Direction of Association Between Depressive Symptoms and Lifestyle Behaviors in Patients with Coronary Heart Disease: the Heart and Soul Study

Understanding the Relationship Between Comorbidities, Medication Nonadherence, Activities of Daily Living, and Heart Condition Status Among Older Adults in the United States: A Regression Analysis and Machine Learning Approach

BACKGROUND

Nonadherence to medication among patients with heart disease poses serious risks, including worsened heart failure and increased mortality rates.

OBJECTIVE

This study aims to explore the complex interplay between comorbidities, medication nonadherence, activities of daily living, and heart condition status in older American adults, using both traditional statistical methods and machine learning.

METHODS

Data from 326 older adults with heart conditions, drawn from the Health and Retirement Study, were analyzed. Descriptive statistics characterized demographic profiles and comorbidities, whereas logistic regression, multiple regression analyses, and decision tree models were used to address our research inquiries. In addition, a machine learning approach, specifically decision tree models, was integrated to enhance predictive accuracy.

RESULTS

Our analysis showed that factors like age, gender, hypertension, and stroke history were significantly linked to worsening heart conditions. Notably, depression emerged as a robust predictor of medication nonadherence. Further adjusted analyses underscored significant correlations between stroke and challenges in basic activities such as dressing, bathing, and eating. Depression correlated significantly with difficulties in dressing, bed mobility, and toileting, whereas lung disease was associated with bathing hindrances. Intriguingly, our decision tree model revealed that patients experiencing dressing challenges, but not toileting difficulties, were more prone to report no improvement in heart condition status over the preceding 2 years.

CONCLUSIONS

Blending traditional statistics with machine learning in this study reveals significant implications for crafting personalized interventions to improve patients' depression, leading to increased activities of daily living, medication adherence, reduced severity of comorbidities, and ultimately better management of heart conditions.

Prevalence and management of depressive symptoms in coronary heart disease patients and relationship with cardiovascular prognosis: a prospective cohort study

AIMS

Depressive symptoms are comorbid with coronary heart disease (CHD). There is a controversial debate about whether screening and intervention for depressive symptoms could improve cardiovascular prognosis. This study characterizes the prevalence, characteristics, cardiovascular prognosis and management need of depressive symptoms among CHD patients.

METHODS

CHD patients were recruited between November 18, 2020 and November 26, 2021. Depressive symptoms were evaluated with the Patient Health Questionnaire (PHQ-9). During the 12-month follow-up, cardiovascular disease (CVD) was the endpoint. Time-to-event data were estimated by Kaplan-Meier curves and Cox models.

RESULTS

Of 582 patients (25% women), 21.0% had mild depressive symptoms, and 7.5% had moderate-to-severe depressive symptoms during hospitalization. Mild and moderate-to-severe depressive symptoms were risk factor-adjusted predictors of the primary composite endpoints (adjusted HR = 2.20; 95%CI 1.19-4.03, and adjusted HR = 2.70; 95%CI 1.23-5.59, respectively). Platelet count and low-density lipoprotein were higher in mild depressive symptoms compared to no depressive symptoms.

CONCLUSION

Depressive symptoms are prevalent in CHD patients. Mild and moderate-to-severe depressive symptoms are associated with higher risk of further CVD in CHD patients. Platelet function and behavioral mechanisms may contribute to this association.

TRIAL REGISTRATION

This research was registered at https://www.chictr.org.cn . Full data of first registration is 11/09/2020. The registration number is ChiCTR2000038139.

Functioning in an Illness and Quality of Life versus the Prevalence of Depression and Anxiety Disorders in Patients with High Cardiovascular Risk

BACKGROUND

A chronic disease occurring in a person's life is a stressor, disrupting every aspect of their life.

OBJECTIVES

This study aims to assess the relationship between functioning in chronic illness and quality of life with the prevalence of symptoms of depression and anxiety in patients with high cardiovascular risk.

MATERIAL AND METHODS

This study included 200 patients (aged 18-80 years) under the care of a primary care physician, diagnosed with hypertension and/or hypercholesterolemia, and/or diabetes between 6 and 24 months before the enrollment. The presented analysis assessed the symptoms of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS); and the quality of life of patients with cardiovascular disease using the Heart Quality of Life (HeartQoL) questionnaire and functioning in chronic illness using the Functioning in Chronic Illness Scale (FCIS).

RESULTS

The HADS scores amounted to 4.34 ± 3.414 points for the HADS-Anxiety subscale and 3.20 ± 2.979 points for the HADS-Depression subscale. The score indicative of functioning in chronic illness assessed with the FCIS was 98.32 ± 13.89 points. The independent predictors of HADS-anxiety were HeartQoL Emotional and FCIS Global, while HeartQoL Global and FCIS Global were the independent predictors for HADS-depression. Better functioning in chronic illness (FCIS Global) was associated with less frequent symptoms of anxiety and depression based on the HADS: HADS-Anxiety (R Spearmann = -0.3969; p < 0.0001) and HADS-Depression (R Spearmann = -0.5884; p < 0.0001). Higher HeartQoL scores, both globally, as well as in emotional and physical dimensions, were associated with a lower severity of anxiety and depression assessed with the HADS: HADS-Anxiety (R Spearmann = -0.2909; p = 0.0001) and HADS-Depression (R Spearmann = -0.2583; p = 0.0002).

CONCLUSIONS

The quality of life and functioning in chronic illness are connected with symptoms of depression and anxiety. When assessing the severity of the depression symptoms in relation to the individual aspects of functioning in chronic illness, the areas requiring supportive-educational intervention can be identified. The assessment of both functioning in a chronic disease and the severity of the depression symptoms should be included in a standard nursing diagnosis and further supportive and educational intervention.

Development and external validation of a risk prediction model for depression in patients with coronary heart disease

BACKGROUND

Depression is an independent risk factor for adverse outcomes of coronary heart disease (CHD). This study aimed to develop a depression risk prediction model for CHD patients.

METHODS

This study utilized data from the National Health and Nutrition Examination Survey (NHANES). In the training set, reference literature, logistic regression, LASSO regression, optimal subset algorithm, and machine learning random forest algorithm were employed to screen prediction variables, respectively. The optimal prediction model was selected based on the C-index, Net Reclassification Improvement (NRI), and Integrated Discrimination Improvement (IDI). A nomogram for the optimal prediction model was constructed. 3 external validations were performed.

RESULTS

The training set comprised 1375 participants, with a depressive symptoms prevalence of 15.2 %. The optimal prediction model was constructed using predictors obtained from optimal subsets algorithm (C-index = 0.774, sensitivity = 0.751, specificity = 0.685). The model includes age, gender, education, marriage, diabetes, tobacco use, antihypertensive drugs, high-density lipoprotein cholesterol (HDLC), and aspartate aminotransferase (AST). The model demonstrated consistent discrimination ability, accuracy, and clinical utility across the 3 external validations.

LIMITATIONS

The applicable population of the model is CHD patients. And the clinical benefits of interventions based on the prediction results are still unknown.

CONCLUSION

We developed a depression risk prediction model for CHD patients, which was presented in the form of a nomogram for clinical application.

Depression and Implantable Cardioverter-Defibrillator Implantation in Black Patients at Risk for Sudden Cardiac Death

BACKGROUND

Black patients meeting indications for implantable cardioverter-defibrillators (ICDs) have lower rates of implantation compared with White patients. There is little understanding of how mental health impacts the decision-making process among Black patients considering ICDs. Our objective was to assess the association between depressive symptoms and ICD implantation among Black patients with heart failure.

METHODS AND RESULTS

This is a secondary analysis of the VIVID (Videos to Address Racial Disparities in ICD Therapy via Innovative Designs) randomized trial, which enrolled self-identified Black individuals with chronic systolic heart failure. Depressive symptoms were assessed by the Patient Health Questionnaire-2 and the Mental Component Summary of the 12-Item Short-Form Health Survey. Decisional conflict was measured by an adapted Decisional Conflict Scale (DCS). ANCOVA was used to assess differences in Decisional Conflict Scale scores. Multivariable logistic regression was used to examine the association between depressive symptoms and ICD implantation. Among 306 participants, 60 (19.6%) reported depressed mood, and 142 (46.4%) reported anhedonia. Participants with the lowest Mental Component Summary of the 12-Item Short-Form Health Survey scores (poorer mental health and higher likelihood of depression) had greater decisional conflict regarding ICD implantation compared with those with the highest Mental Component Summary of the 12-Item Short-Form Health Survey scores (adjusted mean difference in Decisional Conflict Scale score, 3.2 [95% CI, 0.5-5.9]). By 90-day follow-up, 202 (66.0%) participants underwent ICD implantation. There was no association between either the Patient Health Questionnaire-2 score or the Mental Component Summary of the 12-Item Short-Form Health Survey score and ICD implantation.

CONCLUSIONS

Depressed mood and anhedonia were prevalent among ambulatory Black patients with chronic systolic heart failure considering ICD implantation. The presence of depressive symptoms did not impact the likelihood of ICD implantation in this population.

