Anxiety, anger, and mortality risk among survivors of myocardial infarction

Anger and aggression research: A bibliometric analysis from 2012 to 2022

Anger and aggression are common sources of distress and impairment. There is, however, no available data on anger and aggression based on bibliometric analysis. This study uses bibliometric analysis to analyze research hotspots and trends in anger and aggression. Publications on anger and aggression within the last ten years were collected from the Web of Science Core Collection. Using descriptive bibliometrics, journals, countries, institutions, authors, references, and keywords in anger and aggression research were visually analyzed via CiteSpace. A total of 3114 articles were included, and studies on anger and aggression increased yearly. The publications are mainly from 106 countries led by the USA and 381 institutions led by Univ Penn. We identified 505 authors, where Emil F. Coccaro had the highest number of articles, while Buss A.H. was the most frequently co-cited author. AGGRESSIVE BEHAVIOR is the journal that bore most of the studies, while PLOS ONE was the most cited journal. Our analysis demonstrated that research on anger and aggression is flourishing. Behaviors of anger and aggression, risk factors, neural mechanisms, personality, and adolescence have been researched hotspots in the past ten years. Besides, victimization, drosophila melanogaster, psychopathic traits, and perpetration are emerging anger and aggression research trends.

The effects of positive psychology interventions on well-being and distress in patients with cardiovascular diseases: A systematic review and Meta-analysis

OBJECTIVE

Positive psychology interventions (PPIs) have been found to be effective for psychiatric and somatic disorders. However, a systematic review and meta-analysis of studies examining the effectiveness of PPIs for patients with cardiovascular disease (CVD) is lacking. This systematic review and meta-analysis aims to synthesize studies examining the effectiveness of PPIs and to examine their effects on mental well-being and distress using meta-analyses.

METHODS

This study was preregistered on OSF (https://osf.io/95sjg/). A systematic search was performed in PsycINFO, PubMed and Scopus. Studies were included if they examined the effectiveness of PPIs on well-being for patients with CVD. Quality assessment was based on the Cochrane tool for assessing risk of bias. Three-level mixed-effects meta-regression models were used to analyze effect sizes of randomized controlled trials (RCTs).

RESULTS

Twenty studies with 1222 participants were included, of which 15 were RCTs. Included studies showed high variability in study and intervention characteristics. Meta-analyses showed significant effects for mental well-being (β = 0.33) and distress (β = 0.34) at post-intervention and the effects were still significant at follow-up. Five of the 15 RCTs were classified as having fair quality, while the remaining had low quality.

CONCLUSION

These results suggest that PPIs are effective in improving well-being and distress in patients with CVD and could therefore be a valuable addition for clinical practice. However, there is a need for more rigorous studies that are adequately powered and that help us understand what PPIs are most effective for which patient.

Cardiovascular disease and subsequent risk of psychiatric disorders: a nationwide sibling-controlled study

Background

The association between cardiovascular disease (CVD) and selected psychiatric disorders has frequently been suggested while the potential role of familial factors and comorbidities in such association has rarely been investigated.

Methods

We identified 869,056 patients newly diagnosed with CVD from 1987 to 2016 in Sweden with no history of psychiatric disorders, and 910,178 full siblings of these patients as well as 10 individually age- and sex-matched unrelated population controls (N = 8,690,560). Adjusting for multiple comorbid conditions, we used flexible parametric models and Cox models to estimate the association of CVD with risk of all subsequent psychiatric disorders, comparing rates of first incident psychiatric disorder among CVD patients with rates among unaffected full siblings and population controls.

Results

The median age at diagnosis was 60 years for patients with CVD and 59.2% were male. During up to 30 years of follow-up, the crude incidence rates of psychiatric disorder were 7.1, 4.6, and 4.0 per 1000 person-years for patients with CVD, their siblings and population controls. In the sibling comparison, we observed an increased risk of psychiatric disorder during the first year after CVD diagnosis (hazard ratio [HR], 2.74; 95% confidence interval [CI], 2.62-2.87) and thereafter (1.45; 95% CI, 1.42-1.48). Increased risks were observed for all types of psychiatric disorders and among all diagnoses of CVD. We observed similar associations in the population comparison. CVD patients who developed a comorbid psychiatric disorder during the first year after diagnosis were at elevated risk of subsequent CVD death compared to patients without such comorbidity (HR, 1.55; 95% CI, 1.44-1.67).

Conclusions

Patients diagnosed with CVD are at an elevated risk for subsequent psychiatric disorders independent of shared familial factors and comorbid conditions. Comorbid psychiatric disorders in patients with CVD are associated with higher risk of cardiovascular mortality suggesting that surveillance and treatment of psychiatric comorbidities should be considered as an integral part of clinical management of newly diagnosed CVD patients.

Funding

This work was supported by the EU Horizon 2020 Research and Innovation Action Grant (CoMorMent, grant no. 847776 to UV, PFS, and FF), Grant of Excellence, Icelandic Research Fund (grant no. 163362-051 to UV), ERC Consolidator Grant (StressGene, grant no. 726413 to UV), Swedish Research Council (grant no. D0886501 to PFS), and US NIMH R01 MH123724 (to PFS).

Patient-reported outcomes, sociodemographic and clinical factors are associated with 1-year mortality in patients with ischemic heart disease-findings from the DenHeart cohort study

PURPOSE

In patients with ischemic heart disease, the objectives were (1) to explore associations between patient-reported outcomes, sociodemographic, and clinical factors at discharge and 1-year all-cause mortality and (2) to investigate the discriminant predictive performance of the applied patient-reported outcome instruments on 1-year all-cause mortality.

