Detection of depression in cardiac inpatients: feasibility and results of systematic screening

Efficacy of Psycho-Cardiology therapy in patients with acute myocardial infarction complicated with mild anxiety and depression

Objective

To evaluate the efficacy of Psycho-Cardiology therapy among patients with acute myocardial infarction (AMI) complicated with mild anxiety and depression.

Methods

Two hundred and fifty-six patients with AMI who were admitted to the Cardiovascular Department of Chenzhou First People's Hospital from January 2018 to January 2020 were selected as subjects, and randomly divided into the control group (n = 128) and the Psycho-Cardiology treatment group (n = 128). Prior to the intervention, the general clinical data of the enrolled patients, such as gender, age, comorbidities (hypertension, diabetes) and smoking history, were compared, which revealed no statistical differences between the two groups (P > 0.05). The control group was given routine treatments such as reperfusion and secondary prevention of coronary heart disease, while the treatment group was given Psycho-Cardiology intervention in addition to the aforementioned treatments.

Results

No significant differences in PHQ-9 and GAD-7 scores were observed between the control and treatment groups at admission (P > 0.05). After the Psycho-Cardiology treatment, the PHQ-9 and GAD-7 scores of the treatment group decreased significantly. Based on the 1-year post-treatment comparison, the left ventricular ejection fraction was improved more significantly in the Psycho-Cardiology treatment group, showing statistical significance (P < 0.05). The treatment group exhibited statistically significantly low incidences of adverse cardiovascular events, such as recurrent angina pectoris, heart failure, malignant arrhythmia, recurrent myocardial infarction and death (P < 0.05).

Conclusions

Psycho-Cardiology therapy is remarkably efficacious in improving the anxiety, depression, cardiac function and reducing the occurrence of adverse cardiovascular events, which can better improve the long-term prognosis of patients with AMI compared to the traditional treatments.

Implementation of systematic screening for anxiety and depression in cardiac rehabilitation: Real world lessons from a longitudinal study

AIMS

Systematic screening for anxiety and depression is widely recommended as a core component of cardiac rehabilitation in ischemic heart disease, however, recommendation-practice gaps are common and limited knowledge exists about factors hindering and supporting implementation. The study aimed to assess adherence to national clinical guideline recommendations and to gain a greater understanding of the implementation of screening in real-world practice.

METHODS

An observational, longitudinal mixed-methods design including hospitals and municipalities in Denmark. We retrieved nationwide survey data from 2013, 2015, 2018 and 2021 to assess adherence to screening on programme level, and clinical quality registry data from 2016 to 2020 to assess proportion of patients screened. Data were analysed descriptively. Semi-structured interviews with healthcare professionals were conducted in 2015 (n = 11) and 2020 (n = 11) to explore how screening was conducted and factors supporting implementation. Normalization Process Theory guided interviews and content analysis.

RESULTS

Screening on programme level increased from 61% to 88% in hospitals and 20% to 89% in municipalities. The individual proportion of patients screened remained relatively stable in both hospitals and municipalities overall, however with considerable inter-site differences. Screening practices became more aligned to guidelines, pushed by formal recommendations and monitoring, and pulled by activities strengthening the knowledge and motivation among staff.

CONCLUSION

Screening for anxiety and depression improved considerably over the seven-year period, from a scattered practice driven by individuals to a movement where healthcare professionals had a feeling of going with the flow. Nationwide implementation of screening requires national and local supporting activities and a continuous effort.

Investigating patients´ views on screening for depression in cardiac practice: A qualitative interview study

OBJECTIVE

Recommendations on screening for depression in patients with coronary heart disease (CHD) are highly debated. While recent research has prioritized efficacy studies, little is known about what is potentially required for screening to be efficacious. Expanding our knowledge of how patients with CHD view screening is likely to pose a first step towards addressing this gap. We aimed to investigate patients ́ views on routine screening for depression in cardiac practice.

METHODS

This exploratory, qualitative study was conducted among 12 patients with CHD, who completed semi-structured interviews. We used a purposive sampling strategy to include patients within a range of ages, gender and self-reported depression. Thematic analysis was carried out.

RESULTS

We identified four main themes: Acceptance, utility, barriers and expectations. Patients in this sample appeared to be in favor of standardized routine screening for depression in cardiac practice, if the rationale was disclosed. Patients reported that standardized screening addresses holistic care demands, promotes validation of individual symptom burden and legitimizes the display of psychological distress in cardiac practice. Yet, skepticism towards the validity of screening instruments and perceived stigmatization could pose a main barrier to screening efficacy. Patients expected to receive feedback on results and consecutive recommendations.

CONCLUSION

We found that depression screening is endorsed by patients with CHD in this study sample. Standardized routine screening procedures could serve as a useful tool to combat stigmatization, and encourage patients to display symptoms of depression towards cardiologists. The efficacy of depression screening could potentially be enhanced by tailoring the screening process towards patients´ needs.

Depression as a predictor of postoperative delirium after cardiac surgery: a systematic review and meta-analysis

OBJECTIVES

Depression is common in patients with cardiac disease. The importance of preoperative depression for development of postoperative delirium (POD) following cardiac surgery is not well known. The aim is to provide a summary estimate of depression as a predictor of POD following cardiac surgery.

METHODS

Systematic search of MEDLINE, EMBASE, Cochrane Library, Web of Science Core Collection and Psycinfo (Ovid) was performed from inception to October 2019, including cohort studies reporting odds ratios (ORs) and 95% confidence intervals (CIs) for POD following cardiac surgery in patients with preoperative depression compared to patients without depression. ORs and 95% CIs for POD were calculated using random-effects meta-analyses. Subgroup and sensitivity analyses were performed.

RESULTS

Seven studies were included with a combined study population of 2066 patients. The pooled prevalence of POD in the combined study population was 26% and preoperative depression was present in ∼9% of the total study population. All studies showed a positive association between preoperative depression and POD; and in 5 studies, the association was statistically significant. Patients with depression had a pooled OR of 2.31 (95% CI 1.37-3.90) for POD.