The Impact of Anxiety and Depression Symptoms on Cardiovascular Risk Factor Control in Patients Without a History of Atherosclerotic Cardiovascular Disease

Background

Anxiety and depression by affecting lifestyle interfere with preventive actions aimed at eliminating or reducing modifiable risk factors for cardiovascular diseases (CVD).

Purpose

The objective of the study was to assess the impact of anxiety and depression on the achievement of therapeutic goals regarding CVD risk factors in patients without a history of atherosclerotic CVD.

Patients and Methods

The study included 200 patients (median age 52.0 [IQR 43.0-60.5] years). Control of the basic risk factors was assessed: blood pressure, BMI, waist circumference, physical activity, smoking status, LDL cholesterol, triglycerides, and blood glucose. The data analysis included a comparison of the number of controlled risk factors and the percentage of subjects who achieved the therapeutic goal for each of the cardiovascular risk factors. The risk of CVD was assessed with SCORE2 and SCORE2-OP. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS). On both subscales (HADS Anxiety and HADS Depression), subjects could achieve normal, borderline, and abnormal scores.

Results

The median number of controlled CVD risk factors was 4.0 (IQR 3.0-5.0), and the median CVD risk assessed with SCORE2 and SCORE2-OP was 3.0% (IQR 1.5-7.0%). Median scores for HADS Anxiety were 3.0 (IQR 2.0-6.0) and for HADS Depression 3.0 (1.0-5.0). Patients with symptoms of anxiety and depression had significantly fewer controlled risk factors (HADS Anxiety p=0.0014; HADS Depression p=0.0304). Among subjects with anxiety and depression, there was a significantly lower percentage of those with a normal waist circumference (HADS Anxiety p=0.0464; HADS Depression p=0.0200) and regular physical activity (HADS Anxiety p=0.0431; HADS Depression p=0.0055). Among subjects with anxiety, there was a significantly lower percentage of those with a normal BMI (p=0.0218) and normal triglyceride concentrations (p=0.0278).

Conclusion

The presence of anxiety and depression may affect the control of CVD risk factors in individuals without a history of atherosclerotic CVD. Assessment of anxiety and depression symptoms should be part of a comprehensive examination of patients with high CVD risk.

Patient characteristics and reasons for discontinuation in a cardiovascular risk management programme in The Netherlands

BACKGROUND

Since 2010, an increasing number of patients have participated in a nurse-led integrated cardiovascular risk management programme in the Netherlands. Because it is important to understand which patients discontinue and why, when evaluating the effectiveness of the care programme, the aim was to identify the reasons for discontinuation.

METHODS

Electronic health records of 3997 patients enrolled in a nurse-led integrated cardiovascular risk management programme that started on April 1st, 2010, were manually scrutinized for reasons for discontinuation between April 1st, 2010, and April 1st, 2018. In addition to death and moving to a diabetes care programme, we describe 7 different reasons why patients discontinued the programme and compared the patient characteristics of those who discontinued the programme without specific reasons with those who remained in the care programme for 8 years.

RESULTS

Between April 1st, 2010, and April 1st, 2018, 1,190 participants (29.8%) discontinued the CVRM care programme, of whom 271 participants died (6.8%) and 195 were transferred to a diabetes care programme (4.9%). The remaining 724 patients (18.1%) participated 5 years before discontinuation. Of these, 67 (9.3%) had a previous cardiovascular event at the start of the programme. In 355 patients, a specific reason for discontinuation was not found. At baseline, these patients less frequently had a history of CVD than those who continued the programme for 8 years (1.7 vs. 22.6%), were younger (62 vs. 67 years), had less registered cardiovascular comorbidity (atrial fibrillation: 1.1 vs. 7.2%; congestive heart failure 0.3 vs. 1.2%; chronic kidney disease 0.0 vs. 4.5%), were more often smokers (13.0% vs. 4.3%) and took blood pressure- and lipid-lowering drugs twice as often.

CONCLUSIONS

In our study we observed that participants who discontinued the nurse-led integrated CVRM care programme between 2010 and 2018 without specific reason or on request were younger, without previous CVD, had less cardiovascular comorbidity and were better adjusted to medication. Exploring the patients' reasons for discontinuation can contribute to an individualized approach to prevent or reduce discontinuation.

Plasma neurofilament light chain in association to late-life depression in the general population

AIM

Investigating what is underlying late-life depression is becoming increasingly important with the rapidly growing elderly population. Yet, the associations between plasma biomarkers of neuroaxonal damage and late-life depression remain largely unclear. Therefore, we determined cross-sectional and longitudinal associations of neurofilament light chain (NfL) with depression in middle-aged and elderly individuals, and total tau, β-amyloid 40 and 42 for comparison.

METHODS

We included 3,895 participants (71.78 years [SD = 7.37], 53.4% women) from the population-based Rotterdam Study. Between 2002 and 2005, NfL, total tau, β-amyloid 40 and β-amyloid 42 were determined in blood and depressive symptoms were measured with the Center for Epidemiologic Studies Depression scale (CES-D). Incident depressive events (clinically relevant depressive symptoms, depressive syndromes, major depressive disorders) were measured prospectively with the Center for Epidemiologic Studies Depression, a clinical interview and follow-up of medical records over a median follow-up of 7.0 years (interquartile range 1.80). We used linear and Cox proportional hazard regression models.

RESULTS

Each log2 pg./mL increase in NfL was cross-sectionally associated with more depressive symptoms (adjusted mean difference: 0.32, 95% CI 0.05-0.58), as well as with an increased risk of any incident depressive event over time (hazard ratio: 1.22, 95% CI 1.01-1.47). Further, more amyloid-β 40 was cross-sectionally associated with more depressive symptoms (adjusted mean difference: 0.70, 95% CI 0.15-1.25).

CONCLUSION

Higher levels of NfL are cross-sectionally associated with more depressive symptoms and a higher risk of incident depressive events longitudinally. The association was stronger for NfL compared to other plasma biomarkers, suggesting a potential role of neuroaxonal damage in developing late-life depression.

Feasibility, Acceptability, and Preliminary Effectiveness of a Sleep Intervention in Adults at Risk for Metabolic Syndrome With Short Sleep Duration

BACKGROUND

The prevalence of short sleep duration is rising and is linked to chronic comorbidities, such as metabolic syndrome (MetS). Sleep extension interventions in adults with MetS comorbidities and short sleep duration are limited and vary widely in terms of approach and duration.

OBJECTIVES

This pilot study aimed to test the feasibility and acceptability of a personalized 12-week systematic sleep time extension intervention on post-intervention sleep outcomes in middle-aged adults at risk for MetS with actigraphy-estimated short sleep duration.

METHODS

A single-arm, 12-week, 12-session systematic sleep time extension intervention was delivered weekly via videoconferencing. Feasibility and acceptability were assessed using retention rates and mean sleep diary completions. Sleep was estimated for 14 consecutive days prior to and immediately following the 12-week intervention using wrist actigraphy. Daytime sleepiness was assessed using the Epworth Sleepiness Scale. Paired sample t -tests modeled changes in study outcomes.

RESULTS

Study participants ( N = 41) had a mean age of 52 years and were mostly female and White; 86% attended >80% of sessions, and mean sleep diary completion was 6.7 diaries/week. Significant improvements in sleep from pre- to post-intervention included increased total sleep time, earlier sleep onsets, more regular sleep onsets, a higher sleep regularity index, and reduced daytime sleepiness. Extending sleep, as well as improving sleep timing and regularity in middle-aged adults with actigraphy-estimated short sleep duration and at risk for MetS, is feasible and acceptable.

DISCUSSION

Behavioral sleep characteristics may be modifiable and present a novel behavioral paradigm for mitigating MetS risk. This pilot study provides a proof of concept for the feasibility, acceptability, and preliminary effectiveness of a systematic sleep time extension for middle-aged adults at risk for MetS with actigraphy-estimated short sleep duration.

Association between depression and stroke and the role of sociodemographic factors: A study among hypertensive populations

OBJECTIVES

Studies have shown that depression increases the risk of stroke, and that this relationship can be modified by sex. However, few studies have explored this relationship in a hypertensive population, and an examination of sociodemographic factors may be useful in determining whether depression and stroke are related.

MATERIALS AND METHODS

We used data from the National Health and Nutrition Examination Survey conducted between 2005-2018. The relationship between depression and stroke was investigated using a multivariate logistic regression. Effect modification by sex was examined using an interaction analysis model.

RESULTS

Participants with mild or moderate depression had a 53 % (odds ratio, [OR] 1.53; 95 % confidence interval [CI], 1.15-2.04) higher risk of stroke than those without depression, with 1.76 times (95 % CI, 1.14-2.72) greater risk for major depression. Interaction analysis indicated that sex had no effect on this relationship (OR, 1.30; 95 % CI, 0.85-1.47, P=0.430). In comparison with Hispanics, non-Hispanic blacks and others/mixed-race individuals with depression had a greater risk of stroke (OR, 2.26; 95 % CI, 1.5-3.14; OR, 2.67, 95 % CI, 1.29-5.55).

