Recent evidence linking coronary heart disease and depression

Depression, hypertension, and comorbidity: disentangling their specific effect on disability and cognitive impairment in older subjects

We aimed to demonstrate that depression and hypertension are associated independently of each other with disability and cognitive impairment in older subjects and that such an association is not attributable to number and severity of comorbidities. An observational study was performed on elderly patients admitted to the Hospital Network of the Italian National Research Center on Aging (INRCA) from January 2005 to December 2006. Depression was defined according to 15-item geriatric depression scale (GDS) score; physical disability according to activities of daily living (ADL) and instrumental activities of daily living (IADL) scores; cognitive impairment on the mini-mental state examination (MMSE) test; the number and severity of comorbidities by means of physician-administered cumulative illness rating scale (CIRS). Among 6180 older subjects (age=79.3 ± 5.8 years; 47% men), 48.3% were normotensive, 21.8% normotensive depressed, 21.7% hypertensive, and 8.2% hypertensive and depressed. Both depression and hypertension remained significantly associated with functional disability and cognitive impairment. When controlling for age, gender, the number and severity of comorbidities, hypertension was associated with a significantly higher likelihood of having functional disability or cognitive impairment only in the presence of depression (odds ratio=OR=2.02, 95% confidence interval=95%CI=1.60-2.54, p<0.001 for functional disability; OR=2.21, 95%CI=1.79-2.74, p<0.001 for cognitive impairment) as compared to normotensive controls without depression. We conclude that depression per se' or co-occurrence of hypertension and depression is associated with higher functional disability and cognitive impairment in older subjects. This effect is not attributable to the number or to the severity of comorbidities.

Enhanced depression care for patients with acute coronary syndrome and persistent depressive symptoms: coronary psychosocial evaluation studies randomized controlled trial

BACKGROUND

Depressive symptoms are an established predictor of mortality and major adverse cardiac events (defined as nonfatal myocardial infarction or hospitalization for unstable angina or urgent/emergency revascularizations) in patients with acute coronary syndrome (ACS). This study was conducted to determine the acceptability and efficacy of enhanced depression treatment in patients with ACS.

METHODS

A 3-month observation period to identify patients with ACS and persistent depressive symptoms was followed by a 6-month randomized controlled trial. From January 1, 2005, through February 29, 2008, 237 patients with ACS from 5 hospitals were enrolled, including 157 persistently depressed patients randomized to intervention (initial patient preference for problem-solving therapy and/or pharmacotherapy, then a stepped-care approach; 80 patients) or usual care (77 patients) and 80 nondepressed patients who underwent observational evaluation. The primary outcome was patient satisfaction with depression care. Secondary outcomes were depressive symptom changes (assessed with the Beck Depression Inventory), major adverse cardiac events, and death.

RESULTS

At the end of the trial, the proportion of patients who were satisfied with their depression care was higher in the intervention group (54% of 80) than in the usual care group (19% of 77) (odds ratio, 5.4; 95% confidence interval [CI], 2.2-12.9 [P < .001]). The Beck Depression Inventory score decreased significantly more (t(155) = 2.85 [P = .005]) for intervention patients (change, -5.7; 95% CI, -7.6 to -3.8; df = 155) than for usual care patients (change, -1.9; 95% CI, -3.8 to -0.1; df = 155); the depression effect size was 0.59 of the standard deviation. At the end of the trial, 3 intervention patients and 10 usual care patients had experienced major adverse cardiac events (4% and 13%, respectively; log-rank test, chi(2)(1) = 3.93 [P = .047]), as well as 5 nondepressed patients (6%) (for the intervention vs nondepressed cohort, chi(2)(1) = 0.48 [P = .49]).

CONCLUSION

Enhanced depression care for patients with ACS was associated with greater satisfaction, a greater reduction in depressive symptoms, and a promising improvement in prognosis.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00158054.

Culture and comorbidity in East and West berliners

Following the collapse of socialism, fluctuations in cardiac mortality rates in East Germany and a West-to-East cardiac health gradient became topics of interest. Researchers suggested possible causes for these phenomena, including stress from postsocialism. I proposed that a cultural investigation of heart disease comorbid with depression could inform our understanding of the potential health effects of the postsocialist transition. I conducted ethnographic and survey research. In the study described here, I administered a depression scale (CES-D) and an ethnographically derived measure of cultural stress (Good Life Survey) to over 200 East and West Berliners with cardiovascular disease. Comparison of the groups' depression means revealed no difference. However, correlation of the Good Life Survey and the CES-D revealed unique profiles of cultural variables associated with depression in the two groups, suggesting that culture shapes depression and cardiac risk. I discuss the value of cultural studies to comorbidity research.

Quality of parental emotional care and calculated risk for coronary heart disease

OBJECTIVE

To evaluate associations between perceived quality of parental emotional care and calculated 10-year risk for coronary heart disease (CHD). Little is understood about the role of parental emotional care in contributing to the risk for CHD.