CONCLUSIONS

This systematic review and meta-analysis confirm the findings that the previous association between preoperative depression and increased risk for developing POD reported for other patient groups is found also in cardiac surgery. Depression screening prior to cardiac surgery may be effective in identifying patients at higher risk for POD.

Examination of the best cut-off points of PHQ-2 and GAD-2 for detecting depression and anxiety in Italian cardiovascular inpatients

OBJECTIVE

Despite the frequent association between anxiety, depression and cardiovascular diseases (CVD), cardiovascular inpatients are not usually screened for these psychopathological conditions. To fill this gap, especially in hospital environments, there is the need of brief screening instruments that provide reliable information in a very short time. According to this need, the aim of this study was to examine the best cut-off points of two brief and easy-to-use questionnaires in a sample of Italian cardiovascular inpatients: the 2-item Patient Health Questionnaire (PHQ-2) and the 2-item Generalized Anxiety Disorder (GAD-2).

DESIGN

3500 cardiovascular inpatients were recruited and completed both the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder (GAD-7). PHQ-2 and GAD-2 were then obtained extracting the first two item from PHQ-9 and GAD-7.

MAIN OUTCOME MEASURES

The PHQ-2 and GAD-2 psychometric properties were calculated comparing them with PHQ-9 and GAD-7, respectively.

RESULTS

The PHQ-2 threshold of ≥ 2 and the GAD-2 threshold of ≥ 3 are the best solutions in balancing between sensitivity and specificity, also providing acceptable rates of false positives and false negatives.

CONCLUSIONS

the PHQ-2 and GAD-2 Italian versions showed good diagnostic features for measuring depression and anxiety in CVD patients.

Depressive and Anxiety Symptoms Screening in Cardiac Inpatients: A Virtuous Italian Approach to Psychocardiology

Despite the fact that American Heart Association (AHA) recommended a systematic screening for depression in cardiovascular inpatients, poor attention has been given to this issue. Furthermore, no specific guidelines exist for anxiety screening in cardiovascular inpatients. Thus, the aims of this study were to verify the feasibility of a depressive and anxiety symptoms screening protocol in an Italian hospital specializing in cardiovascular diseases and to evaluate both anxiety and depressive symptoms prevalence. A group of 2009 consecutive inpatients completed the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder (GAD-7). The rates of depressive and anxiety symptoms were almost 9% and 16% respectively. Men were less likely than women to experience both depressive and anxiety symptoms. Patients who were admitted to the heart failure unit reported higher risk of experiencing both symptoms compared to patients in other wards. Similarly, patients admitted to the cardiac surgery unit showed a higher risk of experiencing anxiety symptoms compared to other patients. The proposed screening procedure showed a good feasibility and acceptance. This study highlighted the importance of implementing a short screening procedure in hospitals dealing with cardiovascular inpatients to identify those individuals who require specific attention and interventions.

Suicidal ideation in patients with coronary heart disease and hypertension: Baseline results from the DEPSCREEN-INFO clinical trial

BACKGROUND

A high proportion of cardiac patients suffers from depression, which is an antecedent for suicidal ideation. This study identifies clinical vulnerabilities for suicidal ideation in cardiac patients.

METHODS

The primary outcome of the study was severity of suicidal ideation as measured with the Patient Health Questionnaire (PHQ-9) item No. 9. Covariates were demographics, cardiac characteristics (i.e., Canadian Cardiovascular Society angina rating of chest pain and New York Heart Association rating of shortness of breath), depression (PHQ-8,i.e., PHQ-9 minus item No. 9), anxiety (Generalized Anxiety Disorder-7, GAD-7), somatic symptoms (PHQ-15), illness perception (Brief-Illness Perception Questionnaire), and health-related quality of life (EuroQol-5D, EQ 5D).

RESULTS

Data from 1,976 patients were analysed. At least 14% (95% CI [12%, 16%]) of patients indicated suicidal ideations within the last 2 weeks. Bivariate analyses yielded associations between suicidal ideation and higher levels of depression severity, anxiety severity, somatic symptom burden, chest pain, shortness of breath, negative illness perceptions, reduced health-related quality of life, and a higher probability of living alone (all p < 0.001). A multivariable ordinal regression revealed depression severity and anxiety severity to show the highest associations with suicidal ideation (OR_PHQ-8  = 1.22, p < 0.001; OR_GAD-7  = 1.09, p < 0.001). Having a defibrillator implant was associated with a lower probability of suicidal ideation (OR = 0.27, p = 0.017).

CONCLUSIONS

This study identified several clinical vulnerabilities of suicidal ideation. The results stress the importance of screening for suicidal ideation in clinical practice.

Depression Screening in Cardiac Surgery Patients

BACKGROUND

Depression is common in patients with ischaemic heart disease and preoperative depression is a risk factor following coronary artery bypass grafting. The American Heart Association recommends depression screening in all patients with heart disease. Our aim was to assess the feasibility and results of a depression screening program in cardiac surgery patients.

METHODS

We introduced a depression screening project at the cardiac surgery department at Karolinska University Hospital and included patients between 2013 and 2016. Patients scheduled for elective surgery recieved the Patient Health Questionnaire (PHQ-9), a depression screening instrument, by mail approximately 2weeks before surgery. Urgent patients recieved the PHQ-9 on the ward. Baseline characteristics, medical history, and medications were collected from patient charts, and entered into a study database together with the results from the PHQ-9 questionaires.

RESULTS

During the study period, 2,512 patients underwent cardiac sugery; 1,133 (45%) completed PHQ-9. The response-rate in patients scheduled for elective surgery was 64%, and 15% in urgent patients. Fifteen per cent (15%) had a PHQ-9 score ≥10 suggestive of major depression. Reporting a PHQ-9 score ≥10 was twice as common in women as in men (23% vs 12%).

CONCLUSIONS

Systematic depression screening using PHQ-9 in cardiac surgery patients was feasible and not very resource-intensive. The project showed a satisfactory response-rate in elective patients, but adjustments to increase the response-rate in urgent patients are needed. Future studies should investigate if and how patients with symptoms of depression would benefit from depression management.

