-II scores of 14 or higher and lower than 14. Three separate agreement analyses were conducted using categorized BDI-II scores (≥14, ≥20, and ≥29). Agreement of the BDI-II categories with the responses to the single screening question was assessed with the simple κ statistic. Sensitivity and specificity were calculated using the BDI-II categories as the criterion standards for depressive symptom screening.

RESULTS

The agreement analysis revealed a moderate level of agreement (κ coefficient = 0.42) between the BDI-II scores of 14 or higher and the single screening question. Of the participants who reported a BDI-II score of 14 or higher, 61.65% answered yes to the single screening question (sensitivity, 0.62). For those who had BDI-II scores of lower than 14, a total of 82% responded no to the single screening question (specificity, 0.82). When using higher BDI-II scores to define depressive symptoms (≥20 and ≥29), the level of agreement decreased, whereas sensitivity increased to 0.76 and 0.90, with a trade-off in specificity (0.79 and 0.74, respectively).

CONCLUSIONS

These results suggest that the single screening question for depressive symptoms correctly identifies depressive symptoms 62% of the time but inappropriately identifies depressive symptoms 18% of the time in patients hospitalized for ACS. This suggests that the single screening question for depressive symptoms may be used with caution to initially screen patients with ACS, who can then undergo a more thorough assessment for clinical depression.

The association between sleep disturbance, depressive symptoms, and health-related quality of life among cardiac rehabilitation participants

PURPOSE

Recent guidelines from the Canadian Association of Cardiac Rehabilitation highlight the importance of addressing sleep disturbance among participants of cardiac rehabilitation (CR) programs. The primary objective of this study was to examine the relationship between depressive symptoms, health-related quality of life, and sleep disturbance in CR participants. The secondary objective was to estimate the prevalence of sleep disturbance among CR participants with and without depressive symptoms and explore demographic, medical, and psychological predictors of poor sleep quality.

METHODS

Cardiac rehabilitation participants (N = 259) were included in this study. Participants completed a standardized questionnaire package including demographic, health-related, and psychosocial measures. Physiologic and anthropometric measurements were taken at baseline. Descriptive statistics were calculated for all variables, and data were analyzed using multivariate logistic regression.

RESULTS

Poor sleep quality was reported by 52% of participants in the sample, and 47% of participants in the sample reported experiencing at least mild depressive symptoms. Poor sleep occurred more often in individuals with depressive symptoms, and after adjustment for medical factors and health-related quality of life, participants with symptoms of depression were still more likely to experience sleep disturbance than those without depressive symptoms (OR = 2.80; 95% CI, 1.37-5.77). An important gender difference emerged in the relationship between symptoms of depression and sleep disturbance.

CONCLUSION

Among participants of a CR program, disturbed sleep was strongly associated with depressive symptoms and decreased health-related quality of life. Results demonstrate the importance of sleep evaluation in CR programs.

Incident depression increases medical utilization in Medicaid patients with hypertension

Hypertension is an important risk factor for cardiovascular disease and occurs disproportionately among patients with depression. Few studies have rigorously examined outcomes specifically among hypertensive patients with newly diagnosed comorbid depression.

AIM

We hypothesized that incident depression would exacerbate hypertensive disease and that this would be evident through greater utilization of medical services than would otherwise occur in the absence of depression.

METHODS

Claims data for hypertensive patients enrolled in Maryland Medicaid (2005-2010) were used to estimate the change in annualized utilization following incident depression, compared to a matched cohort of hypertensive patients never diagnosed with depression. Multivariate regression was used to adjust for changes in antihypertensive medications, adherence and comorbidity that followed depression onset.

RESULTS

While medical utilization increased after incident depression, additional encounters tended to be for nonacute medical care and there was no significant increase in encounters specifically for cardiovascular or hypertension-related conditions.

DISCUSSION

The results contribute to the discussion on the relationship between depression and cardiovascular disease and will inform future studies that aim to look at longer term outcomes in patients with hypertension.