METHODS

The study sample was composed of 267 participants from the New England Family Study. Quality of parental emotional care was measured, using a validated short version of the Parental Bonding Instrument (PBI) as the average care scores for both parents (range = 0-12), with higher scores indicating greater care. Ten-year CHD risk was calculated, using the validated Framingham Risk Algorithm that incorporates the following prevalent CHD risk factors: age, sex, diabetes, smoking, total cholesterol, high-density lipoprotein cholesterol, and blood pressure. Multiple linear regression assessed associations of PBI with calculated CHD risk after adjusting for childhood socioeconomic status, depressive symptomatology, educational attainment, and body mass index.

RESULTS

Among females, a 1-unit increase in the parental emotional care score resulted in a 4.6% (p = .004) decrease in the 10-year CHD risk score, after adjusting for covariates. There was no association between parental emotional care score and calculated CHD risk score in males (p = .22).

CONCLUSION

Quality of parental emotional care was inversely associated with calculated 10-year CHD risk in females, and not males. Although the gender differences need further investigation and these findings require replication, these results suggest that the early childhood psychosocial environment may confer risk for CHD in adulthood.

Clustering of negative affectivity and social inhibition in the community: prevalence of type D personality as a cardiovascular risk marker

OBJECTIVE

To explore the prevalence of Type D personality-the combination of negative affectivity and social inhibition-in the general population and its relationship to other cardiovascular risk factors, including psychopathological symptoms. Type D personality has been identified as a prognostic risk factor for various cardiovascular disease conditions.

METHODS

In a representative sample of 2698 individuals (aged 35-74 years), psychological, lifestyle, and somatic risk factors were investigated with laboratory testing, self-report measures, and a clinical interview. Type D was assessed with the German Type D Scale-14.

RESULTS

The prevalence of Type D was 23.4% (95% confidence interval [CI], 21.2-25.6) in men and 26.9% (95% CI, 23.7-30.1) in women and, thus, in the range of classical risk factors (e.g., hypercholesterolemia). In age-adjusted analysis, Type D was associated with psychopathological symptoms, including depression and somatic symptom burden. With the exception of physical inactivity in both sexes, hypertension in women and hypercholesterolemia in men, Type D was not associated with classical cardiovascular risk factors. Multivariate analysis revealed depression, exhaustion, anxiety, and low self-rated health as associated with Type D in both sexes (odds ratios, 1.97-3.21 in men, 1.52-2.44 in women).

CONCLUSIONS

A Type D personality disposition can be found in about a quarter of the general population, which is comparable to the prevalence of classical cardiovascular risk factors. In both sexes, an independent association to Type D appeared mainly in psychopathological symptoms. Type D constitutes a relevant and independent risk marker in the community and should receive attention in clinical practice.

Association of n-3 long-chain PUFA and fish intake with depressive symptoms and low dispositional optimism in older subjects with a history of myocardial infarction

Individuals with CHD are at increased risk of poor mental well-being. Dietary intake of EPA and DHA, the main n-3 fatty acids from fish, may be beneficial to mental well-being. We examined the association of EPA+DHA and fish intake with mental well-being in 644 participants, aged 60–80 years, with a history of myocardial infarction. Habitual food intake was assessed with a 203-item FFQ. Depressive symptoms were assessed with the self-report geriatric depression scale, and dispositional optimism was assessed with the revised life orientation test (LOT-R) and a four-item questionnaire (4Q). In Cox-regression models modified for cross-sectional analyses, we adjusted for sex, age, energy intake, BMI, family history of depression, education, marital status, smoking, physical activity and intake of saturated fat, alcohol and fibre. Compared with the lower tertile, subjects in the higher tertile of EPA+DHA intake had a lower prevalence of depressive symptoms, but this association was not statistically significant (prevalence ratio (PR) 0·78; 95 % CI 0·50, 1·22, P-trend 0·27). The higher tertile of EPA+DHA intake was positively associated with dispositional optimism measured with the 4Q (PR 0·69; 95 % CI 0·46, 1·03, P-trend 0·05), but not according to the LOT-R. Fish intake was not related to either depressive symptoms or dispositional optimism. In conclusion, intake of EPA+DHA was positively associated with dispositional optimism assessed with the 4Q, but not with optimism assessed with the LOT-R or with depressive symptoms.