Prevalence of depression in cardiovascular patients in Iran: A systematic review and meta-analysis from 2000 to 2017

BACKGROUND

In both developed and developing countries, cardiovascular disease is on the rise, representing nowadays one of the main challenges for the health systems worldwide. This increase generates relevant costs. The aim of this study was to conduct a systematic and meta-analytical review of the prevalence of depression in cardiovascular patients in Iran.

METHODS

Articles written in English and Persian were searched from January 2000 to July 2017 in different scholarly databases.

RESULTS

12 studies were retained and included in the current meta-analysis. Selected studies were published between 2008 and 2016. The number of patients participating in these studies was 9292. Based on the random-effects model, the prevalence of depression in cardiovascular patients in Iran was 47% [95% confidence interval or CI 38-56], I²=98.2% with P = 0.000. The relative risk (RR) of depression in cardiovascular patients yielded a value of 1.30 [95%CI 1.05-1.62] with P < 0.001. Women are more at risk for depression than men.

CONCLUSION

The current meta-analysis estimated the prevalence of depression among cardiovascular patients in Iran. The prevalence found computed by the present study is higher than the figures found in developed countries. Depression with cardiovascular disease causes many problems for these patients, and early diagnosis and treatment significantly helps in improving quality of life, as well as saving costs and resources.

The impact of major physical diseases and its outcomes on depressive symptoms among Chinese population

BACKGROUND

Depression was common among people with physical diseases. Evidence was lacked on the impact of outcomes of physical diseases on mental health.

AIM

Using a national representative data of the China Health and Retirement Longitudinal Study, we aimed to explore the impact of major physical diseases and its outcomes on mental health among Chinese population.

METHODS

Using a multi-stage cluster sampling design, the CHARLS survey collected information of 19 549 subjects in the 2013/2014 follow-up survey. Depressive symptoms were measured by the 10-item version of the Center for Epidemiological Studies Depression (CES-D).

RESULTS

The prevalence rate of depressive symptoms in the study population was 21.2%. Major physical diseases were significantly associated with depressive symptoms. Compared to people who did not experience major physical diseases, participants who fully recovered after hospitalization were at similar level of developing depressive symptoms (OR = 1.16), participants who experienced major physical diseases but were not admitted to hospitals were more likely to develop depressive symptoms (OR = 2.14), and those who discharged from hospitals without recovery were also more likely to have depressive symptoms (OR = 2.24).

CONCLUSIONS

Screening for depression among hospitalized population and training among general practitioners were necessary. During hospitalization, collaborative care for both physical and mental health could be beneficial.

Screening for depression in primary care: a Rasch analysis of the PHQ-9

Aims and method To explore the modern psychometric properties of the Patient Health Questionnaire (PHQ-9), we used the Rasch analysis in a sample of 767 primary care patients with depression. Results The analysis highlighted dependency issues between items 1 and 2 ('Little interest or pleasure in doing things' and 'Feeling down, depressed, or hopeless'), and items 3 and 4 ('Trouble falling or staying asleep, or sleeping too much' and 'Feeling tired or having little energy'). Items 1 and 2 displayed an over-discrimination, suggesting their potential redundancy within the complete item set. Clinical implications In its current format the PHQ-9 displays some problems with regard to its measurement structure among a sample of primary care patients. These problems can be addressed by removing potentially redundant items to deliver a stable screening tool. The results also lend support for the PHQ-2 to be used as a screening tool in a primary care setting.

Depression in heart failure: Intricate relationship, pathophysiology and most updated evidence of interventions from recent clinical studies

Heart failure (HF) is a burgeoning chronic health condition affecting more than 20million people worldwide. Patients with HF have a significant (17.1%) 30-day readmission rate, which invites substantial penalty in payment to hospitals from Centers for Medicare and Medicaid Services, as per the newly introduced Hospital Readmissions Reduction Program. Depression is one of the important risk factors for readmission in HF patients. It has a significant prevalence in patients with HF and contributes to the overall poor quality of life in them. Several behavioral (smoking, obesity, lack of exercise and medication noncompliance) and pathophysiological factors (hypercortisolism, elevated inflammatory biomarkers, fibrinogen, and atherosclerosis) have been found responsible for the adverse outcome in patients with HF and concomitant depression. Hippocampal volume loss noted in patients with acute HF exacerbations may contribute to the development of depressive symptoms in them. Screening for depression in HF patients continues to be challenging due to a considerable overlap in symptoms. Published trials on the use of antidepressants and cognitive behavioral therapy (CBT) have shown variable outcomes. Newer modalities like internet-based CBT have been tried in small studies, with promising results. A recent meta-analysis observed the beneficial role of aerobic exercise training in patients with HFrEF. Future long-term prospective studies may contribute to the formulation of a detailed screening and management guideline for patients with HF and depression. Our review is aimed to summarize the intricate relationship between depression and heart failure, with respect to their epidemiology, pathophysiological aspects, and optimal management approach.

Relevance of depression for anticoagulation management in a routine medical care setting: results from the ThrombEVAL study program

BACKGROUND

Depressive symptoms have detrimental effects on quality of life and mortality. Poor adherence to a treatment regimen is a potential mechanism for the increased risk of adverse medical events associated with depression. Regarding oral anticoagulation with vitamin K antagonists, adherence is crucial for the outcome. Little is known about the clinical relevance of current depressiveness for anticoagulation treatment.

OBJECTIVES

To examine the impact of current depressiveness on anticoagulation treatment in regular medical care.

PATIENTS/METHODS

We examined the association between clinically significant depressiveness as assessed by the Patient Health Questionnaire-2 ≥ 2 (PHQ-2 ≥ 2) with the percentage of time in the therapeutic range (TTR), self-rated compliance, several aspects of health literacy, anticoagulation side-effects and treatment satisfaction in a cross-sectional study of 1790 oral anticoagulation outpatients.

RESULTS

Seven hundred and sixteen participants (40.0%) had clinically significant depressive symptoms. Depressed persons reported lower compliance with intake of prescribed medication and regular visits for control of anticoagulation, more unspecific side-effects (e.g. pruritus) and lower satisfaction with the anticoagulation treatment and their doctors' expertise and empathy. Depressed as compared with non-depressed individuals had a lower TTR (-4.67; 95% CI, -8.39 to -0.95). Increasing severity of depressiveness was related with decreasing TTR. However, depressiveness lost its significant impact on TTR after multivariable adjustment (-3.11; 95% CI, -6.88 to 0.66).