Sequential multiple assignment randomized trial (SMART) with adaptive randomization for quality improvement in depression treatment program

Implementation study is an important tool for deploying state-of-the-art treatments from clinical efficacy studies into a treatment program, with the dual goals of learning about effectiveness of the treatments and improving the quality of care for patients enrolled into the program. In this article, we deal with the design of a treatment program of dynamic treatment regimens (DTRs) for patients with depression post-acute coronary syndrome. We introduce a novel adaptive randomization scheme for a sequential multiple assignment randomized trial of DTRs. Our approach adapts the randomization probabilities to favor treatment sequences having comparatively superior Q-functions used in Q-learning. The proposed approach addresses three main concerns of an implementation study: it allows incorporation of historical data or opinions, it includes randomization for learning purposes, and it aims to improve care via adaptation throughout the program. We demonstrate how to apply our method to design a depression treatment program using data from a previous study. By simulation, we illustrate that the inputs from historical data are important for the program performance measured by the expected outcomes of the enrollees, but also show that the adaptive randomization scheme is able to compensate poorly specified historical inputs by improving patient outcomes within a reasonable horizon. The simulation results also confirm that the proposed design allows efficient learning of the treatments by alleviating the curse of dimensionality.

Collaborative care for the treatment of comorbid depression and coronary heart disease: a systematic review and meta-analysis protocol

BACKGROUND

Depression and coronary heart disease (CHD) are frequently comorbid and portend higher morbidity, mortality and poorer quality of life. Prior systematic reviews of depression treatment randomized controlled trials (RCTs) in the population with CHD have not assessed the efficacy of collaborative care. This systematic review aims to bring together the contemporary research on the effectiveness of collaborative care interventions for depression in comorbid CHD populations.

METHODS/DESIGN

Electronic databases (Cochrane Central Register of Controlled Trials MEDLINE, EMBASE, PsycINFO and CINAHL) will be searched using a sensitive search strategy exploding the topics CHD, depression and RCT. Full text inspection and bibliography searching will be conducted, and authors of included studies will be contacted to identify unpublished studies. Eligibility criteria are: population, depression comorbid with CHD; intervention, RCT of collaborative care defined as a coordinated model of care involving multidisciplinary health care providers, including: (a) primary physician and at least one other health professional (e.g. nurse, psychiatrist, psychologist), (b) a structured patient management plan that delivers either pharmacological or non-pharmacological intervention, (c) scheduled patient follow-up and (d) enhanced inter-professional communication between the multiprofessional team; comparison, either usual care, enhanced usual care, wait-list control group or no further treatment; and outcome, major adverse cardiac events (MACE), standardized measure of depression, anxiety, quality of life, cost-effectiveness. Screening, data extraction and risk of bias assessment will be undertaken by two reviewers with disagreements resolved through discussion. Meta-analytic methods will be used to synthesize the data collected relating to the outcomes.

DISCUSSION

This review will evaluate the effectiveness and cost-effectiveness of collaborative care for depression in populations primarily with CHD. The results will facilitate integration of evidence-based practice for this precarious population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014013653.

The diagnostic accuracy of the Patient Health Questionnaire-2 (PHQ-2), Patient Health Questionnaire-8 (PHQ-8), and Patient Health Questionnaire-9 (PHQ-9) for detecting major depression: protocol for a systematic review and individual patient data meta-analyses

BACKGROUND

Major depressive disorder (MDD) may be present in 10%-20% of patients in medical settings. Routine depression screening is sometimes recommended to improve depression management. However, studies of the diagnostic accuracy of depression screening tools have typically used data-driven, exploratory methods to select optimal cutoffs. Often, these studies report results from a small range of cutoff points around whatever cutoff score is most accurate in that given study. When published data are combined in meta-analyses, estimates of accuracy for different cutoff points may be based on data from different studies, rather than data from all studies for each possible cutoff point. As a result, traditional meta-analyses may generate exaggerated estimates of accuracy. Individual patient data (IPD) meta-analyses can address this problem by synthesizing data from all studies for each cutoff score to obtain diagnostic accuracy estimates. The nine-item Patient Health Questionnaire-9 (PHQ-9) and the shorter PHQ-2 and PHQ-8 are commonly recommended for depression screening. Thus, the primary objectives of our IPD meta-analyses are to determine the diagnostic accuracy of the PHQ-9, PHQ-8, and PHQ-2 to detect MDD among adults across all potentially relevant cutoff scores. Secondary analyses involve assessing accuracy accounting for patient factors that may influence accuracy (age, sex, medical comorbidity).

