Sensitivity and specificity of observer and self-report questionnaires in major and minor depression following myocardial infarction

The symptomatology of post-stroke depression: comparison of stroke and myocardial infarction patients

BACKGROUND

Depression is a frequent problem in stroke patients but, all too often, the problem goes unrecognized. How depression-like symptoms in post-stroke depression (PSD) should be interpreted is still subject to debate. If PSD has a distinct symptom profile of depression accompanying other chronic vascular somatic conditions then this could imply that PSD is a specific disease entity.

OBJECTIVE

To study whether depressed stroke patients exhibit other signs and symptoms than patients suffering from depression after myocardial infarction (MI).

METHODS

Depressive signs and symptoms were measured using the Hospital Anxiety and Depression Scale and the 17-item Hamilton Depression Rating Scale. The results of 190 stroke patients were compared with the results of 198 MI patients every 3 months during the first year after the event.

RESULTS

Depressed stroke patients exhibited more loss of interest, psychomotor retardation, and gastro-intestinal complaints as compared to depressed MI patients. However, in multivariate analyses including both depressed and non-depressed stroke and MI patients, no specific symptom profile was found to differentiate between the two depressive syndromes by looking at the modifying effect of stroke vs MI on the occurrence of specific symptoms in depression.

CONCLUSION

Although in their clinical presentation, depressed stroke patients exhibit a symptom profile different from depressed MI patients, this is not due to differences in the depressive syndrome in these two patient groups but it reflects differences between stroke and MI patients in general.

Association between symptoms of depression and anxiety with heart rate variability in patients with implantable cardioverter defibrillators

OBJECTIVE

This study investigated whether depression and anxiety symptoms are associated with measures of autonomic nervous system dysfunction in patients with implantable cardioverter defibrillators who are at high risk of cardiac rhythm disturbances. Depression and anxiety are associated with autonomic nervous system dysfunction, which may promote the risk of malignant cardiac arrhythmias.

METHODS

Patients with an implantable cardioverter defibrillator (ICD) underwent ambulatory electrocardiographic (ECG) monitoring (n = 44, mean age = 62.1 +/- 9.3 years). Depression was assessed using the Beck Depression Inventory and anxiety was evaluated using the Taylor Manifest Anxiety Scale. Heart rate variability was assessed using time (RMSSD, pNN50, and SDNN) and frequency domain measures derived from 24-hour R-R intervals. Multivariate models were adjusted for age, sex, hypertension, diabetes, and smoking status.

RESULTS

Defibrillator patients with elevated depression symptoms (n = 12) had significantly lower RMSSD (15.25 +/- 1.66 ms versus 24.97 +/- 2.44 ms, p = .002) and pNN50 (1.83 +/- 0.77 versus 5.61 +/- 1.04, p = .006) than defibrillator patients with low depression symptoms (n = 32). These associations remained significant after multivariate adjustment for covariates. ICD patients with high anxiety levels (n = 10) displayed lower RMSSD (p = .013), which became marginally significant when adjusting for covariates (p = .069).

CONCLUSIONS

Depression and anxiety in defibrillator patients are associated with autonomic nervous system dysfunction indices of reduced parasympathetic control. Autonomic nervous system dysfunction may partially explain the association between depression and anxiety with life-threatening cardiac outcomes in vulnerable patients.

Risk of ventricular arrhythmia after implantable defibrillator treatment in anxious type D patients

OBJECTIVES

We sought to examine the combination of adverse psychological factors (anxiety, depression, and distressed or Type D personality) as a predictor of ventricular arrhythmias in patients with implantable cardioverter-defibrillators (ICDs).

BACKGROUND

Little is known about the role of psychological factors and their clustering in the occurrence of life-threatening arrhythmias.

METHODS

In this prospective study, 391 patients with an ICD (81% men, age 62.3 +/- 10.4 years) completed anxiety, depression, and Type D personality scales at the time of implantation. The end point was occurrence of ventricular arrhythmia, defined as appropriate ICD therapies, in the first year after implantation.

RESULTS

Ventricular arrhythmias occurred in 19% (n = 75) of patients. Increased symptoms of depression (p = 0.81) or anxiety (p = 0.31) did not predict arrhythmias. However, anxious patients with a Type D personality had a significantly increased rate of ventricular arrhythmias (21 of 71; 29.6%) as compared with other ICD patients (54 of 320; 16.9%; hazard ratio [HR]: 1.89; 95% confidence interval [CI]: 1.14 to 3.13; p = 0.013). When controlled for the effects of sex, age, ischemic etiology, left ventricular dysfunction, prolonged QRS duration, and medication, anxious Type D patients (HR: 1.72; 95% CI: 1.03 to 2.89; p = 0.039) and secondary prevention patients (HR: 1.91; 95% CI: 1.14 to 3.20; p = 0.014) were at increased risk of ventricular arrhythmias.

CONCLUSIONS

Personality modulated the effect of emotional distress; anxiety predicted a 70% increase in risk of arrhythmia in Type D patients but not in other patients. Anxious Type D patients may be identified and offered additional behavioral support after ICD implantation.

Is depression after an acute coronary syndrome simply a marker of known prognostic factors for mortality?

OBJECTIVE

Controversy remains over whether the association between depression and mortality in patients with acute coronary syndrome (ACS) is confounded by incomplete adjustment for measures of known prognostic markers. We assessed a) whether depression was associated with the most comprehensive empirically derived index of clinical mortality predictors: the Global Registry of Acute Coronary Events (GRACE) risk score for predicting 6-month mortality after discharge for ACS; and b) whether depression remained an independent predictor of all-cause mortality after adjustment for the GRACE score and left ventricular dysfunction.

METHODS

We surveyed prospectively 457 patients with ACS (aged 25-92 years; 41% women, 13% black, and 11% Hispanic), hospitalized between May 2003 and June 2005. Depressive symptoms were assessed with the Beck Depression Inventory (BDI) and diagnosis of major depressive disorder (MDD) was made by a structured psychiatric interview, within 1 week of hospitalization.

RESULTS

Despite differences in individual components of the GRACE score between depressed and nondepressed participants, neither depression measure was associated with overall GRACE score. For participants with MDD, the mean +/- standard deviation GRACE score was 84 +/- 33, compared with 92 +/- 31 for those without MDD (p = .09). Using Cox proportional hazards regression analysis, MDD and depressive symptom severity each predicted mortality after controlling for GRACE score and left ventricular dysfunction (adjusted hazard ratio for MDD = 2.51; 95% Confidence Interval = 1.45-4.37).

CONCLUSION

Depression is not simply a marker of clinical indicators that predict all-cause mortality after ACS. This strengthens the assertion that there is something unique in the association between depression and post-ACS prognosis, independent of known prognostic markers.

Health-related quality of life one month after thrombolysis or primary PCI in patients with ST-elevation infarction. A DANAMI-2 sub-study

OBJECTIVES

To evaluate the health-related quality of life (HRQoL) following Primary percutaneous coronary intervention (PCI) or thrombolytic treatment for ST-elevation myocardial infarction (STEMI).

DESIGN

A questionnaire based study on patients randomised in the DANAMI-2 study to Primary PCI or thrombolysis for STEMI. A total of 1 351 patients (93.2% response rate) randomised in the DANAMI-2 study completed the HRQoL questionnaire one month after the infarction.