CONCLUSIONS

Our study found that the degree of depression was positively correlated with stroke in a hypertensive population, and that this relationship was not affected by sex.

Examining the relationship between depression and medication adherence among elderlies suffering from cardiovascular disease referring to the clinics affiliated with Kermanshah University of Medical Sciences: A cross-sectional study

Background

In recent years, around 30% of all mortalities worldwide has been related to cardiovascular disease (CVD). The most important predictor solution of cardiovascular events is enhancing medication adherence. Meanwhile, the main reason behind development of physical disorders among the elderly is depression. In this regard, the present research was performed to determine the relationship between depression and medication adherence among the elderly suffering from CVD.

Methods

A cross-sectional study was done via an analytical approach on 188 elderlies fulfilling the inclusion criteria. The participants were chosen through convenience nonrandomized sampling from March to July 2022. The data were collected through demographic and healthcare information form plus Madanloo chronic disease medication adherence and geriatric depression scale. The analysis of the data was done by SPSS 26 plus Stata 14.2.

Results

The mean depression score was 5.6(4.3) and the mean score of medication adherence in the elderlies was 168.03(23.85). The prevalence of depression was higher in women than in men (p = 0.015), and the elderlies differing from heart failure reported the minimum extent of medication adherence. The findings obtained from analysis of variance showed that age, level of education, and monthly level of income were among the effective demographic factors in the extent of depression and medication adherence (p < 0.05). Meanwhile, 26% of changes in medication adherence can be attributed to depression. Further, the results of the multiple linear regression model reported that depression, age, and polypharmacy are among the predictors of medication adherence.

Discussion and Conclusion

A weak to moderate relationship existed between depression and medication adherence among these elderlies. Given the growing elderly population, the importance of depression, and lack of medication adherence in incidence of CVD events, it is recommended to train the healthcare team to monitor the elderly regarding depression symptoms.

Factors associated with new-onset depressive symptoms in patients starting cardiac rehabilitation: Pre-COVID-19 and COVID-19 period comparison

OBJECTIVE

We aim to: 1) investigate whether starting cardiac rehabilitation (CR) during the COVID-19 period was influential on new-onset depressive symptoms, 2) examine the relationship between sociodemographic and medical factors with the new-onset of depressive symptoms before and during the COVID-19 period in UK patients commencing CR.

METHODS

The national audit of cardiac rehabilitation (NACR) data were used and the two years of data before COVID-19 and during COVID-19 were analysed (Feb,2018 - Nov,2021). Hospital Anxiety and Depression Scale measurement was used to assess depressive symptoms. Bivariate analysis and logistic regression were conducted to examine the influence of the COVID-19 period on new-onset depressive symptoms and the patient characteristics associated with it.

RESULTS

71055 patients screened for new-onset depressive symptoms were included in the analysis. Based on multivariate analysis, patients commencing CR during COVID-19 were 8% more likely to have new onset depressive symptoms compared to patients commencing before COVID-19. Smoking (OR: 1.26, 95%CI: 1.11, 1.43), physical inactivity (OR: 1.86, 95%CI: 1.74, 1.98), high anxiety (OR: 1.45, 95%CI: 1.44, 1.46), being male (OR: 1.21, 95%CI: 1.12, 1.30), single (OR: 1.25, 95%CI: 1.16, 1.35), having comorbidities of arthritis, diabetes, chronic bronchitis, emphysema, claudication (OR range: 1.19 to 1.60), receiving CABG treatment (OR: 1.47, 95%CI: 1.25, 1.73), and having heart failure (OR: 1.33, 95%CI: 1.19, 1.48) were the factors associated with having new-onset depressive symptoms at the start of CR.

CONCLUSION

Our findings have shown that starting CR during the COVID-19 period was associated with increased odds of having new-onset depressive symptoms.

Clinical practice guidelines for cardiovascular disease: how is depression addressed? Protocol for a systematic review

INTRODUCTION

Depression frequently affects patients with cardiovascular disease (CVD). When these conditions co-occur, outcomes such as quality of life and life expectancy worsen. In everyday practice, this specific and prevalent disease-disease interaction complicates patient management. Clinical practice guidelines (CPGs) aim to provide the best available advice for clinical decision-making to improve patient care. This study will aim to evaluate how CPGs specifically address depression in patients with CVD, and whether they provide any operational guidance for screening and management of depression in the primary care and outpatient setting.

METHODS AND ANALYSIS

We will conduct a systematic review of CPGs on CVD management published from 2012 to 2023. A broad literature search for guidelines will be performed through electronic medical databases, grey literature search tools, and websites of national and professional medical organisations.Based on the inclusion criteria, two independent reviewers will evaluate eligible guidelines for screening and management recommendations on depression in patients with CVD. Additional points to be evaluated will be any mention of drug-drug or drug-disease interactions, other aspects of specific relevance to treating physicians, as well as general information on mental health. We will assess the quality of CPGs with a recommendation regarding depression in CVD patients using the Appraisal of Guidelines for Research and Evaluation II.

ETHICS AND DISSEMINATION

As this systematic review is based on available published data, ethics approval and consent are not applicable. Our intent is that our results will be published in a peer-reviewed journal, presented at international scientific meetings, and distributed to healthcare providers.

PROSPERO REGISTRATION NUMBER

CRD42022384152.

A comparison of cognitive performances based on differing rates of DNA methylation GrimAge acceleration among older men and women

Cognitive heterogeneity increases with age rendering sex differences difficult to identify. Given established sex differences in biological aging, we examined whether comparisons of men and women on neuropsychological test performances differed as a function of age rate. Data were obtained from 1921 adults enrolled in the 2016 wave of the Health and Retirement Study. The residual from regressing the DNA methylation GrimAge clock on chronological age was used as the measure of aging rate. Slow and fast age rates were predefined as 1 standard deviation below or above the sex-specific mean rates, respectively. ANCOVAs were used to test group differences in test performances. Pairwise comparisons revealed that slow aging men outperformed fast aging women (and vice versa) on measures of executive function/speed, visual memory and semantic fluency; however, when groups were matched by aging rates, no significant differences remained. In contrast, women, regardless of their aging rates, education or depressive symptoms maintained their advantage on verbal learning and memory. Implications for research on sex differences in cognitive aging are discussed.

A pilot randomized clinical trial of tDCS for increasing exercise engagement in individuals with elevated depressive symptoms: Rationale, design, and baseline characteristics

Regular exercise protects against overweight/obesity as well as numerous chronic diseases. Yet, less than half of Americans exercise sufficiently. Elevated levels of depressive symptoms have been identified as an important correlate of physical inactivity as well as poor adherence to exercise programs. Individuals with depression are less sensitive to rewards and demonstrate an attentional bias toward negative stimuli. These, and other features of depression, may place them at increased risk for effectively managing the affective experience of exercise. Lower baseline levels of activation of the left (vs right) frontal cortex, an area implicated in affect regulation, have also been found in depression, potentially pointing to this region as a potential target for intervening on affect regulation during exercise. Transcranial direct current stimulation (tDCS) has shown promise in impacting a variety of cognitive and affective processes in a large number of individuals, including people with depression. Some findings have suggested that tDCS targeting the left dorsolateral prefrontal cortex (DLPFC), specifically, may improve emotion regulation. Transcranial direct current stimulation could theoretically be a novel and potentially promising approach to improving the affective experience of exercise, thereby increasing exercise adherence among individuals with depressive symptoms. Here we present the rationale, design, and baseline characteristics of a pilot randomized controlled trial of tDCS versus sham delivered 3x/week for 8 weeks in the context of supervised aerobic exercise (AE) program among 51 low-active individuals with elevated depressive symptoms (86.3% female; mean age = 49.5). Follow-up assessments were conducted at end of treatment, and three and six months after enrollment to examine changes in levels of objectively-measured moderate-to-vigorous physical activity (MVPA). If effective, this approach could have high public health impact on preventing obesity and chronic diseases among these at-risk individuals.

Factors related to the accumulation of healthy behavior among older adults attending primary Health Care

The adoption and maintenance of healthy behaviors contribute for its accumulation throughout life, which require more than information disclosure and recommendations. Biopsychosocial factors may work as barriers to adherence to healthier behaviors, and yet have been underexplored. The objective was to investigate the factors related to the accumulation of healthy behavior among older adults attending Primary Health Care. Cross-sectional analysis with 201 older adults from baseline of Longitudinal Investigation of Functioning Epidemiology (LIFE) was performed in a Southeastern Brazilian city. The Healthy Behavior Score (HBS), ranging from 0 to 8, was calculated by the sum of the following habits: Physical activity practice, healthy eating, water consumption, night sleep time, not smoking, not drinking alcohol, frequent social relations, and spirituality. A linear multivariate regression was performed to test the influence of biopsychosocial aspects on HBS, with 95% confidence interval. Higher number of healthy behaviors was related to high social support, better cognitive status, less depressive symptoms and lower functional performance. Additionally, age and resilience score were correlated to healthy behaviors, which were higher among women and those with sufficient income. Multivariate analysis revealed depressive symptoms, functional performance and education as independent predictors of HBS. Depressive symptoms, functional performance and education are predictors of accumulation of health behaviors, independently of health status, contextual and sociodemographic aspects. Higher social support partially contributed to the higher number of healthy behaviors, and should be considered in public health policies for healthy longevity.