METHODS/DESIGN

Data sources will include MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science. We will include studies that included a Diagnostic and Statistical Manual or International Classification of Diseases diagnosis of MDD based on a validated structured or semi-structured clinical interview administered within 2 weeks of the administration of the PHQ. Two reviewers will independently screen titles and abstracts, perform full article review, and extract study data. Disagreements will be resolved by consensus. Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects meta-analysis will be conducted for the full range of plausible cutoff values.

DISCUSSION

The proposed IPD meta-analyses will allow us to obtain estimates of the diagnostic accuracy of the PHQ-9, PHQ-8, and PHQ-2.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014010673.

Reliability and validity of depression assessment among persons with HIV in sub-Saharan Africa: systematic review and meta-analysis

OBJECTIVE

The aim of this study was to systematically review the reliability and validity of instruments used to screen for major depressive disorder or assess depression symptom severity among persons with HIV in sub-Saharan Africa.

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic evidence search protocol was applied to 7 bibliographic databases. Studies examining the reliability and/or validity of depression assessment tools were selected for inclusion if they were based on the data collected from HIV-positive adults in any African member state of the United Nations. A random-effects meta-analysis was used to calculate pooled estimates of depression prevalence. In a subgroup of studies of criterion-related validity, the bivariate random-effects model was used to calculate pooled estimates of sensitivity and specificity.

RESULTS

Of 1117 records initially identified, I included 13 studies of 5373 persons with HIV in 7 sub-Saharan African countries. Reported estimates of Cronbach alpha ranged from 0.63 to 0.95, and analyses of internal structure generally confirmed the existence of a depression-like construct accounting for a substantial portion of variance. The pooled prevalence of probable depression was 29.5% [95% confidence interval (CI): 20.5 to 39.4], whereas the pooled prevalence of major depressive disorder was 13.9% (95% CI: 9.7 to 18.6). The Center for Epidemiologic Studies Depression scale was the most frequently studied instrument, with a pooled sensitivity of 0.82 (95% CI: 0.73 to 0.87) for detecting major depressive disorder.

CONCLUSIONS

Depression-screening instruments yielded relatively high false positive rates. Overall, few studies described the reliability and/or validity of depression instruments in sub-Saharan Africa.

The presence of a depressive episode predicts lower return to work rate after myocardial infarction

CONTEXT

No studies have evaluated whether the presence of a depressive episode is associated with an increased risk of not returning to work following myocardial infarction (MI).

OBJECTIVES

To examine the prospective associations between depressive episode and anxiety disorders with return to work (RTW) after MI at 3 and 12 months based on International Classification of Diseases, 10th Revision.

DESIGN

Prospective cohort study.

SETTING

Four hospitals in the North of The Netherlands.

PARTICIPANTS

From a sample of patients hospitalized for MI (n=487), we selected those who had a paid job at the time of the MI (N=200).

MAIN EXPOSURE MEASURES

Presence of a depressive episode and presence of any anxiety disorder during the first 3 months post-MI.

MAIN OUTCOME MEASURES

RTW at 12 months post-MI.

RESULTS

Of the patients with work prior to MI, 75% had returned to work at 12 months. The presence of a depressive episode during the first 3 months (prevalence: 19.4%) was a significant predictor of no RTW at 12 months post-MI, also after controlling for confounders [odds ratio (OR) 3.48; 95% confidence interval (CI): 1.45-8.37]. The presence of an anxiety disorder (prevalence: 11.9%) had a borderline significant association with no RTW as well. This association remained after controlling for confounders (OR 2.90; 95% CI: 1.00-6.38) but diminished when controlling for depression.

CONCLUSIONS

The presence of a depressive episode was associated with an increased risk of no RTW in MI patients. The association between anxiety and risk of no RTW could in part be explained by the presence of depression. Further studies may address the possibility of countering the effect of depression by effective treatment.

Depression and anxiety following myocardial infarction and their inverse associations with future health behaviors and quality of life

BACKGROUND

Post-myocardial infarction (MI) depression and anxiety were found to predict prognosis and quality of life.

PURPOSE

The purpose of this study was to test a behavioral pathway from post-MI depression/anxiety to future quality of life.

METHODS

This is a longitudinal cohort study. Five hundred forty patients (≤65 years old) filled out questionnaires after a first MI, including socio-demographics, pre-MI health status and behaviors, MI severity, social support, sense of coherence, depression, and anxiety. Reports of health behaviors were obtained 5 years and of quality of life 10 years later.