RESULTS

With respect to the primary end-points (SF-36 physical component score, angina pectoris, and dyspnoea), patients randomised to primary PCI scored better on the SF-36 physical component score (PCS) (p=0.007), and reported significantly less angina pectoris (p=0.010) and dyspnoea (p=0.010). Higher scores among PCI patients were also found on the SF-36 scales physical functioning (p=0.015), role-physical (p=0.017), and general health (p=0.009).

CONCLUSION

The results in this study support the hypothesis that primary PCI is superior to thrombolysis in treating STEMI, not only in clinical outcome, but also in quality of life outcome.

Prediction of biliary excretion in rats and humans using molecular weight and quantitative structure-pharmacokinetic relationships

The aims were (1) to evaluate the molecular weight (MW) dependence of biliary excretion and (2) to develop quantitative structure-pharmacokinetic relationships (QSPKR) to predict biliary clearance (CL(b)) and percentage of administered dose excreted in bile as parent drug (PD(b)) in rats and humans. CL(b) and PD(b) data were collected from the literature for rats and humans. Receiver operating characteristic curve analysis was utilized to determine whether a MW threshold exists for PD(b). Stepwise multiple linear regression (MLR) was used to derive QSPKR models. The predictive performance of the models was evaluated by internal validation using the leave-one-out method and external test groups. A MW threshold of 400 Da was determined for PD(b) for anions in rats, while 475 Da was the cutoff for anions in humans. MW thresholds were not present for cations or cations/neutral compounds in either rats or humans. The QSPKR model for human CL(b) showed a significant correlation (R (2) = 0.819) with good prediction performance (Q (2) = 0.722). The model was further assessed using a test group, yielding a geometric mean fold-error of 2.68. QSPKR models with significant correlation and good predictability were also developed for CL(b) in rats and PD(b) data for anions or cation/neutral compounds in rats and humans. Both CL(b) and PD(b) data were further evaluated for subsets of MRP2 or P-glycoprotein substrates, and significant relationships were derived. QSPKR models were successfully developed for biliary excretion of non-congeneric compounds in rats and humans, providing a quantitative prediction of biliary clearance of compounds.

The Hospital Anxiety and Depression Scale (HAD) as a screening instrument in tinnitus evaluation

The identification of anxiety and depressive disorders in tinnitus patients is important from a therapeutic point of view. We have addressed this question by investigating the screening performance of the Hospital Anxiety and Depression Scale (HAD) in a consecutive series of tinnitus patients (n = 82) without severe socially disabling hearing loss referred to an audiological clinic. The structured clinical interview for DSM-III criteria was used as the gold standard. Receiver operating characteristic (ROC) curves were used to compare the screening abilities of the HAD subscales for anxiety and depression and the total HAD Scale. The ROC analysis showed that the HAD Scale was better at detecting depression than anxiety disorders in tinnitus patients. The optimal cut-off score for the subscales was > or = 5 when we were screening for any anxiety or depressive disorder as well as for major depression. The performance of the HAD depression subscale was superior, especially when we were screening for major depression only (sensitivity 1.00; specificity 0.75). The findings of the study suggest that the HAD Scale is more useful for screening for depression than for anxiety disorders in tinnitus patients

Overlap and distinctiveness of psychological risk factors in patients with ischemic heart disease and chronic heart failure: are we there yet?

OBJECTIVE

Growing evidence supports the importance of psychological factors in the etiology and progression of cardiovascular disease (CVD). However, this research has been criticized due to overlap between psychological constructs. We examined whether psychological questionnaires frequently used in cardiovascular research assess distinct constructs in a mixed group of ischemic heart disease (IHD) and chronic heart failure (CHF) patients.

METHODS

565 patients with CHF (n=118) or IHD (n=447) completed the Type D scale (DS14), Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory (BDI), and State Trait Anxiety Inventory (STAI). Pearson product moment correlations were computed to determine the interrelatedness between psychological constructs. Principal component analyses (PCA) were conducted on both scale scores and items to determine higher-order constructs and distinctiveness of psychological questionnaires.

RESULTS

Two higher-order constructs were identified, namely negative affect and social inhibition. PCA on all 69 items showed that anxiety, depression, negative affectivity, and social inhibition were distinct constructs. The original structure of the DS14 was confirmed, whereas items of the HADS and BDI loaded more diffusely; items of the STAI reflected two different components.

CONCLUSION

The use of multiple questionnaires in cardiac patients is justified, as the higher order construct negative affect comprised different facets. Social inhibition was also shown to be a distinct construct, indicating that it may timely for cardiovascular research to look at the role of inhibition in addition to negative emotions. Future studies are warranted to determine whether these findings are replicable in other cardiac samples and to specify the unique prognostic value of these psychological facets.

Use of the hospital anxiety and depression scale (HADS) in a cardiac emergency room: chest pain unit

OBJECTIVE

To determine the prevalence of anxiety and depression in patients complaining of chest pain who seek a chest pain unit attendance.

INTRODUCTION

Patients arriving at a Chest Pain Unit may present psychiatric disorders not identified, isolated or co-morbid to the main illness, which may interfere in the patient prognosis.

METHODOLOGY

Patients were assessed by the 'Hospital Anxiety and Depression Scale' as a screening instrument wile following a systematized protocol to rule out the diagnosis of acute coronary syndrome and other potentially fatal diseases. Patients with 8 or more points in the scale were considered 'probable case' of anxiety or depression.

RESULTS

According to the protocol, 59 (45.4%) of 130 patients studied presented Chest Pain of Determined Cause, and 71 (54.6%) presented Chest Pain of Indefinite Cause. In the former group, in which 43 (33.1%) had acute coronary syndrome, 33.9% were probable anxiety cases and 30.5% depression cases. In the second group, formed by patients without acute coronary syndrome or any clinical conditions involving greater morbidity and mortality risk, 53.5% were probable anxiety cases and 25.4% depression.

CONCLUSION

The high anxiety and depression prevalence observed may indicate the need for early and specialized approach to these disorders. When coronary arterial disease is present, this may decrease complications and shorten hospital stay. When psychiatric disorder appears isolated, is possible to reduce unnecessary repeated visits to emergency room and increase patient's quality of life.

Screening for anxiety and depression in community mental health: the beck anxiety and depression inventories

Accurate diagnosis is key to providing quality services in community mental health. This research examined the ability of the Beck Anxiety and Depression Inventories to identify anxiety and depression in community settings. The diagnostic accuracy of these instruments was compared with the Structured Clinical Interview for DSM-IV in a sample of 288 distressed women seeking treatment for their children. Operating characteristic curves indicated the Beck Anxiety and Depression Inventories hold utility as screens for panic and major depressive disorder, respectively. Deploying these instruments as initial screens in a tiered diagnostic system may improve diagnostic accuracy in community settings.

Functional status outcomes in mothers with and without postpartum depression

Our objective was to compare functional status between women with and without postpartum depression (PPD). A two-group cross-sectional design compared functional status between 23 women with and 23 women without PPD. Participants were 6 to 26 weeks postpartum and from obstetric practices in the northeastern United States. Structured clinical interviews were used to establish diagnoses of PPD. Participants were matched on type of delivery, weeks postpartum, and parity. Participants compared current functioning to prepregnancy functioning using the Inventory of Functional Status After Childbirth. The Postpartum Depression Screening Scale was used to measure PPD severity. Hierarchical multiple and logistic regression models were used to analyze data. We found that after controlling for infant gender, number of nighttime infant awakenings, and income, PPD predicted lower personal (P < .001), household (P < .05), and social functioning (P < .001), but no difference in infant care. Women with PPD were 12 times less likely to achieve prepregnancy functional levels. We conclude that interventions are needed to address household, social, and personal functioning in women with PPD. Clinicians may find functional assessment is a useful adjunct and a less threatening way to screen and monitor treatment for PPD.