Anxiety and Depression Following Aortic Valve Replacement

Background The aim of this study was to identify patients vulnerable for anxiety and/or depression following aortic valve replacement (AVR) and to evaluate factors that may mitigate this risk. Methods and Results This is a retrospective cohort study conducted using a claims database; 18 990 patients (1/2013-12/2018) ≥55 years of age with 6 months of pre-AVR data were identified. Anxiety and/or depression risk was compared at 3 months, 6 months, and 1 year following transcatheter aortic valve replacement or surgical AVR (SAVR) after risk adjustment using logistic regression and Cox proportional hazards models. Separate models were estimated for patients with and without surgical complications and discharge location. Patients with SAVR experienced a higher relative risk of anxiety and/or depression at 3 months (12.4% versus 8.8%; adjusted hazard ratio [HR] 1.39 [95% CI, 1.19-1.63]) and 6 months (15.6% versus 13.0%; adjusted HR, 1.24 [95% CI, 1.08-1.42]), with this difference narrowing by 12 months (20.1% versus 19.3%; adjusted HR, 1.14 [95% CI, 1.01-1.29]) after AVR. This association was most pronounced among patients discharged to home, with patients with SAVR having a higher relative risk of anxiety and/or depression. In patients who experienced operative complications, there was no difference between SAVR and transcatheter aortic valve replacement. However, among patients without operative complications, patients with SAVR had an increased risk of postoperative anxiety and/or depression at 3 months (adjusted HR, 1.47 [95% CI, 1.23-1.75]) and 6 months (adjusted HR 1.26 [95% CI, 1.08-1.46]), but not at 12 months. Conclusions There is an associated reduction in the risk of new-onset anxiety and/or depression among patients undergoing transcatheter aortic valve replacement (versus SAVR), particularly in the first 3 and 6 months following treatment.

[Long-term course of heart disease: How can psychosocial care be improved?]

Cardiovascular diseases, which primarily include coronary artery disease (CAD), heart failure (HF) and cardiac arrhythmias, are the leading causes of death in the European Union and responsible for most of the serious courses of coronary disease. Acute events are usually the focus of clinical attention. In contrast, there are hardly any structured care and therapy concepts for the long-term course of these diseases. Based on a literature review, this article provides an overview of the long-term consequences and long-term care of heart diseases. Deficits in the psychosocial care of patients and possible solutions are discussed.Patients with CAD often experience problems with medication adherence and compliance to behavioural recommendations due to inadequate long-term psychosocial care. Psychological comorbidities reduce the quality of life and are a driver for health-damaging behaviour. Patients with cardiac arrhythmias often get into a vicious circle of recurrent physical complaints interacting with anxiety and panic attacks and the associated use of outpatient, emergency, or inpatient care facilities. In the course of heart failure, a clinically significant growing number of patients are treated with antidepressants, the benefit of which is rather doubtful.The apparent deficits in long-term psychosocial care of cardiovascular disease and the quality of life of patients could be improved through the increased use of systematic collaborative care models by specialised care facilities with the involvement of general practitioners.

The development and pilot testing of a behavioral activation-based treatment for depressed mood and multiple health behavior change in patients with recent acute coronary syndrome

BACKGROUND

Patients with acute coronary syndrome (ACS) with depressed mood demonstrate poor cardiovascular behavioral risk profiles and elevated risk for recurrent ACS and mortality. Behavioral Activation (BA) offers an intervention framework for an integrated treatment targeting both depression and critical health behaviors post-ACS. Behavioral Activation for Health and Depression (BA-HD) was developed and pilot tested in a multiphase iterative process.

METHODS

First, an initial treatment manual was conceptualized based on the team's prior work, as well as the extant literature. Second, qualitative interviews were conducted with target patients and target providers on the proposed BA-HD treatment rationale, content, and structure. Framework matrix analyses were used to summarize and aggregate responses. Third, an expert panel was convened to elicit additional manual refinements. Finally, patients with post-ACS depression and health behavior non-adherence were recruited to complete an open pilot trial to evaluate acceptability (Client Satisfaction Questionnaire [CSQ], exit interview) and treatment engagement (number of sessions attended; treatment completion was considered completion of 8 out of 10 possible sessions).

RESULTS

The initial BA-HD treatment manual expanded an existing treatment manual for post-ACS BA-based mood management and smoking cessation to target four health behaviors relevant to post-ACS patients (e.g., smoking cessation, medication adherence, physical activity, and diet). After the initial conceptualization, ten post-ACS patients and eight cardiac rehabilitation professionals completed qualitative interviews. Patients endorsed bi-directional interactions between mood and health behaviors post-ACS. Both patients and providers expressed general support of the proposed treatment rationale and values-guided, collaborative goal-setting approach. Patients, providers, and experts provided feedback that shaped the iterative manual development. After the BA-HD manual was finalized, eight participants were enrolled in a single-arm pilot trial. The mean CSQ score was 30.57 ± 2.23, indicating high satisfaction. Seven out of eight (88%) completed treatment. Pre- to post treatment improvements in depressed mood and health behaviors were promising.

CONCLUSIONS

BA-HD treatment is an acceptable approach to target both mood and health behaviors in post-ACS patients with depression. A future larger, controlled trial is needed to evaluate the efficacy of the BA-HD treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04158219.

The Relationship Between Obesity and Depression Is Partly Dependent on Metabolic Health Status: A Nationwide Inpatient Sample Database Study

OBJECTIVE

Some studies have demonstrated a bidirectional association between obesity and depression, whereas others have not. This discordance might be due to the metabolic health status. We aimed to determine whether the relationship between obesity and depression is dependent on metabolic health status.

METHODS

In total, 9,022,089 participants were enrolled and classified as one of four obesity phenotypes: metabolically healthy nonobesity (MHNO), metabolically unhealthy nonobesity (MUNO), metabolically healthy obesity (MHO), and metabolically unhealthy obesity (MUO). We then divided the population into eight phenotypes based on obesity and the number of metabolic risk factors. Furthermore, the associations of eight phenotypes, based on obesity and specific metabolic risk factors, with depression were assessed.

RESULT

Among all participants, a higher risk of depression was observed for MUNO, MHO and MUO than for MHNO. The risk was highest for MUO (OR = 1.442; 95% CI = 1.432, 1.451). However, the association between MHO and depression was different for men and women (OR = 0.941, men; OR = 1.132, women). The risk of depression increased as the number of metabolic risk factors increased. Dyslipidemia was the strongest metabolic risk factor. These relationships were consistent among patients ≥ 45 years of age.

CONCLUSIONS

The increased risk of obesity-related depression appears to partly depend on metabolic health status. The results highlight the importance of a favorable metabolic status, and even nonobese populations should be screened for metabolic disorders.

The effect of home-based cardiac rehabilitation on depression score in patients with ischemic heart disease: A longitudinal clinical trial study

BACKGROUND

Depression is common in patients with cardiovascular disease (CVD). Home-based cardiac rehabilitation (HBCR) is a program that alleviates depression. This study aimed to determine and compare HBCR programs and usual care (UC) effects on depression control in patients with ischemic heart disease (IHD).

METHODS

This clinical trial study was performed on 259 patients with IHD that were randomly allocated to the HBCR and UC groups for stress management. Data were collected using the "Beck Depression Inventory" (BDI) at baseline and 6 and 12 months. Generalized estimating equation (GEE) models were applied to examine the associations between times of the groups and changes in outcomes over the study times. Data analysis was done in SPSS software at the significance level of 0.05.

RESULTS

A total of 247 participants with a mean age of 55.22 ± 7.40 years participated in this study, and 209 (84.6%) of the study participants were men. Among patients, 128 patients in the UC program and 119 patients in the HBCR program attended at least one of the pre-determined visits (months 6 and 12). The patterns of change of the depression parameter were similar through the course of the study between the two groups (P = 0.04). In the HBCR group, the depression reduced continuously from baseline to 6 months, baseline to 12 months, and 6 to 12 months (P < 0.05). In the UC group, depression was significantly reduced from baseline to 6 months and from baseline to 12 months.

CONCLUSION

HBCR was effective in continuous reducing of depression scores in long-term follow-up of patients with IHD. These findings suggest that HBCR can alleviate depression in patients who do not participate in hospital-based cardiac rehabilitation (CR).

Sociodemographic moderation of the association between depression and stroke incidence in a retrospective cohort of 0.4 million primary care recipients with hypertension

BACKGROUND

Previous research has suggested an association between depression and subsequent acute stroke incidence, but few studies have examined any effect modification by sociodemographic factors. In addition, no studies have investigated this association among primary care recipients with hypertension.