CONCLUSIONS

Clinically significant depressiveness was highly prevalent and impaired several aspects of anticoagulation treatment. Depressiveness should be regarded as a clinically significant condition that needs to be addressed in the management of anticoagulation patients.

Screening for geriatric depression in residential care facilities: a systematic narrative review

Studies in residential care facilities suggest that routine screening can assist in the early detection of geriatric depression. However, the effectiveness of screening instruments in residential care in the US and Canada has not been adequately evaluated. We conducted a systematic narrative review of the English-language literature published between 2000 and 2010 on screening instruments used for depression detection in older adults living in residential care facilities. The review yielded nine scales and their modifications tested in residential care, which we evaluated. We provide specific recommendations for the use of effective scales and discuss implications for practice, policy and research.

Depression screening among older adults attending low-vision rehabilitation and eye-care services: Characteristics of those who screen positive and client acceptability of screening

AIM

To investigate characteristics associated with screening positive for depressive symptoms among older adults accessing low-vision rehabilitation and eye-care services and to determine client acceptability of depression screening using the Patient Health Questionnaire-2 (PHQ-2) in these settings.

METHODS

One-hundred and twenty-four older adults (mean = 77.02 years, SD = 9.12) attending low-vision rehabilitation and eye-care services across Australia were screened for depression and invited to complete a telephone-administered questionnaire to determine characteristics associated with depressive symptoms and client acceptability of screening in these settings.

RESULTS

Thirty-seven per cent (n = 46/124) of participants screened positive for depressive symptoms, and the majority considered the new depression screening method to be a 'good idea' in vision services (85%). Severe vision loss (<6/60 in the better eye) was associated with an increased odds of screening positive for depressive symptoms (odds ratio 2.37; 95% confidence interval 1.08-6.70) even after adjusting for potential confounders. Participants who screened positive had a preference for 'talking' therapy or a combination of medication and 'talking therapy' delivered within their own home (73%) or via telephone (67%).

CONCLUSION

The PHQ-2 appears to be an acceptable method for depression screening in eye-care settings among older adults. Targeted interventions that incorporate home-based or telephone delivered therapy sessions may improve outcomes for depression in this group.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Effect of Educational Intervention on Nurses' Attitudes and Beliefs about Depression in Heart Failure Patients

Systematic depression screening is feasible, efficient, and well accepted; however the lack of consistent assessment in heart failure inpatients suggests barriers preventing its effective diagnosis and treatment. This pilot study assessed the impact of an educational intervention on nurses' beliefs about depression and their likelihood of routinely screening heart failure patients. Registered nurses (n = 35) from adult medical-surgical units were surveyed before and after an educational intervention to assess their beliefs about depression prevalence and screening in heart failure patients. There was no significant influence on nurses' beliefs about depression, but the results suggested an increased likelihood that nurses would routinely screen for depression. The moderately significant correlation between beliefs and intent to screen for depression indicates that educational intervention could ultimately have a positive influence on patient outcomes through early detection and treatment of depression in patients with cardiovascular disease; however the observed increase in the intent to screen without a corresponding change in beliefs indicates other influences affecting nurses' intent to screen heart failure patients for depression.

Diagnosis and treatment of depression in patients with congestive heart failure: a review of the literature

CONTEXT

Major depressive disorder (MDD) can be challenging to diagnose in patients with congestive heart failure, who often suffer from fatigue, insomnia, weight changes, and other neurovegetative symptoms that overlap with those of depression. Pathophysiologic mechanisms (eg, inflammation, autonomic nervous system dysfunction, cardiac arrhythmias, and altered platelet function) connect depression and congestive heart failure.

OBJECTIVE

We sought to review the prevalence, diagnosis, neurobiology, and treatment of depression associated with congestive heart failure.

DATA SOURCES

A search of all English-language articles between January 2003 and January 2013 was conducted using the search terms congestive heart failure and depression.

STUDY SELECTION

We found 1,498 article abstracts and 19 articles (meta-analyses, systematic reviews, and original research articles) that were selected for inclusion, as they contained information about our focus on diagnosis, treatment, and pathophysiology of depression associated with congestive heart failure. The search was augmented with manual review of reference lists of articles from the initial search. Articles selected for review were determined by author consensus.

DATA EXTRACTION

The prevalence, diagnosis, neurobiology, and treatment of depression associated with congestive heart failure were reviewed. Particular attention was paid to the safety, efficacy, and tolerability of antidepressant medications commonly used to treat depression and how their side-effect profiles impact the pathophysiology of congestive heart failure. Drug-drug interactions between antidepressant medications and medications used to treat congestive heart failure were examined.

RESULTS

MDD is highly prevalent in patients with congestive heart failure. Moreover, the prevalence and severity of depression correlate with the degree of cardiac dysfunction and development of congestive heart failure. Depression increases the risk of congestive heart failure, particularly in those patients with coronary artery disease , and is associated with a poorer quality of life, increased use of health care resources, more frequent adverse clinical events and hospitalizations, and twice the risk of mortality.

CONCLUSIONS

At present, limited empirical data exist with regard to treatment of depression in the increasingly large population of patients with congestive heart failure. Evidence reveals that both psychotherapeutic treatment (eg, cognitive-behavioral therapy) and pharmacologic treatment (eg, use of the selective serotonin reuptake inhibitor sertraline) are safe and effective in reducing depression severity in patients with cardiovascular disease. Collaborative care programs featuring interventions that work to improve adherence to medical and psychiatric treatments improve both cardiovascular disease and depression outcomes. Depression rating scales such as the 9-item Patient Health Questionnaire should be used to monitor therapeutic efficacy.

Feasibility and utility of screening for depression and anxiety disorders in patients with cardiovascular disease

BACKGROUND

Depression and anxiety in patients with cardiac disease are common and independently associated with morbidity and mortality. We aimed to explore the use of a 3-step approach to identify inpatients with cardiac disease with depression, generalized anxiety disorder (GAD), or panic disorder; understand the predictive value of individual screening items in identifying these disorders; and assess the relative prevalence of these disorders in this cohort.