Sleep quality in women with and without postpartum depression

OBJECTIVE

To compare and measure the effects of sleep quality in women with and without postpartum depression.

DESIGN

A case-control repeated measures matched pairs design.

SETTING

Home and obstetric office.

PARTICIPANTS

Forty-six women who were 6 to 26 weeks postpartum. Two participants were dropped from the final analysis because they were outliers.

METHODS

Participants underwent wrist actigraphy at home for 7 consecutive days to measure sleep quality. The Postpartum Depression Screening Scale measured depression severity. Psychosocial variables were collected during a screening interview. A structured clinical interview was used to diagnose postpartum depression. Correlations, t tests, and hierarchical multiple regressions were run to analyze data.

RESULTS

With the exception of wake episodes, sleep latency (B=1.80, SE=0.73, p<.05), wake after sleep onset (B=6.85, SE=2.85, p<.05), and thus sleep efficiency (B=-6.31, SE=3.13, p<.05) predicted postpartum depression symptom severity.

CONCLUSIONS

Women with postpartum depression experienced poorer sleep quality than women without postpartum depression, and sleep quality worsened with increasing postpartum depression symptom severity. Clinicians need to address measures to improve sleep quality in depressed mothers to decrease symptom severity, and researchers need to develop interventions to facilitate better sleep quality in women with postpartum depression.

Is the MacNew quality of life questionnaire a useful diagnostic and evaluation instrument for cardiac rehabilitation?

Purpose

The MacNew health-related quality of life questionnaire is internationally used as a standard for psychosocial assessment in many cardiac rehabilitation centres. This study investigates its discriminating capacity between diagnostic disease categories, sex and age at entry (T1) and at the end (T2) of cardiac rehabilitation as well as the responsiveness of the MacNew during this period.

Method

Data were used from 6749 cardiac rehabilitation patients at T1 and 1654 at T2.

Results

Results show that the global MacNew as well as the three (physical, emotional, social) subscales have high internal consistencies, and differentiate well and in the expected direction at T1 between diagnostic groups (heart surgery, myocardial infarction with and without percutaneous coronary intervention, stable angina with and without percutaneous coronary intervention, implantable cardioverter defibrillator, and heart failure patients), sex and age. The MacNew also proves to be an adequate evaluation instrument for cardiac rehabilitation, as all scales are responsive enough to capture changes from T1 to T2. At T2, however, the MacNew seems to lose some of its discriminating power, partly because of ceiling effects.

Conclusion

It is suggested to complement the use of the MacNew both at T1 and T2 with a brief anxiety and depression measure, which is valid and responsive for different groups of cardiac rehabilitation patients.

Treatment of post-myocardial infarction depressive disorder

Both major and minor depressive disorder post-myocardial infarction (MI) are associated with an increased risk of all-cause mortality, cardiac mortality and new cardiovascular events. Post-MI depressive disorder predicts slow recovery and poor quality of life. This review attends to post-MI depressive disorder, its underlying mechanisms and options for and effects of treatment. Evidence has been found for several mechanisms to be involved in the pathophysiology, including hypothalamus-pituitary-adrenal axis activity, immune activity, polyunsaturated fatty acids, serotonin, platelet activation, type D personality and negative health behavior. Five leading randomized controlled trials are discussed, showing safety and efficacy of antidepressive treatment in post-MI patients. Effects on cardiac outcome remain unclear.

Depression and five year survival following acute myocardial infarction: a prospective study

Depression has been shown to be a risk factor for mortality during the 12 months following an acute myocardial infarction (MI), but few studies have examined whether it is associated with increased risk over longer periods. Most of the existing studies utilized depression questionnaires rather than diagnostic interviews, the gold standard for clinical depression diagnosis. The purpose of this study was to determine whether interview-diagnosed clinical depression affects survival for at least 5 years after an acute MI. Vital status was determined for 163 patients with major depression, 195 with minor depression or dysthymia, and 408 nondepressed patients, during a median follow-up period of 60 months after an acute MI. Survival analysis was used to model time from the index MI to death. There were 106 deaths during the follow-up. After adjusting for other risk factors for mortality, patients with either major or minor depression (HR=1.76; 95% CI: 1.19 to 2.60), major depression alone (HR=1.87; 95% CI: 1.17 to 2.98), or minor depression alone (HR=1.67; 95% CI: 1.06 to 2.64) were at higher risk for all-cause mortality compared to the nondepressed patients. Depression is an independent risk factor for death 5 years after an acute MI. Even minor depression is associated with an increased risk. Although it is not known whether treating depression can improve survival, patients with depression should be recognized as being at increased risk long after their acute MI.

Receiver Operating Characteristics for the Brief Symptom Inventory Depression, Paranoid Ideation, and Psychoticism Scales in a Large Sample of Clinical Inpatients

A commonly used screening tool for psychopathology, the Brief Symptom Inventory, provides normative data for assessing current mental functioning across multiple domains. Using data from 654 psychiatric inpatients, receiver operating characteristic (ROC) analyses were conducted for three scales, Depression, Paranoid Ideation, and Psychoticism. t ratios identified significant group differences on the Depression scale between patients diagnosed with or without depression but no differences on the Paranoid Ideation and Psychoticism scales between patients diagnosed with or without schizophrenia. Area under the curve for Depression was .65, indicating that the scale improved diagnostic prediction somewhat beyond chance; for Paranoid Ideation, the area was .52 and for Psychoticism, the area was .53, indicating that these two scales did not significantly improve diagnostic prediction beyond chance.

Effect of depression on late (8 years) mortality after myocardial infarction

Depression during hospitalization for myocardial infarction (MI) is associated with subsequent mortality, but whether this risk persisted long term is not well studied. This study was performed to determine whether depression during hospitalization for MI, which predicted mortality at 4 months, predicted mortality 8 years later. This was a prospective observational study of 284 hospitalized patients with MI. Major depression and dysthymia were assessed using structured interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, and depressive symptoms, using the Beck Depression Inventory. Mortality was determined using the Social Security Death Index. Mean age during MI hospitalization was 64.8 years, 43.0% of patients were women, 66.7% had hypertension, and 35.7% had diabetes mellitus. Any depression (major depression, dysthymia, and/or Beck Depression Inventory score > or =10) was present in 76 patients (26.8%). The 8-year mortality rate was 47.9% (136 deaths). Any depression at the time of MI was not associated with mortality at 8 years in unadjusted (hazard ratio 1.25, 95% confidence interval 0.87 to 1.81, p = 0.22) or multivariate models (hazard ratio 0.76, 95% confidence interval 0.47 to 1.24, p = 0.27). In conclusion, depression after MI was associated with increased short-term mortality, but its relation with mortality over time appeared to wane, at least in a group of older patients who had multiple co-morbidities.

Type-D personality but not depression predicts severity of anxiety in heart failure patients at 1-year follow-up

BACKGROUND

Chronic heart failure (CHF) is a debilitating condition associated with poor outcome, including increased anxiety. However, anxiety and its determinants have not yet been studied systematically in CHF. We examined whether type-D personality and depressive symptoms would predict clinically significant anxiety at 1-year follow-up.