RESULTS

A structural equations model confirmed that depression and anxiety were directly related to poorer quality of life 10 years later. These relationships were partly mediated by a positive association between anxiety and health behaviors at 5 years and a negative one between depression and health behaviors.

CONCLUSIONS

The opposite effects of anxiety and depression underscore the need to attend to both emotional reactions to MI while encouraging preventive health behaviors.

Quality of life impacts on 16-year survival of an older ethnically diverse cohort

OBJECTIVE

The objective of this study is to examine the prediction of mortality, over 16 years, by the domains and domain elements underlying generic measures of quality of life (QoL).

METHODS

The method used was an analysis of mortality in an older (65 + years) representative sample (N = 2130) of a multicultural community in North Manhattan. Five conventional QoL domains were measured by in-home, rater-administered, and computer-assisted questionnaire: depressed mood, pain, self-perceived health, and function and social relationships.

RESULTS

Some domain scales that qualitatively express distress, such as depressed mood and widespread pain, significantly predicted lower mortality (were protective) and felt isolation trended in that direction, whereas domains indicating quantitative limitations such as impairment of functioning in daily tasks, stair climbing, as well as social disengagements and lack of support network significantly predicted higher mortality. Domain elements also mattered; contrary to their domain predictions, increased mortality was predicted by the domain elements of somatic symptoms of depression. Self-perceived poor health reflected the predictive (higher mortality) direction of the limitations cluster.

CONCLUSIONS

The internal complexity of QoL is underscored by differential impacts of domains and elements on mortality. Clinical implications include setting distress domains as important clinical goals, whereas strengthening limiting domains could result in lengthening life and secondarily relieving distress. The relative weighting of these goals could be derived from patient preferences and clinical efficacy. Fundamental implications lie in the interaction between the person's qualitative evaluations of choices and the quantitative building of desired choices for a better QoL.

Depressive symptoms, diet quality, physical activity, and body composition among populations in Nova Scotia, Canada: report from the Atlantic Partnership for Tomorrow's Health

OBJECTIVE

To investigate the association between depressive symptoms and diet quality, physical activity, and body composition among Nova Scotians.

METHODS

4511 men and women aged 35-69 years were recruited to the Atlantic Partnership for Tomorrow's Health study from 2009 through 2010 in Nova Scotia, Canada. Depressive symptoms were assessed by using the Patient Health Questionnaire. Anthropometric indexes and body composition were measured. Current antidepressant use, habitual diet intake, physical activity, and potential confounders were collected through questionnaires.

RESULTS

In multivariable regression analyses, depressive symptoms were positively associated with all obese indexes after controlling for potential confounders (all P for trend<0.001). Compared with non-depressed individuals, those with mild and major depression had significantly increased odds ratios (ORs) for both obesity and abdominal obesity (OR 1.84; 95% confidence interval [CI], (1.50, 2.25) and 1.56 (95% CI, 1.30, 1.87) for obesity and 1.46 (95% CI, 1.20, 1.77) and 1.88 (95% CI, 1.58, 2.24) for abdominal obesity, respectively). Depressed individuals were less likely to have a high quality diet or engage in high levels of physical activity compared with their non-depressed counterparts.

CONCLUSIONS

Depressive symptoms are associated with higher levels of obesity, poor diet, and physical inactivity among Nova Scotians in Canada.

Psychometric properties of the Cardiac Depression Scale: a systematic review

BACKGROUND

The prevalence of depression is high in cardiac patients. Depression has a significant impact on quality of life, adherence to therapy, and an independent effect on prognosis. The Cardiac Depression Scale (CDS) is the only instrument designed to measure depression in cardiac patients. This study systematically reviewed the psychometric properties of the CDS for screening of depression in patients with coronary heart disease (CHD).

METHODS

A search of MEDLINE, EMBASE, CINAHL Plus, PsycINFO, Scopus and Web of Science was performed using the search term Cardiac Depression Scale in the title or abstract. Eligible studies were those that assessed reliability, validity or diagnostic accuracy of the CDS in patients with CHD. Methodological quality was assessed using the QUADAS-2 and STARD.

RESULTS

Most studies assessed the reliability and validity of the CDS: three studies assessed construct validity using factor analysis; six studies assessed the validity of the CDS with other measures of depression; and four studies assessed its diagnostic accuracy. However, some studies reported overlapping samples, which reduces confidence in their evaluation.