The relationships among heart rate variability, inflammatory markers and depression in coronary heart disease patients

Studies show negative correlations between heart rate variability (HRV) and inflammatory markers. In cardiac patients, depression is related to both. We investigated links between short-term HRV and inflammatory markers in relation to depression in acute coronary syndrome (ACS) patients. We measured C-reactive protein (CRP), interleukin-6 (IL-6), depression symptoms (Beck Depression Inventory, BDI-II), and SDNN, high frequency (HF) and low frequency (LF) power at rest in 682 (553 men) patients approximately two months post-ACS. There were no differences in HRV measures between those with and without elevated depressions symptoms (BDI-II >or= 14). However, all HRV measures were negatively and significantly associated with both inflammatory markers. Relationships were stronger in patients with BDI-II >or= 14. Differences were significant for CRP and not explained by covariates (including age, sex, previous MI, left ventricular ejection fraction, coronary bypass surgery at index admission, diabetes, smoking, body mass index (BMI), fasting cholesterol, fasting glucose, angiotensin-converting-enzyme inhibitors, beta-blockers, statins, and antidepressants). HRV independently accounted for at least 4% of the variance in CRP in the depressed, more than any factor except BMI. Relationships between measures of inflammation and autonomic function are stronger among depressed than non-depressed cardiac patients. Interventions targeting regulation of both autonomic control and inflammation may be of particular importance.

Plasma levels of lipoprotein (a) in patients with major depressive disorders

Depression and cardiovascular disease are among the most prevalent health problems. The evidence that depression is a risk factor for the development and progression of coronary heart disease has strengthened over the past several years, but the exact reasons are not yet clear. Elevated lipoprotein (a) (Lp(a)) concentrations seem to be the major factor for the progression of the atherosclerosis and coronary heart disease. In this study, we measured the plasma levels of Lp(a) in 35 patients with major depressive disorder and 35 healthy controls. The two groups were matched by age and gender. Lp(a) measurement was performed using an immunoturbidimetric method. Total cholesterol was significantly lower in the patient group (mean +/-SD: 144.65+/-22.13 vs. 186.14+/-34.48 mg/dl. The Lp(a) levels of the patient group differed significantly from control values. Patients with major depressive disorder had higher plasma levels of Lp(a) than healthy controls (34.94+/-18.01 vs. 20.08+/-11.27 mg/dl). The results of the present study suggest that the increase of Lp(a) may contribute to higher cardiovascular risk in patients with major depressive disorder.

Psoriasis Comorbidities

Psoriasis has been associated with a number of behavioral and systemic comorbidities, including psoriatic arthritis, anxiety, depression, obesity, hypertension, diabetes mellitus, hyperlipidemia, metabolic syndrome, smoking, cardiovascular disease, alcoholism, Crohn's disease, lymphoma, and multiple sclerosis. Many of these conditions have a similar immunologic pathogeneses. Canadian and international studies have not only confirmed the presence of these comorbidities but also have demonstrated that patients with psoriasis have a significantly reduced life span. Given that patients with psoriasis are often unaware of their comorbidities, they should be screened for these conditions and treated if required by their dermatologist and/or primary care physician. It is important to keep in mind that the comorbidities and drugs used to treat them have an impact on the choice of anti-psoriatic treatment. In addition, comorbidities often preclude the use of traditional systemic agents. Recent studies have demonstrated that patients with preexisting comorbidities can be safely and effectively treated with biologic therapy. Furthermore, literature is evolving to suggest that better control of psoriasis might decrease cardiovascular mortality and prolong life.

Smoking cessation initiated during hospital stay for patients with coronary artery disease: a randomized controlled trial

BACKGROUND

Programs for smoking cessation for cardiac patients are underused in Canada. We examined the efficacy of an intervention for smoking cessation for patients admitted to hospital for coronary artery bypass graft (CABG) or because of acute myocardial infarction (MI).

METHODS

Nurses randomly assigned 276 sequential patients admitted because of acute MI or for CABG who met the inclusion criteria. Participants received an intensive or minimal smoking-cessation intervention. The minimal intervention included advice from physicians and nurses and 2 pamphlets. The intensive intervention included the minimal intervention plus 60 minutes of bedside counselling, take-home materials and 7 nurse-initiated counselling calls for 2 months after discharge. The outcomes were point prevalence of abstinence at 3, 6 and 12 months after discharge.

RESULTS

The 12-month self-reported rate of abstinence was 62% among patients in the intensive group and 46% among those in the minimal group (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.2-3.1). Abstinence was confirmed for 54% of patients in the intensive group and 35% in the minimal group (OR 2.0, 95% CI 1.3-3.6). Abstinence was significantly lower among those who used pharmacotherapy than among those who did not (p < 0.001). Continuous 12-month abstinence was 57% in the intensive group and 39% in the minimal group (p < 0.01). It was significantly higher among patients admitted for CABG than among those admitted because of acute MI (p < 0.05).

INTERPRETATION

Providing intensive programs for smoking cessation for patients admitted for CABG or because of acute MI could have a major impact on health and health care costs.

Elevated Depression Symptoms Predict Long-Term Cardiovascular Mortality in Patients With Atrial Fibrillation and Heart Failure

Background— Depression predicts prognosis in many cardiac conditions, including congestive heart failure (CHF). Despite heightened cardiac risk in patients with comorbid atrial fibrillation (AF) and CHF, depression has not been studied in this group. This substudy, from the AF-CHF Trial of rate- versus rhythm-control strategies, investigated whether depression predicts long-term cardiovascular mortality in patients with left ventricular ejection fraction ≤35%, CHF symptoms, and AF history who receive optimal medical care.