METHODS

Consecutive patients with systolic CHF (n=149; 79% men; mean age 66+/-8.6) completed the type-D Scale (DS14), the Beck Depression Inventory, and the Anxiety Sensitivity Index at baseline. A clinical interview (Hamilton Anxiety Rating Scale) was used to assess clinically significant anxiety at 1-year follow-up.

RESULTS

At 12 months follow-up, 26% (9/35) of type-D patients had clinically significant anxiety versus only 6% (7/114) of the non type-Ds (p=0.001). In univariable analyses, type-D personality (OR=5.3; p=0.002) and anxiety sensitivity (OR=4.5; p=0.009), but not depressive symptoms (p=0.27) predicted clinically significant anxiety. Type-D remained an independent predictor of anxiety at 1 year (OR=5.7; p=0.01), controlling for depressive symptoms, anxiety sensitivity, socio-demographic and clinical variables. Adding type-D in a hierarchical logistic regression model, comprising standard and psychological risk factors, enhanced the level of prediction of clinically significant anxiety substantially (-2LL=75.16 chi(2)=26.46; p=0.009).

CONCLUSIONS

Type-D personality, but not depressive symptoms predicted 1-year clinically significant anxiety. The type-D scale could be used to identify CHF patients at high risk of anxiety, as these patients may be at an increased risk of adverse prognosis and impaired quality of life.

Depression and perceived behavioral control are independent predictors of future activity and fitness after coronary syndrome events

OBJECTIVE

Physical inactivity increases the risk of recurrent coronary events, and both depression and perceived behavioral control (PBC) have been shown to influence levels of physical activity. However, it is not known whether depression and PBC affect activity levels independently of one another. The present study investigates whether depression and PBC exert independent effects on future exercise and fitness in patients hospitalized for coronary syndrome events.

METHODS

Five hundred and two patients (hospitalized for myocardial infarction or newly diagnosed angina) reported their levels of depression, PBC, and current regular exercise prior to discharge from hospital, and leisure activities, fitness, regular exercise, and depression 12 months later. The ability of depression and PBC to predict patient's reported levels of activity (n=388) and fitness (n=361) was determined with regression analyses.

RESULTS

Depression prior to discharge from hospital reliably predicted fitness (P<.005), self-reported leisure activities (P<.005), and taking regular exercise (P<.005) 12 months after hospitalization for coronary syndrome events when controlling for age, gender, socio-economic status, illness severity, and reported activity prior to hospitalization. Depression at 12 months explained the variance in all outcome measures previously explained by depression at discharge, but PBC during hospitalization independently predicted leisure activities (P<.005) and taking regular exercise (P<.005) 12 months later.

CONCLUSIONS

Perceived behavioral control and depression independently predict activity and fitness in patients 12 months after hospitalization for coronary syndrome events. Consequently, interventions aiming to increase activity and fitness in these patients should take account of both patients' perceptions of control and their level of depression.

Treatment of post-myocardial infarction depressive disorder: a randomized, placebo-controlled trial with mirtazapine

OBJECTIVE

To examine the antidepressant efficacy of a dual-acting antidepressant (mirtazapine) in patients with post-myocardial infarction (MI) depressive disorder. Antidepressants used in post MI trials with a randomized, double-blind, placebo-controlled design have been restricted to selective serotonin reuptake inhibitors (SSRIs). Antidepressant effects have been limited.

METHODS

In a prospective multicenter study, 2177 patients with MI were evaluated for depressive disorder during the first year post MI. Ninety-one patients who met the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for major or minor depressive disorder were randomized to a 24-week, double-blind, placebo-controlled trial. Antidepressant efficacy was tested using last-observation-carried-forward procedure and repeated measurements analysis using the SPPS mixed models approach, with as primary outcome reduction in depressive symptomatology on the 17-item Hamilton-Depression Rating Scale (Ham-D), and secondary outcomes the Beck Depression Inventory (BDI) and depression subscale of the Symptom Check List 90 items (dSCL-90) as well as the Clinical Global Impression (CGI) scale.

RESULTS

Using the "last observation carried forward" (LOCF) method, mirtazapine did not show to be superior to placebo on the Ham-D, but did on the BDI, dSCL-90, and CGI scale over the acute treatment phase of 8 weeks (n = 91). Using mixed models analysis over the entire 24 weeks of treatment (n = 40), we did find a significant difference favoring mirtazapine to placebo on the Ham-D, BDI, and CGI, but on the dSCL-90, this difference was not significant.

CONCLUSIONS

This trial shows efficacy of mirtazapine on primary and secondary depression measures. Mirtazapine seems to be safe in the treatment of post-MI depression.

Validity of the Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9 to screen for depression in patients with coronary artery disease

OBJECTIVE

Depression is common but frequently undetected in patients with coronary artery disease (CAD). Self-report screening instruments for assessing depression such as the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire-9 (PHQ-9) are available but their validity is typically determined in depressed patients without comorbid somatic illness. We investigated the validity of these instruments relative to a referent diagnostic standard in recently hospitalized patients with CAD.

METHOD

Three months post-discharge for a cardiac admission, 193 CAD patients completed the HADS and PHQ-9. The Mini International Neuropsychiatric Interview (MINI) was the criterion standard. Scale reliability was calculated using Cronbach's alpha. Convergent validity was computed using Pearson's intercorrelations. Sensitivity and specificity for various cut-off scores for both measures and for the PHQ-9 categorical algorithm were calculated using receiver operating characteristics (ROC). For analyses, participants were assigned to two groups, 'major depressive disorder' or 'any depressive disorder'.

RESULTS

For all calculations, alpha was 0.05 and tests were two-tailed. Internal consistencies for the two measures were excellent. Criterion validity for the PHQ-9 and HADS was good. We found no statistical differences between the PHQ-9 and HADS for detecting either group; however, the categorical algorithm of the PHQ-9 for diagnosing major depression had a superior LR+ when compared with the summed HADS or PHQ-9. The operating characteristics of the screening instruments for 'any depressive disorder' were slightly lower than for 'major depressive disorder'. Some optimum cut-off scores were lower than the generally recommended cut-off scores, particularly when screening for major depression (e.g., > or = 5/6 vs. > or = 10 and > or = 8 for PHQ-9 and HADS, respectively). Lowering the cut off scores substantially improved the sensitivity of these instruments while retaining specificity, thereby improving their usefulness to screen for CAD patients with depression.

CONCLUSIONS

Both instruments have acceptable properties for detecting depression in recently hospitalized cardiac patients, and neither scale is statistically superior when summed scores are used. The categorical algorithm of the PHQ-9 for diagnosing major depression has a superior LR+ compared to the summed PHQ-9 and HADS scores. Use of the generally recommended cut-off scores should be cautious. In light of the aversive outcomes associated with depression in CAD, screening for depression is a clinical priority.

Increased emotional distress in type-D cardiac patients without a partner

OBJECTIVE

The distressed (type D) personality is an emerging risk factor in coronary artery disease that has been associated with adverse prognosis, impaired health status, and emotional distress. Little is known about factors that may influence the impact of type-D personality on health outcomes. Therefore, the aim of this study was to determine the combined effect of type-D and not having a partner on symptoms of anxiety and depression.

METHODS

Patients (n=554) hospitalized for acute myocardial infarction or implantable cardioverter defibrillator implantation completed the 14-item type-D Scale (DS14) during hospitalization and the State-Trait Anxiety Inventory and Beck Depression Inventory at 2 months follow-up.