METHODS AND RESULTS

To identify depression and anxiety disorders in inpatients with cardiac disease as part of a care management trial, an iterative 3-step screening procedure was used. This included an existing 4-item (Coping Screen) tool in nursing data sets, a 5-item screen for positive Coping Screen patients (Patient Health Questionnaire-2 [PHQ-2], GAD-2, and an item about panic attacks), and a diagnostic evaluation using PHQ-9 and the Primary Care Evaluation of Mental Disorders anxiety disorder modules. Overall, 6210 inpatients received the Coping Screen, 581 completed portions of all 3 evaluation steps, and 210 received a diagnosis (143 depression, 129 GAD, 30 panic disorder). Controlling for age, sex, and the other screening items, PHQ-2 items independently predicted depression (little interest/pleasure: odds ratio [OR]=6.65, P<0.001; depression: OR=5.24, P=0.001), GAD-2 items predicted GAD (anxious: OR=4.09, P=0.003; unable to control worrying: OR=10.46, P<0.001), and the panic item predicted panic disorder (OR=49.61, P<0.001).

CONCLUSIONS

GAD was nearly as prevalent as depression in this cohort, and GAD-2 was an effective screening tool; however, panic disorder was rare. These results support the use of 2-step screening for depression and GAD beginning with a 4-item scale (GAD-2 plus PHQ-2).

CLINICAL TRIAL REGISTRATION

Unique Identifier: NCT01201967. URL: http://www.clinicaltrials.gov/ct2/show/NCT01201967.

Depression and cardiac disease: epidemiology, mechanisms, and diagnosis

In patients with cardiovascular disease (CVD), depression is common, persistent, and associated with worse health-related quality of life, recurrent cardiac events, and mortality. Both physiological and behavioral factors—including endothelial dysfunction, platelet abnormalities, inflammation, autonomic nervous system dysfunction, and reduced engagement in health-promoting activities—may link depression with adverse cardiac outcomes. Because of the potential impact of depression on quality of life and cardiac outcomes, the American Heart Association has recommended routine depression screening of all cardiac patients with the 2- and 9-item Patient Health Questionnaires. However, despite the availability of these easy-to-use screening tools and effective treatments, depression is underrecognized and undertreated in patients with CVD. In this paper, we review the literature on epidemiology, phenomenology, comorbid conditions, and risk factors for depression in cardiac disease. We outline the associations between depression and cardiac outcomes, as well as the mechanisms that may mediate these links. Finally, we discuss the evidence for and against routine depression screening in patients with CVD and make specific recommendations for when and how to assess for depression in this high-risk population.

Depression and chronic diseases: it is time for a synergistic mental health and primary care approach

OBJECTIVE

To identify the growing significance of depression as a global leading cause of years lost to disability and its role as a major independent risk factor in many chronic illnesses. The distinct effects of depression on morbidity and mortality in cancer, diabetes, heart disease, and stroke are investigated, including behavioral factors and plausible biological mechanisms (psychoneuroimmunology of depression).

DATA SOURCES

PubMed articles in English were searched from 1992 to 2012 (20-year span) using the following search criteria: psychoneuroimmunology of depression, immune-mediated inflammation, depression treatment recommendations, depression screening, years lost to disability, underserved populations and depression, chronic illnesses and depression, and selective serotonin reuptake inhibitors and immune system.

DATA SYNTHESIS

Evidence of the robust bidirectional relationship between depression and individual chronic diseases is presented and discussed. A brief overview of currently recommended psychotherapeutic and psychopharmacologic treatment approaches in regard to depression in chronic diseases is provided.

RESULTS

Discordance between mental health and primary care within the US public health system is a systematic problem that must be addressed. This situation leads to a potentially high hidden prevalence of underdiagnosed and undertreated depression, especially in the underserved populations.

CONCLUSION

Measures must be implemented across the communities of mental health and primary care practitioners in order to achieve a synergistic approach to depression.

Lessons learned from study of depression in cardiovascular patients in an acute-care heart and vascular hospital

Depression is highly prevalent in patients with cardiovascular disease, but questions about the effectiveness of screening and intervention remain unanswered. To evaluate the effects of proactive intervention at an acute-care heart and vascular hospital, patients who reported depressive symptoms on admission were randomized to an active, counseling-based depression intervention plus standard care (referral to a primary or psychiatric care physician) or to standard care alone. Despite early termination of patient enrollment because of lower-than-expected recruitment rates, the project had a positive impact. By involving and educating staff, the investigators raised awareness and improved the process of identifying and helping depressed patients. The lessons in study design and execution gained from this experience will help ensure success in future studies of this condition.

Does evidence support the American Heart Association's recommendation to screen patients for depression in cardiovascular care? An updated systematic review

Objectives

To systematically review evidence on depression screening in coronary heart disease (CHD) by assessing the (1) accuracy of screening tools; (2) effectiveness of treatment; and (3) effect of screening on depression outcomes.

Background

A 2008 American Heart Association (AHA) Science Advisory recommended routine depression screening in CHD.

Methods

CINAHL, Cochrane, EMBASE, ISI, MEDLINE, PsycINFO and SCOPUS databases searched through December 2, 2011; manual journal searches; reference lists; citation tracking; trial registries. Included articles (1) compared a depression screening instrument to a depression diagnosis; (2) compared depression treatment to placebo or usual care in a randomized controlled trial (RCT); or (3) assessed the effect of screening on depression outcomes in a RCT.

Results

There were few examples of screening tools with good sensitivity and specificity using a priori-defined cutoffs in more than one patient sample among 15 screening accuracy studies. Depression treatment with antidepressants or psychotherapy generated modest symptom reductions among post-myocardial infarction (post-MI) and stable CHD patients (N = 6; effect size = 0.20–0.38), but antidepressants did not improve symptoms more than placebo in 2 heart failure (HF) trials. Depression treatment did not improve cardiac outcomes. No RCTs investigated the effects of screening on depression outcomes.