Methods and Results— Depression symptoms (Beck Depression Inventory-II) were assessed in 974 participants (833 men), with 32.0% showing elevated scores (Beck Depression Inventory-II ≥14). Over a mean follow-up of 39 months, there were 246 cardiovascular deaths (111 presumed arrhythmic; 302 all-cause deaths). Cox proportional hazards models adjusted for other prognostic factors (including age, marital status, cause of CHF, creatinine level, left ventricular ejection fraction, paroxysmal AF, previous AF hospitalization, previous electrical conversion, and baseline medications) showed that elevated depression scores significantly predicted cardiovascular mortality (primary outcome), arrhythmic death, and all-cause mortality. The adjusted hazard ratios were 1.57 (95% confidence interval 1.20 to 2.07, P <0.001), 1.69 (95% confidence interval 1.13 to 2.53, P =0.01), and 1.38 (95% confidence interval 1.07 to 1.77, P =0.01), respectively. The risks associated with depression and marital status were additive, with the highest risk in depressed patients who were unmarried.

Conclusions— Elevated depression symptoms are related to cardiovascular mortality even after adjustment for other prognostic indicators in patients with comorbid AF and CHF who receive optimized treatment. Unmarried patients are also at increased risk. Mechanisms and treatment options deserve additional study.

Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence

OBJECTIVE

To review the evidence for an association between depression and anxiety and the National Health Priority Area conditions -- heart disease, stroke, diabetes mellitus, asthma, cancer, arthritis and osteoporosis -- and for the effectiveness of treatments for depression and anxiety in these settings.

DATA SOURCES

Systematic literature search of systematic reviews, meta-analyses and evidence-based clinical practice guidelines published between 1995 and 2007, inclusive.

DATA EXTRACTION

Each review was examined and summarised by two people before compilation.

DATA SYNTHESIS

Depression is more common in all disease groups than in the general population; anxiety is more common in people with heart disease, stroke and cancer than in the general population. Heterogeneity of studies makes determination of risk and the direction of causal relationships difficult to determine, but there is consistent evidence that depression is a risk factor for heart disease, stroke and diabetes mellitus. Antidepressants appear to be effective for treating depression and/or anxiety in patients with heart disease, stroke, cancer and arthritis, although the number of studies in this area is small. A range of psychological and behavioural treatments are also effective in improving mood in patients with cancer and arthritis but, again, the number of studies is small.

CONCLUSION

The evidence for the association of physical illness and depression and anxiety, and their effects on outcome, is very strong. Further research to establish the effectiveness of interventions is required. Despite the limits of current research, policy and practice still lags significantly behind best evidence-based practice. Models of integrated care need to be developed and trialled.

The association among depressive symptoms, smoking status and antidepressant use in cardiac outpatients

Both depression and smoking are highly prevalent and related to poorer outcomes in cardiac patients. In this study, the authors examined the association between depressive symptoms and smoking status, described the frequency and type of antidepressant use, and prospectively tested the effects of antidepressant use in smokers on smoking status and psychosocial outcomes. Participants comprised 1,498 coronary artery disease (CAD) outpatients who completed a baseline survey which assessed depressive symptoms, current medications, and smoking status. A second survey was mailed 9 months later that assessed depressive symptoms, anxiety, insomnia and smoking status. Results showed that current and former-smokers had significantly greater depressive symptoms than non-smokers. Ten percent of patients were taking antidepressants, most frequently SSRIs, with significantly more smokers on antidepressants than former and non-smokers. At follow-up, smokers on antidepressants were less likely to have quit, had greater anxiety, depressive symptoms and insomnia than smokers not using antidepressants. This study demonstrated that smokers and quitters with CAD had greater depressive symptoms and use of antidepressants than non-smokers, but that the antidepressants utilized may not be optimizing outcomes.

Circulating endothelial progenitor cells and depression: a possible novel link between heart and soul

Although depression is known to be an independent risk factor for cardiovascular disorders, the mechanisms behind this connection are not well understood. However, the reduction in the number of endothelial progenitor cells (EPCs) in patients with cardiovascular risk factors has led us to hypothesize that depression influences the number of EPCs. EPCs labeled with CD34, CD133 and vascular endothelial growth factor receptor-2 (VEGFR2) antibodies were counted by flow cytometry in the peripheral blood (PB) of 33 patients with a current episode of major depression and of 16 control subjects. Mature (CD34+/VEGFR2+) and immature (CD133+/VEGFR2+) EPC counts were decreased in patients (vs controls; P<0.01 for both comparisons), and there was a significant inverse relationship between EPC levels and the severity of depressive symptoms (P<0.01 for both EPC phenotypes). Additionally, we assayed the plasma levels of VEGF, C-reactive protein (CRP) and tumor necrosis factor (TNF)-alpha and observed significantly elevated TNF-alpha concentrations in patients (vs controls; P<0.05) and, moreover, a significant inverse correlation between TNF-alpha and EPC levels (P<0.05). Moreover, by means of a quantitative RT-PCR approach, we measured CD34, CD133 and VEGFR2 mRNA levels of PB samples and found a net trend toward a decrease in all the investigated EPC-specific mRNA levels in patients as compared with controls. However, statistical significance was reached only for VEGFR2 and CD133 levels (P<0.01 for both markers). This is the first paper that demonstrates evidence of decreased numbers of circulating EPCs in patients with a current episode of major depression.