METHODS

We examined the anonymized records of all public general outpatient visits by patients aged 45+ during January 2007-December 2010 in Hong Kong to extract primary care patients with hypertension for analysis. We took the last consultation date as the baseline and followed them up for 4 years (until 2011-2014) to observe any subsequent acute hospitalization due to stroke. Mixed-effects Cox models (random intercept across 74 included clinics) were implemented to examine the association between depression (ICPC diagnosis or anti-depressant prescription) at baseline and the hazard of acute stroke (ICD-9: 430-437.9). Effect modification by age, sex, and recipient status of social security assistance was examined in extended models with respective interaction terms specified.

RESULTS

In total, 396 858 eligible patients were included, with 9099 (2.3%) having depression, and 10 851 (2.7%) eventually hospitalized for stroke. From the adjusted analysis, baseline depression was associated with a 17% increased hazard of acute stroke hospitalization [95% confidence interval (CI) 1.03-1.32]. This association was suggested to be even stronger among men than among women (hazard ratio = 1.29, 95% CI 1.00-1.67).

CONCLUSION

Depression is more strongly associated with acute stroke incidence among male than female primary care patients with hypertension. More integrated services are warranted to address their needs.

Social Support and Self-Efficacy as Mediating Factors Affecting the Association Between Depression and Medication Adherence in Older Patients with Coronary Heart Disease: A Multiple Mediator Model with a Cross-Sectional Study

PURPOSE

Medication non-adherence is a major public health issue. Recent evidence suggests that depression, inadequate social support, and lower levels of self-efficacy are associated with poor medication adherence. However, the mechanism underlying the association among depression, social support, self-efficacy and medication adherence is unclear. This study aims to examine the mediating role of social support and self-efficacy between depression and medication adherence in older patients with coronary heart disease.

PATIENTS AND METHODS

Data were collected from 238 hospitalized older patients with coronary heart disease. Depression, social support, self-efficacy, and medication adherence were assessed using structured questionnaires. A serial multiple mediation model was tested using the PROCESS macro for SPSS.

RESULTS

A total of 238 older patients with CHD with a mean age of 70.5 years were involved in this cross-sectional study. Depression was negatively correlated with medication adherence in older patients with coronary heart disease. Social support and self-efficacy were positively associated with medication adherence, and fully mediated the relationship between depression and medication adherence. Three mediation paths were included in the model: (a) social support, (b) chain combination of social support and self-efficacy, and (c) self-efficacy.

CONCLUSION

Social support and self-efficacy explain the association of depression and medication adherence in older CHD patients and may be the keys target for enhanced intervention to improve medication adherence in older CHD patients with depression.

Examining Adherence to Medication in Patients With Atrial Fibrillation: The Role of Medication Beliefs, Attitudes, and Depression

BACKGROUND/OBJECTIVES

This study examined whether beliefs about medicines, drug attitudes, and depression independently predicted anticoagulant and antiarrhythmic adherence (focusing on the implementation phase of nonadherence) in patients with atrial fibrillation (AF).

METHODS

This cross-sectional study was part of a larger longitudinal study. Patients with AF (N = 118) completed the Patient Health Questionnaire-8. The Beliefs about Medicines Questionnaire, Drug Attitude Inventory, and Morisky-Green-Levine Medication Adherence Scale (self-report adherence measure), related to anticoagulants and antiarrhythmics, were also completed. Correlation and multiple logistic regression analyses were conducted.

RESULTS

There were no significant differences in nonadherence to anticoagulants or antiarrhythmics. Greater concerns (r = 0.23, P = .01) were significantly, positively associated with anticoagulant nonadherence only. Depression and drug attitudes were not significantly associated with anticoagulant/antiarrhythmic adherence. Predictors reliably distinguished adherers and nonadherers to anticoagulant medication in the regression model, explaining 14% of the variance, but only concern beliefs (odds ratio, 1.20) made a significant independent contribution to prediction (χ = 11.40, P = .02, with df = 4). When entered independently into a regression model, concerns (odds ratio, 1.24) significantly explained 10.3% of the variance (χ = 7.97, P = .01, with df = 1). Regressions were not significant for antiarrhythmic medication (P = .30).

CONCLUSIONS

Specifying medication type is important when examining nonadherence in chronic conditions. Concerns about anticoagulants, rather than depression, were significantly associated with nonadherence to anticoagulants but not antiarrhythmics. Anticoagulant concerns should be targeted at AF clinics, with an aim to reduce nonadherence and potentially modifiable adverse outcomes such as stroke.

Depressive symptoms and 5-year incident metabolic syndrome among older adults

Little is known regarding the association between depressive symptoms and metabolic syndrome (MetS) among older Chinese adults. This study aimed to examine the association of depressive symptoms with MetS and its components among Chinese elderly. Based on whether they showed depressive symptoms at baseline, 262 age-gender-matched participants from a community-based cohort study were included. The presence of depressive symptoms was measured using the nine-item Patient Health Questionnaire (PHQ-9). MetS was defined according to the Adult Treatment Panel III of the National Cholesterol Education Program. Linear regression and logistic regression analyses were performed to assess associations of depressive symptoms with MetS and its components. The incidence of MetS among the participants with depressive symptoms at baseline was 15.27% (20/131). The association of the presence of depressive symptoms with MetS was significant (odds ratio [OR] = 2.53, 95% confidence intervals [CI] = 1.07, 5.95). There was a negative association between depressive symptoms and hypertension (OR = 0.04, 95% CI = 0.002, 0.98). The change in mean arterial pressure varies approximately 1.03 mmHg with a 1-point change in PHQ-9 score. In this study, baseline depressive symptoms were associated with subsequent MetS. The presence of depressive symptoms was negatively associated with elevated mean arterial pressure.

Poor adherence to lifestyle recommendations in patients with coronary heart disease: results from the EUROASPIRE surveys

AIMS 

Despite the high use of cardioprotective medications, the risk factor control in patients with coronary heart disease (CHD) is still inadequate. Guidelines identify healthy lifestyles as equally important in secondary prevention as pharmacotherapy. Here, we describe reasons for poor lifestyle adherence from the patient's perspective.

METHODS AND RESULTS 

In the EUROASPIRE IV and V surveys, 16 259 CHD patients were examined and interviewed during a study visit ≥6 months after hospital discharge. Data gathering was fully standardized. The Brief Illness Perception questionnaire was completed by a subsample of 2379 patients. Half of those who were smoking prior to hospital admission, were still smoking; 37% of current smokers had not attempted to quit and 51% was not considering to do so. The prevalence of obesity was 38%. Half of obese patients tried to lose weight in the past month and 61% considered weight loss in the following month. In relation to physical activity, 40% was on target with half of patients trying to do more everyday activities. Less than half had the intention to engage in planned exercise. Only 29% of all patients was at goal for all three lifestyle factors. The number of adverse lifestyles was strongly related to the way patients perceive their illness as threatening. Lifestyle modifications were more successful in those having participated in a cardiac rehabilitation and prevention programme. Patients indicated lack of self-confidence as the main barrier to change their unhealthy behaviour.

CONCLUSION 

Modern secondary prevention programmes should target behavioural change in all patients with adverse lifestyles.

Factors Affecting Medication Adherence in Patients with Mechanical Heart Valves Taking Warfarin: The Role of Knowledge on Warfarin, Medication Belief, Depression, and Self-Efficacy

Non-adherence is highlighted as one of the main contributors to the occurrence of adverse events and negative clinical outcomes in patients treated with warfarin. The aim was to examine knowledge on warfarin, medication belief, depression, and self-efficacy as factors influencing medication adherence for anticoagulation control. This was a cross-sectional study. The participants in this study were patients who visited an outpatient clinic of cardiovascular surgery to administer anticoagulants after mechanical valve replacement surgery at a tertiary hospital in Seoul. Responses of 154 participants on questionnaires were analyzed from 10 September to 26 December 2020. Multiple regression analyses were performed to assess the factors influencing medication adherence among the patients with anticoagulation control. Factors influencing medication adherence were consuming warfarin for 3 to 5 years, awareness of target prothrombin time international normalized ratio, knowledge of warfarin, and depression. Medication beliefs and self-efficacy had no significant influence on medication adherence. The most important factors associated with medication adherence in patients with mechanical heart valves were knowledge about warfarin and depression. In the control of oral anticoagulants that require continuous management, education and providing accurate guidance is more important than personal preferences. Clinical nurses should facilitate educational programs tailored to the characteristics of the patient, including their purpose and method of taking warfarin, specific diets, their knowledge on warfarin's interaction with other drugs, symptoms of adverse events, and self-management. In addition, healthcare providers should check whether warfarin therapy is being controlled by evaluating medication adherence and depression levels among patients.

Contemplation-action-maintenance model of behaviour change for persons with coronary heart disease: A qualitative study

AIMS AND OBJECTIVES

To explore factors of health behaviour maintenance from the perspective of coronary heart disease (CHD) patients.

BACKGROUND

The majority of CHD patients do not achieve appropriate theory-based intervention to maintain health behaviours. Previous health behaviour change theories give little importance to behaviour maintenance.

DESIGN

A qualitative descriptive study.

METHODS

Thirty CHD patients were recruited purposively and interviewed from four hospitals in Beijing, China, during January 2017-August 2019. Data were analysed using template analysis methods. The COREQ checklist was used.