Conclusions

There is evidence that treatment of depression results in modest improvement in depressive symptoms in post-MI and stable CHD patients, although not in HF patients. There is still no evidence that routine screening for depression improves depression or cardiac outcomes. The AHA Science Advisory on depression screening should be revised to reflect this lack of evidence.

Depression screening: utility of the patient health questionnaire in patients with acute coronary syndrome

BACKGROUND

Depression screening in cardiac patients has been recommended by the American Heart Association, but the best approach remains unclear.

OBJECTIVES

To evaluate nurse-administered versions of the Patient Health Questionnaire for depression screening in patients hospitalized for acute coronary syndrome.

METHODS

Staff nurses in an urban cardiac care unit administered versions 2, 9, and 10 of the questionnaire to 100 patients with acute coronary syndrome. The Depression Interview and Structured Hamilton was administered by advanced practice nurses blinded to the results of the Patient Health Questionnaire. With the results of the Depression Interview and Structured Hamilton as a criterion, receiver operating characteristic analyses were done for each version of the Patient Health Questionnaire. The Delong method was used for pairwise comparisons. Cutoff scores balancing false-negatives and false-positives were determined by using the Youden Index.

RESULTS

Each version of the questionnaire had excellent area-under- the-curve statistics: 91.2%, 92.6%, and 93.4% for versions 2, 9, and 10, respectively. Differences among the 3 versions were not significant. Each version yielded higher symptom scores in depressed patients than in nondepressed patients: version 2 scores, 3.4 vs 0.6, P = .001; version 9 scores, 13 vs 3.4, P < .001; and version 10 scores, 14.5 vs 3.6, P < .001.

CONCLUSIONS

For depression screening in hospitalized patients with acute coronary syndrome, the Patient Health Questionnaire 2 is as accurate as longer versions when administered by nurses. Further study is needed to determine if screening with this tool changes clinical decision making or improves outcomes in these patients.

Risk factors for positive depression screens in hospitalized cardiac patients

BACKGROUND

Depression is common in patients with cardiac illness and is independently associated with elevated morbidity and mortality. There are screening guidelines for depression in cardiac patients, but the feasibility and cost-effectiveness of screening all cardiac patients is controversial. This process may be improved if a subset of cardiac patients at high risk for depression could be identified using information readily available to clinicians and screened.

OBJECTIVE

To identify risk factors for a positive depression screen at the time of admission in hospitalized cardiac patients.

METHODS

A total of 561 consecutively screened cardiac inpatients underwent the Patient Health Questionnaire-2 (PHQ-2). A prospective chart review was performed to assess potential risk factors for depression that would be readily available to front-line clinicians. Rates of risk factors were compared between patients with positive and negative PHQ-2 depression screens, and multivariate logistic regression was performed to assess whether specific risk factors were independently associated with positive screens.

RESULTS

Of the 561 patients screened, 13.5% (n=76) had a positive depression screen (PHQ-2≥2). In the univariate analyses, several variables were associated with a positive depression screen. On multivariate analysis, an elevated white blood cell (WBC) count (>10×10(9) cells per liter) and prescription of an antidepressant on admission were independently associated with a positive depression screen, while current smoking showed a trend toward significance.

CONCLUSION

Information on these three identified risk factors (WBC count, antidepressant use, and smoking) is readily available to clinicians, and patients with these diagnoses may represent a cohort who would benefit from targeted depression screening in certain settings.

Recognition and referral of depression in patients with heart disease

BACKGROUND

Routine screening and assessment for depression occurs rarely in clinical practice for a variety of reasons, including the absence of systems to facilitate the process.

AIM

To identify nurses' knowledge and practice regarding depression screening and referral for cardiac patients following the implementation of education workshops and a validated screening tool with referral actions.

METHODS

Pre and post-test design using surveys and semi-structured interviews was conducted with a purposive sample of nurses in a large Australian metropolitan tertiary referral hospital. Prior to the introduction of the screening and referral tool, nurses engaged in an interactive one hour education workshop on the topic of depression and the tool; introduced to improve depression screening following an acute cardiac event.

RESULTS

In the pre and post-survey 40 and 30 nurses, respectively, participated with 14 also engaging in semi-structured interviews. Eighty percent reported a 'good' understanding of depression post-program compared to 30% at baseline. Sixty percent reported routinely using the depression screening and referral tool. The interviews identified three main themes that supported the utility of the education and instrument: knowledge improvement; perceived self-efficacy and new knowledge into practice.

CONCLUSION

The vast majority of participants reported increased skill, knowledge and confidence to screen and refer for depression post an acute cardiac event. The substantial increase in the number of nurses who engaged in screening and referral actions further demonstrated the success of the program. These encouraging results provide evidence that screening for depression can be achieved through adopting formalised processes.

Validation of simple visual-analogue thermometer screen for mood complications of cardiovascular disease: the Emotion Thermometers

OBJECTIVE

Conventional scales may help with the identification of depression but are generally too lengthy for clinical practice and perform poorly against anxiety and distress. We therefore examined the value of a single item NCCN Distress Thermometer and an enhanced visual-analogue method (Emotion Thermometers, ET) that incorporates four emotion thermometers.

METHODS

We examined 228 patients with mixed cardiovascular conditions of whom 200 completed questionnaires. 64.5% suffered from cardiomyopathy/congestive heart failure, 9.5% had coronary artery disease, 4.5% had multiple cardiac diagnoses, 3% suffered from hypertension, 2% had rhythm problem, 2% had valve problems and 1.5% were diagnosed with atrial fibrillation. We used DSM-IV criteria to define current depression, the GAD7 to define current anxiety and the HADS-T to define distress. 13% had DSM-IV MDD and 19.1% had major or minor depression using DSM-IV (any depression). There were also 59 people (29.6%) with clinically significant distress and 46 with clinically significant anxiety (23.1%).

RESULTS

The optimal accuracy for major depression was either the Depression thermometer (DepT) or the Help thermometer (HelpT), as both performed well. They had a sensitivity and specificity of 73.1%, 89.7% and 84.6%, 85.6%, respectively. The DepT was also best for detecting any DSM-IV depression (sensitivity 68.4% and specificity 93.2%) and HAD-T based distress (sensitivity 79.7% and specificity 82.9%). The Anxiety thermometer (AnxT) performed best against the GAD7 (sensitivity 84.8% and specificity 83.7%).