The association of cognitive and somatic depressive symptoms with depression recognition and outcomes after myocardial infarction

BACKGROUND

Among patients with acute myocardial infarction (AMI), depression is both common and underrecognized. The association of different manifestations of depression, somatic and cognitive, with depression recognition and long-term prognosis is poorly understood.

METHODS AND RESULTS

Depression was confirmed in 481 AMI patients enrolled from 21 sites during their index hospitalization with a Patient Health Questionnaire (PHQ-9) score > or =10. Within the PHQ-9, separate somatic and cognitive symptom scores were derived, and the independent association between these domains and the clinical recognition of depression, as documented in the medical records, was evaluated. In a separate multisite AMI registry of 2347 patients, the association between somatic and cognitive depressive symptoms and 4-year all-cause mortality and 1-year all-cause rehospitalization was evaluated. Depression was clinically recognized in 29% (n=140) of patients. Cognitive depressive symptoms (relative risk per SD increase, 1.14; 95% CI, 1.03 to 1.26; P=0.01) were independently associated with depression recognition, whereas the association for somatic symptoms and recognition (relative risk, 1.04; 95% CI, 0.87 to 1.26; P=0.66) was not significant. However, unadjusted Cox regression analyses found that only somatic depressive symptoms were associated with 4-year mortality (hazard ratio [HR] per SD increase, 1.22; 95% CI, 1.08 to 1.39) or 1-year rehospitalization (HR, 1.22; 95% CI, 1.11 to 1.33), whereas cognitive manifestations were not (HR for mortality, 1.01; 95% CI, 0.89 to 1.14; HR for rehospitalization, 1.01; 95% CI, 0.93 to 1.11). After multivariable adjustment, the association between somatic symptoms and rehospitalization persisted (HR, 1.16; 95% CI, 1.06 to 1.27; P=0.01) but was attenuated for mortality (HR, 1.07; 95% CI, 0.94 to 1.21; P=0.30).

CONCLUSIONS

Depression after AMI was recognized in fewer than 1 in 3 patients. Although cognitive symptoms were associated with recognition of depression, somatic symptoms were associated with long-term outcomes. Comprehensive screening and treatment of both somatic and cognitive symptoms may be necessary to optimize depression recognition and treatment in AMI patients.

The importance of functional impairment to mental health outcomes: a case for reassessing our goals in depression treatment research

Outcomes in depression treatment research include both changes in symptom severity and functional impairment. Symptom measures tend to be the standard outcome but we argue that there are benefits to considering functional outcomes. An exhaustive literature review shows that the relationship between symptoms and functioning remains unexpectedly weak and often bidirectional. Changes in functioning often lag symptom changes. As a result, functional outcomes might offer depression researchers more critical feedback and better guidance when studying depression treatment outcomes. The paper presents a case for the necessity of both functional and symptom outcomes in depression treatment research by addressing three aims-1) review the research relating symptoms and functioning, 2) provide a rationale for measuring both outcomes, and 3) discuss potential artifacts in measuring functional outcomes. The three aims are supported by an empirical review of the treatment outcome and epidemiological literatures.

Depression and risk of sudden cardiac death and coronary heart disease in women: results from the Nurses' Health Study

OBJECTIVES

We assessed the association between depression and sudden cardiac death (SCD) and cardiac events among individuals without baseline coronary heart disease (CHD).

BACKGROUND

Depression is a risk factor for cardiac events and mortality among those with CHD, possibly from arrhythmia.

METHODS

We studied depressive symptoms and a proxy variable for clinical depression consisting of severe symptoms and/or antidepressant medication use and their relationship to cardiac events in the Nurses' Health Study. Questionnaires in 1992, 1996, and 2000 assessed symptoms with the Mental Health Index (MHI-5), and antidepressant use was assessed in 1996 and 2000. Primary end points included SCD, fatal CHD, and nonfatal myocardial infarction.