RESULTS

Stratifying by personality and partner status showed that type-D patients without a partner had a higher risk of both anxiety [odds ratio (OR)=8.27; 95% confidence interval (CI)=2.50-27.32] and depressive symptoms (OR=6.74; 95% CI=2.19-20.76) followed by type-D patients with a partner (OR=3.73; 95% CI=2.16-6.45 and OR=3.81; 95% CI=2.08-6.99, respectively) and non-type-D patients without a partner (OR=2.04; 95% CI=1.05-3.96 and OR=3.03; 95% CI=1.46-6.31, respectively) compared to non-type-D patients with a partner, adjusting for demographic and clinical baseline characteristics, indicating a dose-response relationship.

CONCLUSION

Lack of a partner further exacerbated the risk of symptoms of anxiety and depression in the already distressed type-D patients. In clinical practice, it is important to identify type-D patients without a partner and carefully monitor them, as they may be less likely to alter health-related behaviors due to their increased levels of distress.

Performance characteristics of depression screening instruments in survivors of acute myocardial infarction: review of the evidence

Authors conducted a systematic review to assess performance characteristics of depression screening instruments after acute myocardial infarction (AMI). Among the seven studies identified, the Beck Depression Inventory (BDI) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) were used most frequently. Studies were generally of low quality, and no screening instrument performed notably better than others. Future research should compare the BDI and the HADS-D with instruments such as the Patient Health Questionnaire (PHQ-9 and PHQ-2) in post-AMI patients, should attend to important elements of the screening process, including when, where, and how often to screen patients, and should evaluate serial screening.

Effects of antidepressant treatment following myocardial infarction

BACKGROUND

Depression following myocardial infarction is associated with poor cardiac prognosis. It is unclear whether antidepressant treatment improves long-term depression status and cardiac prognosis.

AIMS

To evaluate the effects of antidepressant treatment compared with usual care in an effectiveness study.

METHOD

In a multicentre randomised controlled trial, 2177 myocardial infarction patients were evaluated for ICD-10 depression and randomised to intervention (n=209) or care as usual (n=122). Both arms were evaluated at 18 months post-myocardial infarction for long-term depression status and new cardiac events.

RESULTS

No differences were observed between intervention and control groups in mean scores on the Beck Depression Inventory (11.0, s.d.=7.5 v.10.2, s.d.=5.1, P=0.45) or presence of ICD-10 depression (30.5 v. 32.1%, P=0.68). The cardiac event rate was 14% among the intervention group and 13% among controls (OR=1.07, 95% CI 0.57-2.00).

CONCLUSIONS

Antidepressant treatment did not alter long-term depression post-myocardial infarction status or improve cardiac prognosis.

The 10-item Remembered Relationship with Parents (RRP10) scale: two-factor model and association with adult depressive symptoms

BACKGROUND

Dysfunctional parenting styles are associated with poor mental and physical health. The 10-item Remembered Relationship with Parents (RRP(10)) scale retrospectively assesses Alienation (dysfunctional communication and intimacy) and Control (overprotection by parents), with an emphasis on deficiencies in empathic parenting. We examined the 2-factor structure of the RRP(10) and its relationship with adult depression.

METHODS

664 respondents from the general population (48% men, mean age 54.6+/-14.2 years) completed the RRP(10), Parental Bonding Instrument (PBI), and Beck Depression Inventory.

RESULTS

The Alienation and Control dimensions of the RRP(10) displayed a sound factor structure, good internal consistency (Cronbach's alpha=0.83-0.86), and convergent validity against the PBI scales. No significant gender differences were found on the RRP(10) scales. Stratifying by RRP(10) dimensions showed that respondents high in Alienation and Control, for both father (33.3% vs. 14.5%, p<0.0001) and mother (42% vs. 12.9%, p<0.0001) items, experienced the highest levels of depressive symptoms compared with respondents low in Alienation and Control. While scoring high on Alienation or Control alone was also significantly and independently associated with depressive symptoms, scoring high on both Alienation and Control was most strongly connected with depressive symptoms for both father (OR=2.48, p<0.004) and mother (OR=5.34, p<0.0001) items.

LIMITATIONS

Cross-sectional study design.

CONCLUSIONS

The RRP(10) is a reliable and valid measure of remembered parental Alienation and Control. High Alienation and Control were independently related to increased risk of depressive symptoms. Given the brevity of the RRP(10), it can easily be used in epidemiological/clinical research on the link between the remembered relationship with parents and mental/physical health.

Depressive symptoms in subjects with diagnosed and undiagnosed type 2 diabetes

OBJECTIVE

To investigate if disturbed glucose homeostasis or known diagnosis of diabetes was associated with depressive symptoms. The reason for the increased prevalence of depression in patients with Type 2 diabetes mellitus (DM2) is unknown.

METHODS

Within the Utrecht Health Project, an ongoing longitudinal study among inhabitants of a residential area of a large city in The Netherlands, 4747 subjects (age: 39.4 +/- 12.5 years) were classified into four mutually exclusive categories: normal fasting plasma glucose (FPG) (<5.6 mmol/l), impaired FPG (> or =5.6 and <7.0 mmol/l), undiagnosed DM2 (FPG > or =7.0 mmol/l), and diagnosed DM2. Presence of depressive symptoms was defined as a score of > or =25 on the depression subscale of the Symptom Check List (SCL-90) or self-reported use of antidepressants.

RESULTS

Diagnosed DM2 was associated with an increased risk of depressive symptoms (odds ratio (OR) = 1.69; 95% confidence interval (CI) 1.06-2.72) after adjustment for demographic and lifestyle variables. Additional adjustment for number of chronic diseases reduced the OR to 1.36 (95% CI 0.83-2.23). Impaired fasting glucose and undiagnosed DM2 were not associated with depressive symptoms.

CONCLUSIONS

Our findings suggest that disturbed glucose homeostasis is not associated with depressive symptoms. The increased prevalence of depressive symptoms among patients with diagnosed DM2 suggests that depressive symptoms might be a consequence of the burden of diabetes. The number of chronic diseases seems to explain part of the association between DM2 and depressive symptoms.

A double-blind placebo-controlled pilot study of controlled-release paroxetine on depression and quality of life in chronic heart failure

BACKGROUND

Depression is frequently observed in patients with heart failure and is associated with poor quality of life and adverse prognosis. However, the prevalence of depression in heart failure could be overestimated because symptoms of depression overlap with those of heart failure. Similarly, the importance of depression may be overestimated if depression merely reflects worse heart failure. Because the response to depression treatment has not been evaluated in this patient population, we evaluated the efficacy of controlled-release paroxetine (paroxetine CR), a selective serotonin reuptake inhibitor, on depression and quality of life in chronic heart failure.

METHODS

A double-blind, randomized, placebo-controlled design was used to evaluate reductions in depression following 12 weeks of treatment with paroxetine CR (n = 14, age 62.1 +/- 12.3 years) or placebo (n = 14, age = 61.9 +/- 9.0 years). Patients with symptomatic congestive heart failure and a score of at least 10 on the Beck Depression Inventory (BDI) were eligible. Beck Depression Inventory was obtained at baseline and 4, 8, and 12 weeks of follow-up. Quality of life was assessed using the Medical Outcomes Study Short Form and the Minnesota Living with Heart Failure Questionnaire.

RESULTS

Controlled-release paroxetine resulted in significantly more recovery from depression (BDI <10) than placebo (69% vs 23%, P = .018) and resulted in lower continuous BDI scores throughout the intervention (P = .024). Controlled-release paroxetine was associated with higher general health levels compared with placebo on the Medical Outcomes Study 36-Item Short Form survey (38 +/- 10 vs 30 +/- 6, P = .016) at 12 weeks of follow-up. Reductions in depression were correlated with improvements in psychological aspects of quality of life (P < .05) but not with physical quality of life measures (P > .10).