CONCLUSION

Innovative visual-analogue screening tools for mood appear to perform well in cardiovascular settings.

Clinical utility of screening for clinical depression and bipolar disorder

PURPOSE OF REVIEW

Screening for clinical depression and bipolar disorder remains controversial. Screening is usually based on finding discriminating symptoms, but not all tools perform equally well. Clinicians should be able to assess the clinical utility of screening tests as well as their accuracy and acceptability.

RECENT FINDINGS

Screening for depression using the Patient Health Questionnaire (PHQ) has been extensively examined. Four main versions of scoring the PHQ exist. The two-item PHQ2, the nine-item PHQ9, the PHQ DSM-IV algorithm, and the two-step PHQ2 then PHQ9. Recent results suggest that the PHQ9 is more accurate than the PHQ2, and that the algorithm scoring method is preferred to the linear cut-off score. The two-step procedure has promise, but it has not been adequately tested. Two screening questions may be a useful compromise in medical settings, as they take less than 2 min, but about a quarter of patients do not receive screening even when implemented systematically. Alternative customized questionnaires have been developed in medical settings such as the Depression Screening in Parkinson's Disease DESPAR and Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). Screening for bipolar disorders is an even greater challenge than screening for unipolar depression. Screening in primary care and the community has low positive predictive value. Screening in high-risk samples, such as those with known depression is somewhat more successful, but not yet sufficiently accurate to be used alone.

SUMMARY

Screening for depression can bring added value to routine unassisted recognition, but only if followed by good-quality treatment. Screening for bipolar disorder is not yet sufficiently accurate to be used reliably in clinical practice.

Emotional triggering and low socio-economic status as determinants of depression following acute coronary syndrome

BACKGROUND

The determinants of depression following acute coronary syndrome (ACS) are poorly understood. Triggering of ACS by emotional stress and low socio-economic status (SES) are predictors of adverse outcomes. We therefore investigated whether emotional triggering and low SES predict depression and anxiety following ACS.

METHOD

This prospective observational clinical cohort study involved 298 patients with clinically verified ACS. Emotional stress was assessed for the 2 h before symptom onset and compared with the equivalent period 24 h earlier using case-crossover methods. SES was defined by household income and education. Depression was measured with the Beck Depression Inventory and the Hamilton Rating Scale for Depression and anxiety with the Hospital Anxiety and Depression Scale 3 weeks after ACS and again at 6 and 12 months. Age, gender, ethnicity, marital status, the Global Registry of Acute Coronary Events risk score, duration of hospital stay and history of depression were included as covariates.

RESULTS

Emotional stress during the 2-h hazard period was associated with increased risk of ACS (odds ratio 1.88, 95% confidence interval 1.01-3.61). Both low income and emotional triggering predicted depression and anxiety at 3 weeks and 6/12 months independently of covariates. The two factors interacted, with the greatest depression and anxiety in lower income patients who experienced acute emotional stress. Education was not related to depression.

CONCLUSIONS

Patients who experience acute emotional stress during their ACS and are lower SES as defined by current affluence and access to resources are particularly vulnerable to subsequent depression and anxiety.

The puzzle of depression and acute coronary syndrome: reviewing the role of acute inflammation

The relationship between depression and coronary heart disease is well-established, but causal mechanisms are poorly understood. The aim of this review is to stimulate different ways of viewing the relationship between depression and adverse outcomes following acute coronary syndrome (ACS) and coronary artery bypass graft (CABG) surgery patients. We present an argument for depression in ACS and CABG patients being a qualitatively distinct form from that observed in psychiatric populations. This is based on three features: (1) depression developing after cardiac events has been linked in many studies to poorer outcomes than recurrent depression; (2) somatic symptoms of depression following cardiac events are particularly cardiotoxic; (3) depression following an ACS does not respond well to antidepressant treatments. We propose that inflammation is a common causal process responsible in part both for the development of depressive symptoms and for adverse cardiac outcomes, and we draw parallels with inflammation-induced sickness behaviour. Clinical implications of our observations are discussed along with suggestions for further work to advance the field.

Depression and cardiac disease: a review

Depression is highly prevalent in cardiac patients, with 20% to 40% of patients meeting criteria for major depressive disorder or experiencing an elevation in depressive symptoms. These depressive symptoms are often chronic and persistent, and they have been associated with the development and progression of coronary artery disease, worse health-related quality of life, poor physical functioning, recurrent cardiac events, and a 2- to 2.5-fold increased risk of mortality. Impaired adherence to health behaviors and adverse physiological effects of depression, including inflammation, endothelial dysfunction, platelet hyperactivity, and autonomic nervous system abnormalities, may link depression with adverse cardiac outcomes. Pharmacologic and psychotherapeutic interventions appear to be safe and effective at reducing depressive symptoms in patients with cardiovascular disease and may impact cardiac outcomes. Unfortunately, depression often is unrecognized and untreated in this population, despite the availability of brief screening tools that can be used for this purpose. We recommend the routine screening of cardiac patients for depression when there are adequate mechanisms for management and referral, such as available consulting psychiatrists or care management programs that facilitate the delivery of pharmacologic and psychotherapeutic treatments in this vulnerable population.

Depression screening in patients with coronary heart disease: a critical evaluation of the AHA guidelines

OBJECTIVE

We lack evidence that routine screening for depression in patients with coronary heart disease (CHD) improves patient outcome. This lack has challenged the advisory issued by the American Heart Association (AHA) to routinely screen for depression in CHD patients. We assess the AHA advisory in the context of well-established criteria of screening for diseases.

METHODS

Using principles and criteria for screening developed by the World Health Organization and the United Kingdom National Screening Committee, we generated criteria pertinent to screening for depression in CHD patients. To find publications relevant to these criteria and clinical setting, we performed a broadly based literature search on "depression and CHD," supplemented by more focused literature searches.