RESULTS

Among 63,469 women without prior CHD/stroke in 1992, 7.9% had MHI-5 scores <53, previously found to predict clinical depression. Depressive symptoms were associated with CHD events, and the relationship was strongest for fatal CHD, where the association remained significant even after controlling for CHD risk factors (hazard ratio [HR]: 1.49; 95% confidence interval [CI]: 1.11 to 2.00 for MHI-5 score <53). In models from 1996 onward, our proxy variable for clinical depression was most associated with SCD in multivariable models (HR: 2.33, 95% CI: 1.47 to 3.70), and this risk was primarily due to a specific relationship between antidepressant use and SCD (HR: 3.34, 95% CI: 2.03 to 5.50).

CONCLUSIONS

In this cohort of women without baseline CHD, depressive symptoms were associated with fatal CHD, and a measure of clinical depression including antidepressant use was specifically associated with SCD. Although antidepressant use might be a marker of worse depression, its specific association with SCD merits further study.

Association between major depressive disorder and C-reactive protein levels in stable coronary heart disease patients

OBJECTIVE

This study aimed for a comprehensive evaluation of major depressive disorder (MDD) in stable coronary heart disease (CHD) patients, excluding all other potential psychiatric comorbidities, and including associations with cardiac biomarkers such as C-reactive protein (CRP), troponin T (TnT), and amino-terminal pro-B-type brain natriuretic peptide (NT-proBNP).

METHODS

Cross-sectional study of a consecutive series of 72 stable CHD outpatients (n=30 with MDD, n=42 with no psychiatric disorder). Psychiatric diagnoses were established by using the Structured Clinical Interview for DSM-IV (SCID), and psychiatric assessment was performed on Axis I, Axis III, Axis IV, and Axis V. Regression analyses were performed including CRP, TnT, and NT-proBNP as dependent variables, and MDD, demographics, and comorbid medical conditions as independent variables.

RESULTS

Stepwise multiple regression analyses showed a significant association between MDD and CRP (beta=0.262, P=.02), excluding all other demographic and medical variables from the models, except age (beta=0.266, P=.02). In addition, the results described a significant relationship between type II diabetes mellitus and TnT (beta=0.267, P=.02), and age and NT-proBNP levels (beta=0.374, P=.001).

CONCLUSION

Major depressive disorder was associated with elevated CRP levels in a consecutive series of stable CHD patients.

Associations of C-reactive protein and interleukin-6 with cognitive symptoms of depression: 12-year follow-up of the Whitehall II study

BACKGROUND

A lack of longitudinal studies has made it difficult to establish the direction of associations between circulating concentrations of low-grade chronic inflammatory markers, such as C-reactive protein and interleukin-6, and cognitive symptoms of depression. The present study sought to assess whether C-reactive protein and interleukin-6 predict cognitive symptoms of depression or whether these symptoms predict inflammatory markers.

METHOD

In a prospective occupational cohort study of British white-collar civil servants (the Whitehall II study), serum C-reactive protein, interleukin-6 and cognitive symptoms of depression were measured at baseline in 1991-1993 and at follow-up in 2002-2004, an average follow-up of 11.8 years. Symptoms of depression were measured with four items describing cognitive symptoms of depression from the General Health Questionnaire. The number of participants varied between 3339 and 3070 (mean age 50 years, 30% women) depending on the analysis.

RESULTS

Baseline C-reactive protein (beta=0.046, p=0.004) and interleukin-6 (beta=0.046, p=0.005) predicted cognitive symptoms of depression at follow-up, while baseline symptoms of depression did not predict inflammatory markers at follow-up. After full adjustment for sociodemographic, behavioural and biological risk factors, health conditions, medication use and baseline cognitive systems of depression, baseline C-reactive protein (beta=0.038, p=0.036) and interleukin-6 (beta=0.041, p=0.018) remained predictive of cognitive symptoms of depression at follow-up.

CONCLUSIONS

These findings suggest that inflammation precedes depression at least with regard to the cognitive symptoms of depression.

[Symptoms of depression and anxiety in patients with coronary heart disease: natural course and results of a psychotherapeutic pilot study]

OBJECTIVES

In this pilot study we examined the natural course of depressive and anxiety symptoms in patients with coronary heart disease over a period of 1(1/2) years. Additionally, we examined patients' interest in participation in a group-psychotherapy. The intervention and its effects on symptom reduction were tested in a subgroup of patients.

METHODS

Assessment of anxiety and depression (HADS) in 58 cardiology inpatients at 3 time points (t1 after one year, t2 after 1(1/2) years). N = 9 patients were additionally included in a 6-month psychotherapy intervention and compared to N = 14 untreated patients.

RESULTS

79 % of the patients were interested in beginning a psychotherapy intervention. Without psychotherapeutic treatment, the average psychological strain remained stable over the time of investigation. Intervention-group patients, however, achieved a significant (60 %) reduction in depression and anxiety scores. Implications for the clinical practice and further investigations are discussed.

Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association

Depression is commonly present in patients with coronary heart disease (CHD) and is independently associated with increased cardiovascular morbidity and mortality. Screening tests for depressive symptoms should be applied to identify patients who may require further assessment and treatment. This multispecialty consensus document reviews the evidence linking depression with CHD and provides recommendations for healthcare providers for the assessment, referral, and treatment of depression.