CONCLUSION

Antidepressant therapy with paroxetine CR results in significant reductions in depression among patients with heart failure. The reductions in depression with paroxetine CR are accompanied by improvements in psychological aspects of quality of life. Larger controlled trials are needed to further document the effectiveness of paroxetine CR and other selective serotonin reuptake inhibitors in patients with heart failure and to determine patient subgroups that are most likely to benefit from antidepressive interventions.

Utility of Observer-Rated and Self-Report Instruments for Detecting Major Depression in Women After Cardiac Surgery: A Pilot Study

Background Major depression is common after coronary artery bypass graft surgery and is associated with increased mortality and morbidity. Clinicians have few practical options for detecting depression, especially in women, who are at higher risk for depression than men.

Objectives To evaluate the clinical utility of common self-report and observer-rated instruments for detection of major depression in women after coronary artery bypass graft surgery.

Methods In 66 women being discharged after coronary artery bypass graft surgery, 4 instruments were completed: the Hamilton Depression Rating Scale, Beck Depression Inventory, Beck Depression Inventory Short Form, and Beck Depression Inventory for Primary Care. For each instrument, receiver-operating-characteristic curves were analyzed, and positive and negative predictive values were calculated for cutoff points determined from the curves.

Results At hospital discharge, all 4 instruments yielded highly accurate curves. Compared with cutoffs suggested for patients without medical illness and hospitalized nonsurgical patients, identified cutoffs for screening were higher when all types of depressive symptoms (cognitive, affective, behavioral, somatic) were measured with the Hamilton Depression Rating Scale and the Beck Depression Inventory but lower when only cognitive and/or affective symptoms were measured with the 2 subscales of the Beck Depression Inventory.

Conclusions The Hamilton Depression Rating Scale and both subscales of the Beck Depression Inventory may be useful for detecting major depression in women shortly after coronary artery bypass graft surgery. Further study is warranted to confirm cutoffs in these patients.

Die Diskriminationsleistung des Beck-Depressions-Inventars (BDI) hinsichtlich depressiver Störungen bei Patienten mit einer körperlichen Erkrankung

Zusammenfassung. Hintergrund: Depressive Störungen und koronare Herzkrankheit (KHK) treten häufig gemeinsam auf. Zur Erkennung depressiver Störungen bieten sich Screeningfragebögen an. Fragestellung: Die vorliegende Studie untersuchte die Diskriminationsleistung des Beck-Depressions-Inventars (BDI) und von vier theoretisch abgeleiteten BDI-Subskalen bei der Erkennung depressiver Störungen und depressiver Anpassungsstörungen bei KHK-Patienten. Methodik: 153 KHK-Patienten, die sich in der Hospital Anxiety and Depression Scale (HADS) als psychisch belastet beschrieben haben, wurden durch ein klinisches Interview diagnostiziert und füllten das BDI aus. Die Daten wurden in Receiver-Operating-Characteristics-Analysen ausgewertet. Ergebnisse: Bei 60 Patienten wurde eine affektive Störung bzw. eine depressive Anpassungsstörung diagnostiziert. In Reliabilitätsanalysen wies das BDI als Gesamtinstrument im Vergleich zu den vier BDI-Subskalen die höchste interne Konsistenz und die höchste Diskriminationsleistung auf. Von den Subskalen zeigte die BDI Short-Form von Beck und Steer (1993) die höchste Reliabilität und die beste Diskriminationsleistung. Für einen BDI-Gesamtwert von 12 als Cut-Off ergab sich eine hohe Sensitivität, bei einem Cut-Off von 15 dagegen ein ausgeglichenes Verhältnis zwischen Sensitivität, Spezifität und dem relativen Anteil an falsch klassifizierten Personen. Ein Cut-Off-Wert von 18 wies mit großer Wahrscheinlichkeit auf das Vorliegen einer affektiven Störung oder einer depressiven Anpassungsstörung hin. Für die BDI-Short Form ergaben sich entsprechend die Cut-Off-Werte 6, 8 und 10. Schlussfolgerung: Für die Erkennung depressiver Störungen bei KHK-Patienten sind das BDI und die BDI-Short Form gut geeignet. Der von Beck (1995) für das Gesamt-BDI vorgeschlagene Schwellenwert von 18 für die Erkennung klinisch relevanter Depression lässt sich auf KHK-Patienten übertragen.

Changes in depressive symptoms and glycemic control in diabetes mellitus

OBJECTIVE

To investigate if changes in depressive symptoms would be associated with changes in glycemic control over a 12-month period in patients with Type 1 and Type 2 diabetes.

METHODS

Ninety (Type 1 diabetes, n = 28; Type 2 diabetes, n = 62) patients having Beck Depression Inventory (BDI) levels of >10 were enrolled in the study. Of those 90 patients, 65 patients completed a 12-week cognitive behavioral therapy intervention. BDI was assessed at baseline and thereafter biweekly during 12 months. Hemoglobin (HbA1c) and fasting blood glucose levels were assessed at baseline and at four quarterly in-hospital follow-up visits. Linear mixed-model analysis was applied to determine the effects of time and diabetes type on depressive symptoms, HbA1c levels, and fasting glucose levels.

RESULTS

Mean and standard deviation baseline BDI and HbA1c levels were 17.9 +/- 5.8 and 7.6 +/- 1.6, respectively, with no significant difference between patients with Type 1 and Type 2 diabetes. Mixed-model regression analysis found no difference between the groups with Type 1 and Type 2 diabetes in the within-subject effect of BDI score on HbA1c or fasting glucose levels during the study. Depressive symptoms decreased significantly (p = .0001) and similarly over a 12-month period in both patients with Type 1 and Type 2 diabetes, whereas HbA1c and fasting glucose levels did not change significantly over time in either group.

CONCLUSION

Changes in depressive symptoms were not associated with changes in HbA1c or fasting glucose levels over a 1-year period in either patients with Type 1 or Type 2 diabetes.

Depression and Quality of Life in Women After a Myocardial Infarction

BACKGROUND

Cardiovascular disease is the number one cause of mortality and morbidity among women in the United States, resulting in 25,000 deaths annually. Despite this high mortality figure, most women survive. Although evidence suggests that depression is common after myocardial infarction (MI), there are limited data on how depression impacts women's recovery after their first event. The purpose of this study was to describe the relationship between depression and quality of life in women after a first MI.

METHOD

A convenience sample of 27 women (mean age = 60.7 years) with first MI completed the study. Depression was measured using the Beck Depression Inventory, and quality of life was measured using the Short Form-36.

RESULTS

The mean (SD) depression score was 9.4 (5.5), indicating mild to moderate depression. Depression had a significant negative correlation with the mental component summary of the Short Form-36 (r = -0.72, P = .0005) but not the physical component summary (r = -0.191, P = .360). In addition, subjects reported lower scores on 3 of the 8 Short Form-36 subscales when compared with national norms of persons experiencing a recent MI.

IMPLICATIONS

Many women continue to report mild to severe depression after MI, and depression seems to be related to some aspects of quality of life. Screening for depression and treating if symptoms are significant is one intervention for improving quality of life after MI.