RESULTS

Evidence for an association between depression and CHD is strong. Despite this, the AHA advisory has several limitations. It did not account for the complexity of the association between depression and CHD. It acknowledged there was no evidence that screening for depression leads to improved outcomes in cardiovascular populations but still recommended routine screening without providing an alternative evidence-based explanation. It ignored the paucity of literature about the safety and cost-effectiveness of routine screening for depression in CHD and failed to define the nature and extent of resources needed to implement such a program effectively.

CONCLUSION

We conclude that the AHA advisory is premature. We must first demonstrate the efficacy, safety, and cost-effectiveness of screening and define the resources necessary for its implementation and monitoring. Meanwhile, organizations representing cardiologists, psychiatrists, and general practitioners must coordinate efforts to manage depression and CHD through collaborative care, and work with the policy makers to develop the necessary infrastructure and services delivery system needed to optimize the outcome of depressed and at-risk-for-depression patients suffering from CHD.

A multinational study of the influence of health-related quality of life on in-hospital outcome after coronary artery bypass graft surgery

BACKGROUND

The effect of health-related quality of life on in-hospital outcomes after coronary artery bypass grafting surgery has not been investigated in international multicenter studies. We hypothesized that poor preoperative health status is associated with mortality and length of hospital stay.

METHODS

In the Multicenter Study of Perioperative Ischemia Epidemiology II, preoperative Short-Form 12, Mental Component Summary (MCS), and Physical Component Summary (PCS) scores were obtained prospectively from 4,811 patients (3,834 men, 977 women) undergoing coronary artery bypass grafting surgery at 72 centers in 17 countries. Primary outcome measures were in-hospital mortality and prolonged (>14 days) length of hospital stay.

RESULTS

One hundred fifty-one patients (3.1%) died. After adjustment for regional differences, a 10-point reduction in MCS score was associated with higher mortality risk (odds ratio [OR] 1.17, 95% CI 1.004-1.37, P = .04) and prolonged hospital stay (OR 1.11, 95% CI 1.01-1.21, P = .03). The preoperative PCS score was not associated with mortality risk but significantly predicted prolonged length of hospital stay (OR 1.20, 95% CI 1.09-1.33, P < .001). There was no significant interaction between gender and either the MCS or the PCS score.

DISCUSSION

The preoperative PCS predicted prolonged postoperative hospital stay, whereas the preoperative MCS score was an independent predictor of both prolonged length of hospital stay and mortality. Preoperative assessment of health-related quality of life factors with the Short-Form 12 might be a useful tool for risk stratification and planning for hospital discharge and rehabilitation.

Real-world lessons from the implementation of a depression screening protocol in acute myocardial infarction patients: implications for the American Heart Association depression screening advisory

BACKGROUND

The American Heart Association (AHA) statement has recommended routine screening for depression in coronary artery disease with a 2-stage implementation of the Patient Health Questionnaire (PHQ). Because there is little evidence on feasibility, accuracy, and impact of such a program on depression recognition in coronary patients, the AHA recommendation has met substantial debate and criticism.

METHODS AND RESULTS

Before the AHA statement was released, the Mid America Heart and Vascular Institute (MAHVI) had implemented a depression screening protocol for patients with acute myocardial infarction that was virtually identical to the AHA recommendations. To (1) evaluate this MAHVI quality improvement initiative, (2) compare MAHVI depression recognition rates with those of other hospitals, and (3) examine health care providers' implementation feedback, we compared the results of the MAHVI screening program with data from a parallel prospective acute myocardial infarction registry and interviewed MAHVI providers. Depressive symptoms (PHQ-2, PHQ-9) were assessed among 503 MAHVI acute myocardial infarction patients and compared with concurrent depression assessments among 3533 patients at 23 US centers without a screening protocol. A qualitative summary of providers' suggestions for improvement was also generated. A total of 135 (26.8%) eligible MAHVI patients did not get screened. Among screened patients, 90.9% depressed (PHQ-9 ≥10) patients were recognized. The agreement between the screening and registry data using the full PHQ-9 was 61.5% for positive cases (PHQ-9 ≥10) but only 35.6% for the PHQ-2 alone. Although MAHVI had a slightly higher overall depression recognition rate (38.3%) than other centers not using a depression screening protocol (31.5%), the difference was not statistically significant (P=0.31). Staff feedback suggested that a single-stage screening protocol with continuous feedback could improve compliance.

CONCLUSIONS

In this early effort to implement a depression screening protocol, a large proportion of patients did not get screened, and only a modest impact on depression recognition rates was realized. Simplifying the protocol by using the PHQ-9 alone and providing more support and feedback may improve the rates of depression detection and treatment.

Impact of a depression care management program for hospitalized cardiac patients

BACKGROUND

Depression is independently associated with poor outcomes among patients with acute cardiac disease. Collaborative care depression management programs have been used in outpatients to improve depression outcomes, but such a program had never been initiated in the hospital or used for patients with a wide range of cardiac illnesses.

METHODS AND RESULTS

This was a prospective, randomized trial of a low-intensity, 12-week collaborative care program versus usual care for 175 depressed patients hospitalized for acute coronary syndrome, arrhythmia, or heart failure. Study outcomes, assessed using mixed regression models to compare groups at 6 weeks, 12 weeks, and 6 months, included mental health (depression, cognitive symptoms of depression, anxiety, and mental health-related quality of life) and medical (physical health-related quality of life, adherence to medical recommendations, and cardiac symptoms) outcomes. Collaborative care subjects (n=90) had significantly greater improvements on all mental health outcomes at 6 and 12 weeks, including rates of depression response (collaborative care, 59.7% versus usual care 33.7%; odds ratio, 2.91; P=0.003 at 6 weeks; 51.5% versus 34.4%; odds ratio, 2.02; P=0.04 at 12 weeks), though these effects decreased after intervention. At 6 months, intervention subjects had significantly greater self-reported adherence and significantly reduced number and intensity of cardiac symptoms.

CONCLUSIONS

Among patients with a broad range of cardiac diagnoses, a collaborative care depression management program initiated during hospitalization led to significant improvements in multiple clinically important mental health outcomes and had promising effects on relevant medical outcomes after intervention. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00847132.