RESULTS

Perceived enjoyment and perceived effectiveness from the newly adopted behaviours emerged as vital factors for maintaining health behaviour; contemplation-action-maintenance (CAM) model to explain the behaviour change and maintenance of CHD patients was constructed.

CONCLUSIONS

The CAM model provides insight into the factors of health behaviour action and maintenance among CHD patients. Professionals can develop interventions from the perspective of patients' experiences to promote maintenance of behaviour.

RELEVANCE TO CLINICAL PRACTICE

Professionals need to consider that the goal of behavioural intervention should initially and continuously target patients' perseverance. Interventions of health behaviour that bring enjoyment may aid long-term maintenance. Also, healthcare providers can enhance patients' perception of effectiveness to motivate their behaviour maintenance in lifestyle change programmes.

Risk of Cardiovascular Disease Mortality in Relation to Depression and 14 Common Risk Factors

Background

Depression has been linked to a worse prognosis of Cardiovascular disease (CVD), and these two diseases share a variety of common risk factors such as unhealthy lifestyles and chronic medical conditions. However, the potential role of these common risk factors in modulating the association between depression and CVD mortality and whether the co-occurrence of depression and a specific common risk factor has a cumulative impact on CVD mortality are still largely unknown.

Methods

We pooled data from 2005–2014 of Nation health and nutritional examination survey, leading to a study population of 22,177 adults. The Patient Health Questionnaire was employed to assess the depression symptoms, and information on CVD mortality was obtained from the linked mortality file of NHANES. Fourteen common risk factors of depression and CVD were included in this study.

Results

Based on the interaction analyses, we found overweight was protective for the risk of CVD death in depressive participants, but not in people without depression. Moreover, relative risk-based analyses indicated a mutually promotive effect of depression and baseline CVD or living alone on CVD mortality.

Conclusion

The novel findings in our study may facilitate risk stratification in the clinical programs targeting CVD mortality and help to shed light on the differential pathophysiological mechanisms in the depression-mediated elevation of CVD mortality.

Undoing resilience: immigrant status and poor health following incarceration

BACKGROUND

In the United States, foreign-born persons often have better health outcomes than their native-born peers, despite exposure to adversity. Nevertheless, it is unclear whether this pattern extends to the consequences of life events, such as incarceration, that separate immigrants from their supportive networks and increase exposure to adversity. Accordingly, using four waves of data from the National Longitudinal Study of Adolescent to Adult Health, hierarchical generalized linear models were used to examine within-individual changes in self-rated health following first incarceration (N = 31,202 person-waves).

RESULTS

The results showed that incarceration was associated with modest health declines that were similar in magnitude for immigrant and native-born persons. Supplemental analyses revealed that these effects did not vary by immigrant race or ethnicity, or by age at immigration. The only exception was for immigrants from low- and middle-income countries, who were marginally less likely to experience health declines following incarceration.

CONCLUSIONS

In general, incarceration appears to be similarly health damaging for immigrants and non-immigrants. These findings raise important questions about how incarceration is linked to health declines for foreign- and native-born populations and emphasize the importance of access to healthcare for individuals released from correctional facilities. More research is needed, however, to further examine the cumulative impacts of incarceration on immigrants' health across the life course, and to assess a broader spectrum of health outcomes.

Immunological substrates of depressive symptoms in patients with severe obesity: An exploratory study

In this pilot study, we explored the immune phenotype of patients with severe obesity and comorbid depressive symptoms compared to non-depressed patients with obesity and normal-weight controls. Immune cell subsets were analysed by flow cytometry and depressive symptoms assessed using the Patient Health Questionnaire (PHQ-9). Cell frequencies were correlated with depressive symptom scores and waist-to-hip ratio (WHR). Patients with obesity and comorbid depression showed significantly lower numbers of circulating cytotoxic natural killer cells, dendritic cells and CD8⁺ effector memory T cells, compared to normal-weight controls. Regulatory T cells and CD4⁺ central memory T cells were increased compared to non-depressed patients with obesity and compared to normal-weight controls, respectively. Frequencies of cytotoxic natural killer cells and CD4⁺ central memory T cells significantly correlated with PHQ-9 scores, but not with WHR. Reduced numbers of dendritic cells were observed in both patient groups with obesity and correlated with PHQ-9 scores and WHR. These findings provide evidence for an altered immune composition in comorbid obesity and depression, supporting a pathobiological overlap between the two disorders.

Depression, anxiety, perceived stress, and their changes predicted medical adherence over 9 months among patients with coronary heart disease

OBJECTIVES

Although effective medical treatments have proved to successfully improve prognoses and outcomes of patients with coronary heart disease (CHD), low adherence to treatments is still common among patients. Deleterious impact of psychological distress on medical adherence has been recognized; however, few studies examined the influence of change in psychological distress on attenuation in adherence. This study investigated whether three common manifestations of distress (depression, anxiety, and perceived stress) and their changes predicted decline in medical adherence among CHD patient over 9 months.

DESIGN

A three-wave longitudinal study.

METHODS

Participants were 255 CHD patients with a mean age of 63 years. Psychological distress, medication adherence, and specific treatment adherence were assessed at baseline, 3 months, and 9 months. Hierarchical regression analyses were conducted to examine the influences of psychological distress on medical adherence over 9 months. All models were adjusted for baseline medication or specific adherence, demographic, and medical covariates.

RESULTS

Baseline depression and its changes over time significantly predicted greater decline in both medication adherence (βs = .15-.20, ps < .05) and specific adherence (βs = -.21 to -.15, ps < .05). Anxiety showed a similar trend. For perceived stress, baseline and its change significantly predicted specific adherence over 9 months (βs = -.30 to -.23, ps < .01), but did not predict medication adherence at 3 and 9 months.

CONCLUSIONS

Findings underline the necessity of tracking various forms of psychological distress over time for CHD patients to promote medical adherence and further improve the disease prognosis.

Self-care and related factors associated with left ventricular systolic function in patients under follow-up after myocardial infarction

BACKGROUND

Recent advances in treatment have led to long-term survival after myocardial infarction (MI), but subsequent complications such as heart failure have also increased, and, therefore, the relationship between prognosis and self-care needs to be investigated.

AIMS

This study aimed to confirm the relationship of potential variables affecting self-care of patients after MI and to determine whether self-care predicts left ventricular systolic function.

METHODS

Using a descriptive study design, a hypothetical model was constructed based on previous studies, and 191 post-MI patients were recruited from three university hospital outpatient clinics in Korea. The modified model was verified by constructing a structural equation model using AMOS version 24.0. The exogenous variables were illness perception, social support, and depression symptoms. The endogenous variables were self-efficacy, self-care compliance, and changes in left ventricular ejection fraction (LVEF).

RESULTS

The average patient age and disease duration were 66.3 (±11.5) years and 62.1 (±56.6) months, respectively. Self-care compliance was directly influenced by self-efficacy and indirectly affected by social support. Self-care compliance had a direct effect on LVEF changes, which was indirectly associated with illness perception, social support, and self-efficacy.

CONCLUSION

This study confirmed the direct effect of self-care compliance on changes in LVEF in patients under follow-up after MI. It is necessary to periodically monitor the degree of self-care in outpatients who are undergoing follow-up after MI to prevent a decrease in cardiac function. Counseling and education may be effective forms of social support to improve disease awareness and self-efficacy among patients with low self-care compliance.

Efficacy of team-based collaborative care for distressed patients in secondary prevention of chronic coronary heart disease (TEACH): study protocol of a multicenter randomized controlled trial

BACKGROUND

Coronary heart disease (CHD) is the leading cause of death and years of life lost worldwide. While effective treatments are available for both acute and chronic disease stages there are unmet needs for effective interventions to support patients in health behaviors required for secondary prevention. Psychosocial distress is a common comorbidity in patients with CHD and associated with substantially reduced health-related quality of life (HRQoL), poor health behavior, and low treatment adherence.

METHODS

In a confirmatory, randomized, controlled, two-arm parallel group, multicenter behavioral intervention trial we will randomize 440 distressed CHD patients with at least one insufficiently controlled cardiac risk factor to either their physicians' usual care (UC) or UC plus 12-months of blended collaborative care (TeamCare = TC). Trained nurse care managers (NCM) will proactively support patients to identify individual sources of distress and risk behaviors, establish a stepwise treatment plan to improve self-help and healthy behavior, and actively monitor adherence and progress. Additional e-health resources are available to patients and their families. Intervention fidelity is ensured by a treatment manual, an electronic patient registry, and a specialist team regularly supervising NCM via videoconferences and recommending protocol and guideline-compliant treatment adjustments as indicated. Recommendations will be shared with patients and their physicians who remain in charge of patients' care. Since HRQoL is a recommended outcome by both, several guidelines and patient preference we chose a ≥ 50% improvement over baseline on the HeartQoL questionnaire at 12 months as primary outcome. Our primary hypothesis is that significantly more patients receiving TC will meet the primary outcome criterion compared to the UC group. Secondary hypotheses will evaluate improvements in risk factors, psychosocial variables, health care utilization, and durability of intervention effects over 18-30 months of follow-up.