Predictors of cognitive function in candidates for coronary artery bypass graft surgery

Candidates for coronary artery bypass graft surgery have been found to exhibit reduced cognitive function prior to surgery. However, little is known regarding the factors that are associated with pre-bypass cognitive function. A battery of neuropsychological tests was administered to a group of patients listed for bypass surgery (n = 109). Medical, sociodemographic and emotional predictors of cognitive function were investigated using structural equation modeling. Medical factors, namely history of hypertension and low ejection fraction, significantly predicted reduced cognitive function, as did several sociodemographic characteristics, namely older age, less education, non-English speaking background, manual occupation, and male gender. One emotional variable, confusion and bewilderment, was also a significant predictor whereas anxiety and depression were not. When significant predictors from the three sets of variables were included in a combined model, three of the five sociodemographic characteristics, namely age, non-English speaking background and occupation, and the two medical factors remained significant. Apart from sociodemographic characteristics, medical factors such as a history of hypertension and low ejection fraction significantly predicted reduced cognitive function in bypass candidates prior to surgery.

Recognizing increased risk of depressive comorbidity after myocardial infarction: looking for 4 symptoms of anxiety-depression

BACKGROUND

Screening for depression in myocardial infarction (MI) patients must be improved: (1) depression often goes unrecognized and (2) anxiety has been largely overlooked as an essential feature of depression in these patients. We therefore examined the co-occurrence of anxiety and depression after MI, and the validity of a brief mixed anxiety-depression index as a simple way to identify post-MI patients at increased risk of comorbid depression.

METHODS

One month after MI, 176 patients underwent a psychiatric interview and completed the Beck Depression Inventory (BDI) and the Symptoms of Anxiety-Depression index (SAD(4)) containing four symptoms of anxiety (tension, restlessness) and depression (feeling blue, hopelessness).

RESULTS

Thirty-one MI patients (18%) had comorbid depression and 37 (21%) depressive or anxiety disorder. High factor loadings and item-total correlations (SAD(4), alpha = 0.86) confirmed that symptoms of anxiety and depression co-occurred after MI. Mixed anxiety-depression (SAD(4)>or=3) was present in 90% of depressed MI patients and in 100% of severely depressed patients. After adjustment for standard depression symptoms (BDI; OR = 4.4, 95% CI 1.6-12.1, p = 0.004), left ventricular ejection fraction, age and sex, mixed anxiety-depression symptomatology was associated with an increased risk of depressive comorbidity (OR = 11.2, 95% CI 3.0-42.5, p < 0.0001). Mixed anxiety-depression was also independently associated with depressive or anxiety disorder (OR = 9.2, 95% CI 3.0-27.6, p < 0.0001).

CONCLUSIONS

Anxiety is underrecognized in post-MI patients; however, the present findings suggest that anxiety symptomatology should not be overlooked in these patients. Depressive comorbidity after MI is characterized by symptoms of mixed anxiety-depression, after controlling for standard depression symptoms. The SAD(4) represents an easy way to recognize the increased risk of post-MI depression.

Impact of anxiety and perceived control on in-hospital complications after acute myocardial infarction

OBJECTIVES

We tested the hypothesis that perception of control moderates any relationship between anxiety and in-hospital complications (i.e., recurrent ischemia, reinfarction, sustained ventricular tachycardia or fibrillation, and cardiac death) in patients with acute myocardial infarction (AMI).

BACKGROUND

Anxiety is common among patients with AMI, but whether it is associated with poorer outcomes is controversial. Conflicting findings about the relationship of anxiety with cardiac morbidity and mortality may result from failure to consider the moderating effect of perceived control.

METHODS

This was a prospective examination of the association among anxiety, perceived control, and subsequent in-hospital complications among patients (N = 536) hospitalized for AMI.

RESULTS

Patients' mean anxiety level was double that of the published mean norm. Patients with higher levels of perceived control had substantially lower anxiety (p = .001). A total of 145 (27%) patients experienced one or more in-hospital complications. Patients with higher levels of anxiety had significantly more episodes of ventricular tachycardia, ventricular fibrillation, and reinfarction and ischemia (p < .01 for all). In a multivariate hierarchical logistic regression model, left ventricular ejection fraction, history of myocardial infarction, anxiety score, and the interaction of anxiety and perceived control were significant predictors of complications.

CONCLUSION

Anxiety during the in-hospital phase of AMI is associated with increased risk for in-hospital arrhythmic and ischemic complications that is independent of traditional sociodemographic and clinical risk factors. This relationship is moderated by level of perceived control such that the combination of high anxiety and low perceived control is associated with the highest risk of complications.

Pre-cessation depressive mood predicts failure to quit smoking: the role of coping and personality traits

AIMS

To examine whether mood, personality and coping predict smoking cessation and whether the associations of personality and coping are mediated through depressed mood.

SETTING

Multicenter (n = 8) smoking cessation trial.

PARTICIPANTS

A total of 600 smokers (> or = 15 cigarettes/day) without current depression who participated in a smoking cessation study.

MEASUREMENTS

The outcome was continuous abstinence during the last 4 weeks of the 3-month trial: depressed mood was measured by the Beck Depression Inventory (BDI), personality by the Revised NEO Personality Inventory (NEO-PI-R) and coping by the Revised Ways of Coping Checklist (RWCC).

FINDINGS

A total of 14.7% (88/600) were abstainers. Controlling for potential confounders, baseline BDI independently predicted smoking cessation. Smokers with BDI > or = 10 were less likely to quit than those with BDI < 10 (odds ratio: 6.39, 95% CI: 1.44-28.3, P = 0.01). Compared to BDI < 10 smokers, BDI > or = 10 smokers had significantly higher scores for neuroticism and lower scores for extraversion and conscientiousness (NEO-PI-R). On the RWCC, BDI > or = 10 smokers scored higher for blame self, wishful thinking and problem avoidance and they scored lower on problem focus than smokers with BDI < 10. A mediational analysis showed that neither personality traits nor coping skills predicted directly smoking cessation. However, low level of problem focusing and social support seeking predicted a negative outcome via depressed mood.

CONCLUSION

A BDI score > or = 10, even in smokers who do not meet a current diagnosis of major depression, directly predicts inability to quit. This suggests the utility of assessing depression symptoms in routine smoking cessation care.

Beta-Blockers and Depression After Myocardial Infarction

OBJECTIVES

The purpose of this research was to explore the prospective relationship between the use of beta-blockers and depression in myocardial infarction (MI) patients.

BACKGROUND

Beta-blocker use has been reported to be associated with the development of depression, but the methodological quality of studies in this field is weak.

METHODS

In a multicenter study, MI patients (n = 127 non-beta-blocker users and n = 254 beta-blocker users) were assessed for depressive symptoms (using the Beck Depression Inventory [BDI] at baseline and t = 3, 6, and 12 months post-MI) and International Classification of Diseases-10 depressive disorder (Composite International Diagnostic Interview). Patients were matched using the frequency matching procedure according to age, gender, hospital of admission, presence of baseline depressive symptoms, and left ventricular function.

RESULTS

No significant differences were found between non-beta-blocker users and beta-blocker users on the presence of depressive symptoms (p > 0.10 at any of the time points) or depressive disorder (p = 0.86). Controlling for confounders did not alter these findings. A trend toward increasing BDI scores was seen in patients with long-term use of beta-blockers and patients with higher beta-blocker dose.

CONCLUSIONS

In post-MI patients, prescription of beta-blockers is not associated with an increase in depressive symptoms or depressive disorders in the first year after MI. However, long-term and high-dosage effects cannot be ruled out.