CONCLUSION

This review finds the CDS to be a psychometrically sound measurement instrument for identifying mild, moderate and severe depression in cardiac populations.

Beck Depression Inventory II: determination and comparison of its diagnostic accuracy in cardiac outpatients

OBJECTIVES

To evaluate the impact of covariates on performance accuracy of the Beck Depression Inventory II (BDI-II) and to determine the optimal cut-off score for the BDI-II in cardiac outpatients. Differences of optimal cut-off scores were also verified across covariate subgroups.

DESIGN AND SETTING

Prospective cross-sectional study at the Department of Nuclear Medicine of the Montreal Heart Institute (Quebec, Canada).

METHODS

A total of 750 adult cardiac outpatients (mean ± SD age 58 ± 10 years, 31% women) completed the BDI-II and the Primary Care Evaluation of Mental Disorders (PRIME-MD; a psychiatric interview used as the reference standard for determining diagnosis of major depressive disorder). The receiver operating characteristics (ROC) curve of the BDI-II was adjusted for age, sex, level of education, smoking status, obesity, anxiety disorder, psychotropic medication, and history of coronary artery disease. The ROC analyses were conducted to determine optimal cut-off scores.

RESULTS

Forty-two (6%) patients met criteria for current major depressive disorder according to the PRIME-MD. After adjusted for covariates, the area under the ROC curve was significantly smaller than the unadjusted curve (0.76, 95% CI 0.66 to 0.85 vs. 0.84, 95% CI 0.77 to 0.89; ΔAUC = -0.07, 95% CI -0.13 to -0.02). While the optimal cut-off score was 10 for the total sample (sensitivity 83%, specificity 73%), the analyses indicated different cut-off scores across covariate subgroups: e.g. sex (women 13; men 10), and anxiety disorders (yes 15; no 10).

CONCLUSIONS

BDI-II is a good screening instrument for depression in cardiac outpatients. However, the present results suggest that covariates can affect the classification accuracy of the BDI-II's original recommended cut-off score. Scholars and clinicians should be aware of the principle that a screening score established in one population may not be relevant to another.

Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association

BACKGROUND

Although prospective studies, systematic reviews, and meta-analyses have documented an association between depression and increased morbidity and mortality in a variety of cardiac populations, depression has not yet achieved formal recognition as a risk factor for poor prognosis in patients with acute coronary syndrome by the American Heart Association and other health organizations. The purpose of this scientific statement is to review available evidence and recommend whether depression should be elevated to the status of a risk factor for patients with acute coronary syndrome.

METHODS AND RESULTS

Writing group members were approved by the American Heart Association's Scientific Statement and Manuscript Oversight Committees. A systematic literature review on depression and adverse medical outcomes after acute coronary syndrome was conducted that included all-cause mortality, cardiac mortality, and composite outcomes for mortality and nonfatal events. The review assessed the strength, consistency, independence, and generalizability of the published studies. A total of 53 individual studies (32 reported on associations with all-cause mortality, 12 on cardiac mortality, and 22 on composite outcomes) and 4 meta-analyses met inclusion criteria. There was heterogeneity across studies in terms of the demographic composition of study samples, definition and measurement of depression, length of follow-up, and covariates included in the multivariable models. Despite limitations in some individual studies, our review identified generally consistent associations between depression and adverse outcomes.

CONCLUSIONS

Despite the heterogeneity of published studies included in this review, the preponderance of evidence supports the recommendation that the American Heart Association should elevate depression to the status of a risk factor for adverse medical outcomes in patients with acute coronary syndrome.

There are no randomized controlled trials that support the United States Preventive Services Task Force Guideline on screening for depression in primary care: a systematic review

BACKGROUND

The United States Preventive Services Task Force (USPSTF) recommends screening adults for depression in primary care settings when staff-assisted depression management programs are available. This recommendation, however, is based on evidence from depression management programs conducted with patients already identified as depressed, even though screening is intended to identify depressed patients not already recognized or treated. The objective of this systematic review was to evaluate whether there is evidence from randomized controlled trials (RCTs) that depression screening benefits patients in primary care, using an explicit definition of screening.