DISCUSSION

TEACH is the first study of a blended collaborative care intervention simultaneously addressing distress and medical CHD risk factors conducted in cardiac patients in a European health care setting. If proven effective, its results can improve long-term chronic care of this vulnerable patient group and may be adapted for patients with other chronic conditions.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00020824, registered on 4 June, 2020; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020824.

Associations of major depressive disorder and related clinical characteristics with 25-hydroxyvitamin D levels in middle-aged adults

Background: Vitamin D deficiency has been suggested to contribute to the onset of depression, but published results are inconsistent. The aims of this study were 1) to compare serum 25-hydroxyvitamin D (25(OH)D) levels in patients with depression and non-depressed controls and 2) to examine whether distinct subtypes and symptom severity of depression may vary in their association with 25(OH)D.Methods: The study involved cross-sectional data of n=1169 participants from the BiDirect Study (n=639 patients with clinically diagnosed major depressive disorder (MDD), n=530 controls). Serum 25(OH)D was measured via LS-MS/MS. We performed analysis of covariance to evaluate adjusted means of 25(OH)D levels and multinomial logistic regression to assess the association of depression and its clinical characteristics, namely distinct subtypes and symptom severity, with 25(OH)D status (adjusted for age, sex, education, season of blood sample collection, and lifestyle factors).Results: In total, 45.0% of the participants had adequate 25(OH)D levels (≥20 ng/ml), whereas 24.9% had a deficiency (<12 ng/ml). Patients with MDD had lower 25(OH)D levels than controls (16.7 vs. 19.6 ng/ml, p<0.001). Patients with atypical depression had the lowest levels (14.6 ng/ml). Symptom severity was inversely related to 25(OH)D. Moreover, patients with MDD had a more than 2-times higher odds of 25(OH)D deficiency than controls. Atypical depression showed the highest odds of deficiency.Conclusions: The results support that patients with depression have lower 25(OH)D concentrations than non-depressed individuals. Distinct subtypes, particularly the atypical subtype, may play a special role in this context. Therefore, depression heterogeneity should be considered in future research.

Depressive symptoms and risk of liver-related mortality in individuals with hepatitis B virus infection: a cohort study

The impact of depression on the risk of liver-related mortality in individuals with hepatitis B virus (HBV) infection remains unclear. We examined the association between depression, HBV infection, and liver-related mortality. A total of 342,998 Korean adults who underwent health examinations were followed for up to 7.8 years. Depressive symptoms were defined as a Center for Epidemiologic Studies-Depression score ≥ 16. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs). During 1,836,508 person-years of follow-up, 74 liver-related deaths and 54 liver cancer deaths were identified (liver-related mortality rate of 4.0 per 10⁵ person-years and liver cancer mortality rate of 2.9 per 10⁵ person-years). Subjects with depressive symptoms had an increased risk of liver-related mortality with a corresponding multivariable aHR of 2.00 (95% CI 1.10–3.63) compared to those without depressive symptoms. This association was more evident in HBsAg-positive participants with a corresponding multivariable aHR of 4.22 (95% CI 1.81–9.88) than HBsAg-negative participants (P for interaction by HBsAg positivity = 0.036). A similar pattern was observed in relation to liver cancer mortality. In this large cohort, depressive symptoms were associated with an increased risk of liver-related mortality, with a stronger association in HBsAg-positive individuals.

Depression Is Associated With Reduced Outpatient Cardiac Rehabilitation Completion Rates: A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS

PURPOSE

Depression is associated with recurrent cardiac events and death in patients with coronary heart disease and congestive heart failure. Furthermore, depression may be associated with reduced completion of outpatient cardiac rehabilitation (CR), an empirically supported treatment for patients with coronary heart disease and congestive heart failure that reduces recurrent coronary events and cardiac mortality. The goal of the current systematic review and meta-analysis was to explore the association between depression and outpatient CR completion.

METHOD

A systematic literature review cross-referenced 3 electronic databases (PsycINFO, MEDLINE, and Dissertation Abstracts International) from inception through February 15, 2015. Studies quantifying an association between depression and outpatient CR completion were identified for review. A random-effects model was used to pool quantitative data, moderators were tested, and publication bias was analyzed.

RESULTS

Seventeen studies with 19 independent samples consisting of 30 586 cardiac patients were included in the meta-analysis. A moderate inverse relationship between depression and outpatient CR completion was observed (g = -0.44; 95% CI, -0.59 to -0.29), indicating that depressed CR patients were significantly less likely to complete their prescribed CR programs. No significant moderator variables were identified. A minor amount of publication bias was detected.

CONCLUSION

Depression is associated with reduced outpatient CR completion rates. Future research should focus on attendance interventions for depressed CR patients, as completion of outpatient CR reduces cardiac and all-cause mortality.

Multiple modifiable lifestyle factors and the risk of perinatal depression during pregnancy: Findings from the GUSTO cohort

BACKGROUND

Studies have identified lifestyle risk factors for perinatal depression, but none have examined the cumulative effect of these risk factors in pregnant women.

METHODS

We considered the following six factors during pregnancy: poor diet quality (Healthy eating index for Singapore pregnant women<median), poor sleep quality (global Pittsburgh sleep quality index score > 5), physical inactivity (<600 MET-minutes/week), vitamin D insufficiency (<50 nmol/l), smoking before or during pregnancy, and the perceived need for social support. Probable depression was assessed using the Edinburgh postnatal depression scale during pregnancy (>15) and at three months postpartum (≥13). Prevalence risk ratios were calculated with Poisson regressions while adjusting for potential confounders.

RESULTS

Of 535 pregnant women, 207 (39%) had zero or one risk factor, 146 (27%) had two, 119 (22%) had three, 48 (9%) had four, and 15 (3%) had ≥5 risk factors at 26-28 weeks' gestation. These six lifestyle habits contributed to 32% of the variance in depressive symptoms during pregnancy. The prevalence of being probably depressed was 6.4 (95% CI 2.1, 19.8; p_trend < 0.001) for expecting women who had ≥4 risk factors compared to women who had ≤1 risk factor. No association was observed between the number of risk factors and depressive symptoms at 3 months postpartum (p_trend = 0.746).

CONCLUSION

Pregnant women with ≥4 lifestyle risk factors showed a higher prevalence of depression during pregnancy, while no associations were observed for postpartum depression.

CLINICAL TRIAL REGISTRATION

This cohort is registered under the Clinical Trials identifier NCT01174875; http://www.clinicaltrials.gov/ct2/show/NCT01174875?term=GUSTO&rank=2.

A Personalized eHealth Intervention for Lifestyle Changes in Patients With Cardiovascular Disease: Randomized Controlled Trial

Background

Behavior change methods involving new ambulatory technologies may improve lifestyle and cardiovascular disease outcomes.

Objective

This study aimed to provide proof-of-concept analyses of an intervention aiming to increase (1) behavioral flexibility, (2) lifestyle change, and (3) quality of life. The feasibility and patient acceptance of the intervention were also evaluated.

Methods

Patients with cardiovascular disease (N=149; mean age 63.57, SD 8.30 years; 50/149, 33.5% women) were recruited in the Do Cardiac Health Advanced New Generation Ecosystem (Do CHANGE) trial and randomized to the Do CHANGE intervention or care as usual (CAU). The intervention involved a 3-month behavioral program in combination with ecological momentary assessment and intervention technologies.

Results

The intervention was perceived to be feasible and useful. A significant increase in lifestyle scores over time was found for both groups (F_2,146.6=9.99; P<.001), which was similar for CAU and the intervention group (F_1,149.9=0.09; P=.77). Quality of life improved more in the intervention group (mean 1.11, SD 0.11) than CAU (mean −1.47, SD 0.11) immediately following the intervention (3 months), but this benefit was not sustained at the 6-month follow-up (interaction: P=.02). No significant treatment effects were observed for behavioral flexibility (F_1,149.0=0.48; P=.07).

Conclusions

The Do CHANGE 1 intervention was perceived as useful and easy to use. However, no long-term treatment effects were found on the outcome measures. More research is warranted to examine which components of behavioral interventions are effective in producing long-term behavior change.

Trial Registration

ClinicalTrials.gov NCT02946281; https://www.clinicaltrials.gov/ct2/show/NCT02946281

Association between heart-focused anxiety, depressive symptoms, health behaviors and healthcare utilization in patients with coronary heart disease

OBJECTIVE

To analyze the association between heart-focused anxiety, depressive symptoms, health behaviors and healthcare utilization in patients with coronary heart disease (CHD).

METHODS

N = 1007 patients with CHD were recruited in hospital and followed for one year in a two-site cohort study. Heart focused anxiety (Cardiac Anxiety Questionnaire [CAQ] with the three subscales fear, attention, and avoidance), depressive symptoms (depression module from the Patient Health Questionnaire [PHQ-9]), health behaviors and healthcare utilization (smoking status, alcohol consumption, physical activity, outpatient physician/psychotherapist visits) were assessed six months after the initial hospitalization. Multiple regression models were used for statistical analysis.