Reliability and validity of the Greek version of the Derogatis Psychiatric Rating Scale (DPRS)

BACKGROUND

The aim of this paper is to report on the Greek version of the Derogatis Psychiatric Rating Scale (DPRS) and its validity and reliability when administered to a Greek sample. The DPRS is a clinician-rated measure of psychiatric symptoms with nine basic and eight complementary symptom dimensions and a Global Pathology Index.

METHOD

The DPRS was translated into Greek and administered to 161 psychiatric patients and healthy volunteers. Its validity was assessed against the Semistructured Clinical Interview (SCID) and the Symptoms Checklist-90-Revised (SCL-90-R). The inter-rater reliability and test-retest reliability were also evaluated for each symptom dimension.

RESULTS

All the symptom dimensions of the DPRS, except euphoria, have concurrent validity with the SCID on the relevant symptom dimensions diagnoses set by the interview. At the cut-off point 2/3 the DPRS has a sensitivity of 98% and a specificity of 74% in indicating active psychiatric patients. The symptom dimensions of the DPRS also have strong correlations with the relevant dimensions of SCL-90-R. The range for inter-rater reliability was from 0.48 to 0.88, the range for test-retest reliability was from 0.25 to 0.85, and the internal consistency was 0.90.

CONCLUSION

The Greek version of the DPRS has acceptable psychometric properties, rendering it a useful screening instrument of global psychopathology as well as a multidimensional measure of some basic psychiatric symptoms.

Persistent depression affects adherence to secondary prevention behaviors after acute coronary syndromes

BACKGROUND

The persistence of depressive symptoms after hospitalization is a strong risk factor for mortality after acute coronary syndromes (ACS). Poor adherence to secondary prevention behaviors may be a mediator of the relationship between depression and increased mortality.

OBJECTIVE

To determine whether rates of adherence to risk reducing behaviors were affected by depressive status during hospitalization and 3 months later.

DESIGN

Prospective observational cohort study.

SETTING

Three university hospitals.

PARTICIPANTS

Five hundred and sixty patients were enrolled within 7 days after ACS. Of these, 492 (88%) patients completed 3-month follow-up.

MEASUREMENTS

We used the Beck Depression Inventory (BDI) to assess depressive symptoms in the hospital and 3 months after discharge. We assessed adherence to 5 risk-reducing behaviors by patient self-report at 3 months. We used chi2 analysis to compare differences in adherence among 3 groups: persistently nondepressed (BDI < 10 at hospitalization and 3 months); remittent depressed (BDI > or = 10 at hospitalization; < 10 at 3 months); and persistently depressed patients (BDI > or = 10 at hospitalization and 3 months).

RESULTS

Compared with persistently nondepressed, persistently depressed patients reported lower rates of adherence to quitting smoking (adjusted odds ratio [OR] 0.23, 95% confidence interval [95% CI] 0.05 to 0.97), taking medications (adjusted OR 0.50, 95% CI 0.27 to 0.95), exercising (adjusted OR 0.57, 95% CI 0.34 to 0.95), and attending cardiac rehabilitation (adjusted OR 0.5, 95% CI 0.27 to 0.91). There were no significant differences between remittent depressed and persistently nondepressed patients.

CONCLUSIONS

Persistently depressed patients were less likely to adhere to behaviors that reduce the risk of recurrent ACS. Differences in adherence to these behaviors may explain in part why depression predicts mortality after ACS.

Post-MI psychiatric syndromes: six unanswered questions

Depression, anxiety, and other psychological variables following acute myocardial infarction (MI) have been the subject of intense study over the last two decades. Through selective literature review and editorial commentary, we address six vital, unanswered questions concerning these psychological variables and their impact on coronary outcome. The picture that emerges is complex. Despite all that has been learned about the nature, consequences, and management of post-MI depression and related disorders, there remain many open issues. First, the prevalence, phenomenology, medical impact, and method of diagnosis of post-MI depression and other psychiatric syndromes remain unclear. In addition, at least four pathophysiologic mechanisms have been proposed to explain the link between depression and cardiac disease, but evidence of causation remains elusive. There have been increasingly well-designed treatment studies of post-MI depression, but the optimal agents and timing of treatment have yet to be defined. Finally, few recent studies of post-MI anxiety have been conducted. To make further progress, large, multicenter trials that use optimized screening tools, obtain data at several time points, consider multiple psychosocial variables, and correct carefully for medical/cardiac severity are required.

Assessment and treatment of depression in patients with cardiovascular disease: National Heart, Lung, and Blood Institute Working Group Report

OBJECTIVE

The National Heart, Lung, and Blood Institute convened an interdisciplinary working group of experts to develop recommendations for the assessment and treatment of depression in patients with coronary heart disease (CHD).

METHOD

Consensus of experts.

RESULTS

Our current recommendations are that the Beck Depression Inventory-I be employed for epidemiological studies of depression and CHD, that the Patient Health Questionnaire 2-item version be employed for screening for trial eligibility, that the Depression Interview and Structured Hamilton (DISH) be employed for diagnostic ascertainment for trial inclusion, and that the Hamilton rating scale, which is part of the DISH, be employed for both depression symptom reduction and the remission criterion in any trial. We further recommend that a randomized controlled trial be undertaken to determine whether selective serotonin reuptake inhibitors, psychotherapy, or combined treatment can reduce the risk of CHD events and mortality associated with depression in CHD patients.

CONCLUSIONS

This report summarizes the recommendations made by the working group and discusses the rationale for each recommendation, the strengths and weaknesses of alternative approaches to assessment and treatment, and the implications for future research in this area.

Cognitive Function in Candidates for Coronary Artery Bypass Graft Surgery

BACKGROUND

While many studies have investigated cognitive impairments in patients after coronary artery bypass graft surgery, very few have closely evaluated presurgical cognitive functioning of bypass candidates.

METHODS

A battery of neuropsychologic tests was administered to a consecutive series of patients listed for bypass surgery (n = 109). Cognitive function of bypass candidates was compared with that of a healthy control group (n = 25) and published test norms.

RESULTS

Cognitive test scores in candidates for bypass were significantly lower than those of the control group on tests of attention, information processing speed, and verbal memory. Additionally, bypass candidates' cognitive test scores were significantly reduced compared with expected values derived from validated test norms, on all but one cognitive test.

CONCLUSIONS

Cognitive performances of candidates for bypass were significantly lower than those of a healthy control group and published cognitive test norms.

Fatigue et maladies cardiovasculaires

Fatigue is a frequent complaint during cardiovascular disease and can sometimes constitute the first clinical manifestation of this disease. It is responsible for deterioration of the quality of life and prognosis. Although physical and mental fatigue are often intimately interrelated, these two aspects of fatigue correspond to different pathophysiological mechanisms and different clinical features and the neurobiological links between the two are only just beginning to be studied. Physical fatigue is related to loss of efficacy of the effector muscle, due to multiple causes: mismatch of cardiac output during exercise, muscle and microcirculatory deconditioning, neuroendocrine dysfunction, associated metabolic disorders. Mental fatigue corresponds to predominantly depressive mood disorders with a particular entity, vital exhaustion. The diagnostic approach is designed to eliminate other organic causes of fatigue. Functional tests investigating physical (exercise capacity) and mental dimensions (mood disorders) can be used to analyse their respective roles and to propose personalized management, in which rehabilitation has an essential place due to its global approach. The objective of this reduction of fatigue is threefold: to improve independence, to improve quality of life and to limit morbidity and mortality.