Platelet function in patients with major depression

Depression, ischaemic heart disease and cerebrovascular disease are important causes of morbidity and are among the leading contributors to global health burden. These conditions often occur in the same patient, resulting in considerably greater effect on health than combinations of chronic diseases without depression. The frequent occurrence of these conditions in the same patient raises the possibility of a common genetic predisposition, similar risk factors or a pathophysiological link. Serotoninergic and adrenergic signalling play important roles in causing major depression and also in platelet activation and aggregation, which underlies vascular disease. This review discusses the potential pathophysiological link between major depression and conditions in which platelet activation plays an important role and also provides evidence linking the use of the most commonly used antidepressant drugs (i.e. the selective serotonin re-uptake inhibitors) to increased risk of bleeding.

Exhaustion measured by the SF-36 vitality scale is associated with a flattened diurnal cortisol profile

The possible association between stress-related exhaustion and reduced activity in the hypothalamo-pituitary-adrenal (HPA) axis is increasingly in focus. The aim of the present study was to examine whether exhaustion measured in a non-patient population is associated with alterations in diurnal cortisol profile. The study population included 78 working individuals. The study group was dichotomised into exhausted and non-exhausted groups by means of the SF-36 vitality scale. Salivary cortisol was measured at three times during 1 workday: at awakening, 30min after awakening, and in the evening. The results showed that diurnal cortisol variation was significantly reduced in exhausted individuals. The difference in cortisol variation was mainly due to lowered morning cortisol in the exhausted group. Differences in cortisol levels at each sampling time or in mean diurnal output of cortisol were not statistically significant. The results would support the notion that exhaustion is associated with HPA axis hypoactivity as assessed by salivary cortisol. Furthermore, the SF-36 vitality provides a measure of exhaustion that may be useful in epidemiological studies in order to explore long-term health effects of stress-related exhaustion.

Anxiety disorders and comorbid medical illness

OBJECTIVE

To provide an overview of the role of anxiety disorders in medical illness.

METHOD

The Anxiety Disorders Association of America held a multidisciplinary conference from which conference leaders and speakers reviewed presentations and discussions, considered literature on prevalence, comorbidity, etiology and treatment, and made recommendations for research. Irritable bowel syndrome (IBS), asthma, cardiovascular disease (CVD), cancer and chronic pain were reviewed.

RESULTS

A substantial literature supports clinically important associations between psychiatric illness and chronic medical conditions. Most research focuses on depression, finding that depression can adversely affect self-care and increase the risk of incident medical illness, complications and mortality. Anxiety disorders are less well studied, but robust epidemiological and clinical evidence shows that anxiety disorders play an equally important role. Biological theories of the interactions between anxiety and IBS, CVD and chronic pain are presented. Available data suggest that anxiety disorders in medically ill patients should not be ignored and could be considered conjointly with depression when developing strategies for screening and intervention, particularly in primary care.

CONCLUSIONS

Emerging data offer a strong argument for the role of anxiety in medical illness and suggest that anxiety disorders rival depression in terms of risk, comorbidity and outcome. Research programs designed to advance our understanding of the impact of anxiety disorders on medical illness are needed to develop evidence-based approaches to improving patient care.

Depression in patients with chronic renal disease: where are we going?

Depression is quite prevalent in the end-stage renal disease (ESRD) population, with rates as high as 30% in some dialysis centers. There are fewer data on the epidemiology of depression in patients with earlier stages of chronic kidney disease (CKD), but the disease burden may be just as high. Depression may be associated with worse medical outcomes, including increased mortality. Close attention to screening and treating depression in all patients may be necessary. Several instruments have been used to screen for depression. The most common validated depression screening measure in ESRD patients is the Beck Depression Inventory. There are limited data on the appropriate therapy for depression in CKD patients. Psychotherapy combined with antidepressant medications, such as selective serotonin reuptake inhibitors, may be the optimal form of therapy (always in close consultation with mental health professionals). Adverse effects of antidepressant medications should be considered before prescribing these agents, particularly in patients with reduced glomerular filtration rate. Additional studies are necessary to further evaluate the optimal methods to screen for and treat depression in patients with CKD.

National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening

There have been several articles and reports in recent months about comorbidities and risks that affect psoriasis patients in addition to their underlying disease. This piece reviews the current literature and begins to address what should be done with this new information by updating the clinician about what health screening tests, preventative exams, and referrals should be considered in this population.