METHODS

We re-evaluated RCTs included in the 2009 USPSTF evidence review on depression screening, including only trials that compared depression outcomes between screened and non-screened patients and met the following three criteria: determined patient eligibility and randomized prior to screening; excluded patients already diagnosed with a recent episode of depression or already being treated for depression; and provided the same level of depression treatment services to patients identified as depressed in the screening and non-screening trial arms. We also reviewed studies included in a recent Cochrane systematic review, but not the USPSTF review; conducted a focused search to update the USPSTF review; and reviewed trial registries.

RESULTS

Of the nine RCTs included in the USPSTF review, four fulfilled none of three criteria for a test of depression screening, four fulfilled one of three criteria, and one fulfilled two of three criteria. There were two additional RCTs included only in the Cochrane review, and each fulfilled one of three criteria. No eligible RCTs were found via the updated review.

CONCLUSIONS

The USPSTF recommendation to screen adults for depression in primary care settings when staff-assisted depression management programs are available is not supported by evidence from any RCTs that are directly relevant to the recommendation. The USPSTF should re-evaluate this recommendation. Please see related article: http://www.biomedcentral.com/1741-7015/12/14 REGISTRATION: PROSPERO (#CRD42013004276).

Prevalence of psychological distress in elderly hypertension patients in primary care

BACKGROUND

Recent guidelines on cardiovascular disease prevention advocate the importance of psychological risk factors, as they contribute to the risk of developing cardiovascular disease. However, most previous research on psychological distress and cardiovascular factors has focused on selected populations with cardiovascular disease.

AIM

The primary aim was to determine the prevalence of depression, anxiety, and Type D personality in elderly primary care patients with hypertension. Secondary aim was to examine the relation between elevated systolic blood pressure and depression, anxiety, and Type D personality.

DESIGN AND SETTING

A cross-sectional study in primary care practices located in the south of the Netherlands.

METHOD

Primary care hypertension patients (N = 605), between 60 and 85 years (45 % men, mean age = 70 ± 6.6), were recruited for this study. All patients underwent a structured interview including validated self-report questionnaires to assess depression (PHQ-9), anxiety (GAD-7), and Type D personality (DS14) as well as blood pressure assessment.

RESULTS AND CONCLUSION

Depression was prevalent in 5 %, anxiety in 5 %, and Type D personality in 8 %. None of the distress measures were associated with elevated systolic blood pressure of >160 mmHg (all p-values >0.05). This study showed no relation between psychological distress and elevated systolic blood pressure in elderly primary care patients with hypertension.

The real world mental health needs of heart failure patients are not reflected by the depression randomized controlled trial evidence

INTRODUCTION

International depression screening guidelines in heart failure (HF) are partly based on depression treatment efficacy from randomized controlled trials (RCTs). Our aim was to test the external validity of depression RCT criteria in a sample of real-world HF patients.

METHODS

HF patients admitted to 3 hospitals in South Australia were referred to a HF psychologist if not already receiving current psychiatric management by psychologist or psychiatrist elsewhere. Screening and referral protocol consisted of the following; (a). Patient Health Questionnaire ≥ 10; (b). Generalized Anxiety Disorder Questionnaire ≥ 7); (c). positive response to 1 item panic attack screener; (d). evidence of suicidality. Patients were evaluated against the most common RCT exclusion criteria personality disorder, high suicide risk, cognitive impairment, psychosis, alcohol or substance abuse or dependency, bi-polar depression.

RESULTS

Total 81 HF patients were referred from 404 HF admissions, and 73 were assessed (age 60.6 ± 13.4, 47.9% female). Nearly half (47%) met at least 1 RCT exclusion criterion, most commonly personality disorder (28.5%), alcohol/substance abuse (17.8%) and high suicide risk (11.0%). RCT ineligibility criteria was more frequent among patients with major depression (76.5% vs. 46.2%, p<.01) and dysthymia (26.5% vs. 7.7%, p = .03) but not significantly associated with anxiety disorders. RCT ineligible patients reported greater severity of depression (M = 16.6 ± 5.0 vs. M = 12.9 ± 7.2, p = .02) and were higher consumers of HF psychotherapy services (M = 11.5 ± 4.7 vs. M = 8.5 ± 4.8, p = .01).

CONCLUSION

In this real-world sample comparable in size to recent RCT intervention arms, patients with depression disorders presented with complex psychiatric needs including comorbid personality disorders, alcohol/substance use and suicide risk. These findings suggest external validity of depression screening and RCTs could serve as a basis for level A guideline recommendations in cardiovascular diseases.