RESULTS

About one third of the sample exhibited clinically significant CAQ scores. Higher CAQ-avoidance scores were associated with current smoking (OR = 1.62; 95%CI: 1.33-1.98), reduced alcohol intake (OR = 0.83; 95%CI: 0.71-0.98), non-participation in a coronary exercise group (OR = 1.76; 95%CI: 1.42-2.17), less regular physical activity (OR = 2.69; 95%CI: 2.32-3.12), and more frequent contact to general practitioners (GPs; b = 0.07, SE: 0.03). CAQ-attention was associated with non-smoking (OR = 0.51; 95%CI: 0.37-0.70), exercise group participation (OR = 0.69; 95%CI: 0.51-0.94), more frequent regular physical activity (OR = 0.55; 95%CI: 0.44-0.68), and more frequent contact to specialists for internal medicine (b = 0.09, SE: 0.04). CAQ-fear was not associated with any of the health behavior or healthcare use measures. Depressive symptoms were associated with reduced regular physical activity (OR = 1.05; 95%CI: 1.02-1.08) and increased contact to mental care specialists (b = 0.03, SE: 0.01) and GPs (b = 0.02, SE: 0.01).

CONCLUSIONS

Heart-focused anxiety and depressive symptoms may impede secondary prevention in patients with CHD and increase outpatient healthcare utilization.

Lower Serum Uric Acid Is Associated With Post-Stroke Depression at Discharge

BACKGROUND

Serum uric acid (SUA) has been shown to play an important role in the pathophysiology of mood disorders including 3- and 6-month post-stroke depression (PSD). This study aimed to investigate whether SUA levels on admission were associated with PSD at discharge.

METHODS

A total of 498 stroke patients were consecutively recruited from Tongji Hospital. Clinical and laboratory test data were collected on admission. They were categorized into equal tertiles according to the distribution of SUA and the number of patients. PSD status was evaluated by DSM-V criteria and 17-item Hamilton Rating Scale for Depression at discharge.

RESULTS

The optimal cut-off points of SUA were: (T1) 80.00~300.80 µmo1/L, (T2) 300.81~391.67 µmo1/L, (T3) 391.68~710.0 µmo1/L. A total of 232 patients (46.59%) were diagnosed as PSD at discharge. Significant differences were found between the PSD and non-PSD groups in SUA tertiles of patients (P = 0.00). After adjustment for conventional confounding factors, the odds ratios of PSD were 5.777 (95% CI = 3.463~9.637, P = 0.00) for the lowest tertile and 4.153 (95% CI = 2.492~6.921, P = 0.00) for the middle tertile of SUA, as compared with the highest tertile. In restricted cubic spline regression, continuous SUA showed linear relation with PSD risk at discharge after 300 µmol/L.

CONCLUSIONS

Lower SUA levels on admission were found to be associated with PSD at discharge and the threshold effect was also revealed. For stroke patients, doctors should pay attention to the baseline SUA for screening high-risk PSD at discharge in clinical practice.

Association of Depression and Unhealthy Lifestyle Behaviors in Chinese Patients With Acute Coronary Syndromes

PURPOSE

This study sought to examine associations between depression and unhealthy lifestyle behaviors in Chinese patients with acute coronary syndromes (ACS).

METHODS

This cross-sectional study included 4043 ACS patients from 16 hospitals across China who participated in the I-Care (Integrating Depression Care in Acute Coronary Syndromes Patients) trial. Patients were enrolled between November 2014 and January 2017. Depression was assessed with the Patient Health Questionnaire-9 (PHQ-9). Five lifestyle behaviors were assessed: smoking, drinking, body mass index (BMI), physical activity, and sleep quality.

RESULTS

A total of 135 patients (3.3%) were considered clinically depressed (PHQ-9 ≥10). After adjusting for covariates, physical activity and sleep quality were inversely related to PHQ-9 scores. Adjusted logistic models showed that depressed patients were 1.7 times likely to be physically inactive (OR = 1.74; 95% CI, 1.15-2.64) and 4.6 times likely to have poor sleep quality (OR = 4.60; 95% CI, 3.07-6.88) compared with nondepressed patients. The association of depression with smoking, unhealthy drinking, and unhealthy BMI was not significant after adjustment for demographic characteristics. Higher depression scores were found to be associated with a greater number of unhealthy lifestyle behaviors (P for trend < .001).

CONCLUSIONS

The association of depression and unhealthy lifestyles in post-ACS patients suggests that reducing depressive symptoms and improving healthy lifestyle behaviors could potentially improve clinical outcomes in this vulnerable patient population.

Are Cardiovascular Risk Factors Stronger Predictors of Incident Cardiovascular Disease in U.S. Adults With Versus Without a History of Clinical Depression?

Background

Several mechanisms underlying the depression-to-cardiovascular disease (CVD) relationship have been proposed; however, few studies have examined whether depression promotes CVD through potentiating traditional cardiovascular risk factors.

Purpose

To test the combined influence of three cardiovascular risk factors and lifetime depressive disorder on incident CVD in a large, diverse, and nationally representative sample of U.S. adults.

Methods

Respondents were 26,840 adults without baseline CVD who participated in Waves 1 (2001-2002) and 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions. Lifetime depressive disorder, tobacco use, hypertension, and incident CVD were determined from structured interviews, and body mass index (BMI) was computed from self-reported height and weight.

Results

Logistic regression models predicting incident CVD (1,046 cases) revealed evidence of moderation, as the interactions between lifetime depressive disorder and current tobacco use (p = .002), hypertension (p < .001), and BMI (p = .031) were significant. The Former Tobacco Use × Lifetime Depressive Disorder interaction was not significant (p = .85). In models stratified by lifetime depressive disorder, current tobacco use (OR = 1.78, 95% CI = 1.36-2.32, p < .001 vs. OR = 1.41, 95% CI = 1.24-1.60, p < .001), hypertension (OR = 2.46, 95% CI = 1.98-3.07, p < .001 vs. OR = 1.39, 95% CI = 1.28-1.51, p < .001), and BMI (OR = 1.10, 95% CI = 1.01-1.20, p = .031 vs. OR = 1.03, 95% CI = 0.99-1.07, p = .16) were stronger predictors of incident CVD in adults with versus without a lifetime depressive disorder.

Conclusions

Our findings suggest that amplifying the atherogenic effects of traditional cardiovascular risk factors may be yet another candidate mechanism that helps to explain the excess CVD risk of people with depression.

Association of Depression With Mortality in Older Adults Undergoing Transcatheter or Surgical Aortic Valve Replacement

Importance

Depression is increasingly recognized as a risk factor for adverse outcomes in cardiovascular disease. However, little is known about depression in older adults undergoing transcatheter (TAVR) or surgical (SAVR) aortic valve replacement.

Objective

To determine the prevalence of depression and its association with all-cause mortality in older adults undergoing TAVR or SAVR.

Design, Setting, and Participants

This preplanned analysis of the Frailty Aortic Valve Replacement (FRAILTY-AVR) prospective cohort study included 14 centers in 3 countries from November 15, 2011, through April 7, 2016. Individuals 70 years or older who underwent TAVR or SAVR were enrolled. Depressive symptoms were evaluated using the Geriatric Depression Scale Short Form at baseline and follow-up.

Main Outcomes and Measures

All-cause mortality at 1 and 12 months after TAVR or SAVR. Logistic regression was used to determine the association of depression with mortality after adjusting for confounders such as frailty and cognitive impairment.

Results

Among 1035 older adults (427 men [41.3%] and 608 women [58.7%]) with a mean (SD) age of 81.4 (6.1) years, 326 (31.5%) had a positive result of screening for depression, whereas only 89 (8.6%) had depression documented in their clinical record. After adjusting for clinical and geriatric confounders, baseline depression was found to be associated with mortality at 1 month (odds ratio [OR], 2.20; 95% CI, 1.18-4.10) and at 12 months (OR, 1.532; 95% CI, 1.03-2.24). Persistent depression, defined as baseline depression that was still present 6 months after the procedure, was associated with a 3-fold increase in mortality at 12 months (OR, 2.98; 95% CI, 1.08-8.20).

Conclusions and Relevance

One in 3 older adults undergoing TAVR or SAVR had depressive symptoms at baseline and a higher risk of short-term and midterm mortality. Patients with persistent depressive symptoms at follow-up had the highest risk of mortality.

Screening and Management of Depression in Patients With Cardiovascular Disease: JACC State-of-the-Art Review

Depression is a common problem in patients with cardiovascular disease (CVD) and is associated with increased mortality, excess disability, greater health care expenditures, and reduced quality of life. Depression is present in 1 of 5 patients with coronary artery disease, peripheral artery disease, and heart failure. Depression complicates the optimal management of CVD by worsening cardiovascular risk factors and decreasing adherence to healthy lifestyles and evidence-based medical therapies. As such, standardized screening pathways for depression in patients with CVD offer the potential for early identification and optimal management of depression to improve health outcomes. Unfortunately, the burden of depression in patients with CVD is under-recognized; as a result, screening and management strategies targeting depression have been poorly implemented in patients with CVD. In this review, the authors discuss a practical approach for the screening and management of depression in patients with CVD.