Cardiac side effects of psychiatric drugs

This review describes the common effects of psychotropic drugs on the cardiovascular system and offers guidance for practical management. Selected reports from the literature describing common side effects associated with psychotropic drugs are reviewed, and suggestions for further reading are given throughout the text. Orthostatic hypotension is the most common adverse autonomic side effect of antipsychotic drugs. Among the atypical antipsychotics the risk of orthostatic hypotension is highest with clozapine and among the conventional drugs the risk is highest with low potency agents. Rarely, orthostatic hypotension may result in neurocardiogenic syncope. QTc prolongation can occur with all antipsychotics but an increased risk is seen with pimozide, thioridazine, sertindole and zotepine. QTc prolongation is a marker of arrhythmic risk. Torsade de pointe, a specific arrhythmia, may lead to syncope, dizziness or ventricular fibrillation and sudden death. Heart muscle disease presents most commonly in the elderly as chronic heart failure, but myocarditis and cardiomyopathy, although relatively rare, are devastating, but potentially reversible complications of psychotropic drug therapy have been particularly linked to clozapine treatment. Patients with severe mental illness (SMI) are a 'high risk' population with regard to cardiovascular morbidity and mortality. It is probable that many patients accumulate an excess of 'traditional' risk factors for the development of cardiovascular disease, but other mechanisms including psychotropic drugs may also be influential in increasing risk in this vulnerable group. These risks need to be seen in the context of the undoubted therapeutic efficacy of the psychotropic armamentarium and the relief that these drugs bring to those suffering from mental disorder.

Symptoms Across the Continuum of Acute Coronary Syndromes: Differences Between Women and Men

Background The urgency and level of care provided for acute coronary syndromes partially depends on the symptoms manifested.

Objectives To detect differences between women and men in the type, severity, location, and quality of symptoms across the 3 clinical diagnostic categories of acute coronary syndromes (unstable angina, myocardial infarction without ST-segment elevation, and myocardial infarction with ST-segment elevation) while controlling for age, diabetes, functional status, anxiety, and depression.

Methods A convenience sample of 112 women and 144 men admitted through the emergency department and hospitalized for acute coronary syndromes participated. Recruitment took place at 2 urban teaching hospitals in the Midwest. Data were collected during structured interviews in each patient’s hospital room. Forty-eight symptom descriptors were assessed. Demographic characteristics, health history, functional status, anxiety, and depression levels also were measured.

Results Regardless of clinical diagnostic category, women reported significantly more indigestion (β = 0.25; confidence interval [CI] = 0.01–0.49), palpitations (β = 0.31; CI = 0.06–0.56), nausea (β = 0.37; CI = 0.10–0.65), numbness in the hands (β = 0.29; CI = 0.02–0.57), and unusual fatigue (β = 0.60; CI = 0.27–0.93) than men reported. Differences between men and women in dizziness, weakness, and new-onset cough did differ by diagnosis. Reports of chest pain did not differ between men and women.

Conclusions Women with acute coronary syndromes reported a higher intensity of 5 symptoms (but not chest pain) than men reported. Whether differences between the sexes in less typical symptoms are clinically significant remains unclear.

Depressive und Angststörungen bei somatischen Krankheiten

Depressiv-ängstliche Störungen sind bei den unterschiedlichen somatischen Erkrankungen häufig. Sie sind nicht nur als Reaktion auf die Situation der Erkrankung zu verstehen, sondern in ein komplexes Bedingungsgefüge eingebettet. Sie sind besonders häufig bei Erkrankungen, die das Zentralnervensystem oder endokrine Regulationssysteme direkt betreffen. Es besteht ein enger Zusammenhang zur Chronizität, Schwere und Prognose der Erkrankung. Eigenständige Effekte von diversen pharmakologischen Substanzgruppen sind wahrscheinlich.

The role of depression in the etiology of acute coronary syndrome

Recent research has confirmed that depression is a risk factor for the development and prognosis of coronary heart disease (CHD). Depressive symptoms are associated with the progression of underlying coronary atherosclerosis and clinical events such as acute coronary syndrome (ACS). Depression is poorly recognized and undertreated in patients following ACS, but progress is being made in developing abbreviated measurement tools that can be used in clinical cardiologic practice. Depressive symptoms emerging at various stages of CHD presentation may have different effects on CHD prognosis. The mechanisms mediating the relationship between depression and CHD include vascular inflammation, autonomic and endothelial dysfunction, and behavior patterns such as poor adherence to medication and advice. The optimal methods of managing depression following ACS have not yet been established.

Coronary heart disease and depression: a review of recent mechanistic research

OBJECTIVE

Both behavioural and physiological factors have been proposed as mechanisms that may explain the negative effect of depression on coronary heart disease (CHD). Our aim is to review some of the most important findings since our prior review.

METHOD

We searched MEDLINE, PsycINFO, and other sources for recent studies of candidate mechanisms, with an emphasis on publications since 2002.

RESULTS

Physiological pathways have received far greater attention than behavioural ones in the emerging literature. Recent studies have identified shared genetic determinants, inflammation, blood clotting, and vascular mechanisms as plausible explanatory mechanisms.

CONCLUSIONS

Future research should focus on relations between behavioural and physiological mechanisms and on the effects of pharmacologic and psychotherapeutic treatments for depression on candidate mechanisms.