METHODS

Data from the Danish national DenHeart cohort study were used. Eligible patients (n = 13,476) were invited to complete a questionnaire-package, of which 7167 (53%) responded. Questionnaires included the 12-item Short form health survey (SF-12), Hospital anxiety and depression scale (HADS), EQ-5D, HeartQoL, Edmonton symptom assessment scale (ESAS), and ancillary questions on, e.g., social support. Clinical and demographic characteristics were obtained from registers, as were data on mortality. Comparative analyses were used to investigate differences in patient-reported outcomes. Mortality associations were explored using multifactorially adjusted Cox regression analyses. Predictive performance was analyzed using receiver operating characteristics (ROC).

RESULTS

Patient-reported outcomes at discharge differed among those alive versus those deceased at one year, e.g., depression (HADS-Depression ≥ 8) 19% vs. 44% (p < 0.001). Associations with 1-year mortality included feeling unsafe about returning home from the hospital; hazard ratio (HR) 2.07 (95% CI 1.2-3.61); high comorbidity level, HR 3.6 (95% CI 2.7-4.8); and being unmarried, HR 1.60 (95% CI 1.33-1.93). Best predictive performance was observed for SF-12 physical component summary (Area under the curve (AUC) 0.706).

CONCLUSION

Patient-reported health, sociodemographic, and clinical factors are associated with 1-year mortality. We propose systematic screening with robust predictive tools to identify patients at risk and healthcare initiatives to explore and offer effective treatment to modify patient-reported health indicators.

Anxiety and prognosis of patients with myocardial infarction: A meta-analysis

Although anxiety is highly prevalent after myocardial infarction (MI), but the association between anxiety and MI is not well established. This study aimed to provide an updated and comprehensive evaluation of the association between anxiety and short-term and long-term prognoses in patients with MI. Anxiety is associated with poor short-term and long-term prognoses in patients with MI. We performed a systematic search in the PubMed and Cochrane databases (January 2000-October 2020). The study endpoints were complications, all-cause mortality, cardiac mortality, and/or major adverse cardiac events (MACEs). Pooled data were synthesized using Stata SE12.0 and expressed as risk ratios (RRs) and 95% confidence intervals (CIs). We included 9373 patients with MI from 16 published studies. Pooled analyses indicated a correlation between high anxiety and poor clinical outcomes (RR: 1.19, 95% CI: 1.13-1.26, p < .001), poor short-term complications (RR: 1.23, 95% CI: 1.09-1.38, p = .001), and poor long-term prognosis (RR: 1.27, 95% CI: 1.13-1.44, p < .001). Anxiety was also specifically associated with long-term mortality (RR: 1.16, 95% CI: 1.01-1.33, p = .033) and long-term MACEs (RR: 1.54, 95% CI: 1.26-1.90, p < .001). This study provided strong evidence that increased anxiety was associated with poor prognosis in patients with MI. Further analysis revealed that MI patients with anxiety had a 23% increased risk of short-term complications and a 27% increased risk of adverse long-term prognosis compared to those without anxiety.

Anxiety and clinical outcomes of patients with acute coronary syndrome: a meta-analysis

OBJECTIVES

Anxiety has been suggested to be associated with poor outcomes in patients with acute coronary syndrome (ACS). However, results of previous follow-up studies were inconsistent. The aim of this meta-analysis was to evaluate the association between anxiety and clinical outcomes in patients with ACS, and to investigate the potential role of depression underlying the above association.

DESIGN

A meta-analysis of prospective follow-up studies.

SETTING

Hospitals.

PARTICIPANTS

Patients with ACS.

INTERVENTIONS

We included related prospective follow-up studies up through 20 July 2019 that were identified by searching PubMed and Embase databases. A random-effect model was used for the meta-analysis. Anxiety was evaluated by validated instruments at baseline.

PRIMARY AND SECONDARY OUTCOME MEASURES

We determined the association between anxiety and risks of mortality and adverse cardiovascular events (MACEs) in patients with ACS.

RESULTS

Our analysis included 17 studies involving 39 038 patients wqith ACS. Anxiety was independently associated with increased mortality risk (adjusted risk ratio (RR) 1.21, 95% CI 1.07 to 1.37, p=0.002) and MACEs (adjusted RR 1.47, 95% CI 1.24 to 1.74, p<0.001) in patients with ACS. Subgroup analyses showed that depression may at least partly confound the association between anxiety and poor outcomes in patients with ACS. Adjustment of depression significantly attenuated the association between anxiety and MACEs (adjusted RR 1.25, 95% CI 1.04 to 1.52, p=0.02). Moreover, anxiety was not significantly associated with mortality risk after adjusting for depression (adjusted RR 0.88, 95% CI 0.66 to 1.17, p=0.37).

CONCLUSIONS

Anxiety is associated with increased risk of mortality and MACEs in patients with ACS. However, at least part of the association may be confounded by concurrent depressive symptoms in these patients.

The Physical and the Emotional: Case Report, Mixed-Methods Development, and Discussion

There is a growing recognition that emotional problems are important to physical health outcomes. In response, primary care clinics have introduced self-report checklists to identify patients with emotional disorders such as depression or anxiety. Yet psychodynamic theory posits that certain emotional problems may be unconscious and unspoken, and thus not discernible on self-report checklists, and studies show that checklists do not identify every patient who needs treatment. New clinical tools are needed to identify subtle and complex presentations. We aimed to develop an innovative mixed-methods approach characterizing different types of verbal expression of feelings, drawing on psychodynamic theory and empirical research. We outline the development of the mixed-methods approach, including our theoretical framework and use of semi-structured interview data from Partners in Care (PIC), a randomized controlled trial of quality improvement for depression. We then illustrate the approach with one case: an older female PIC participant who screened positive for depression on all study self-reports. The approach delineates three qualitatively different categories of words-specific feeling words, vague feeling words, and physical words-that were quantified to define a measurable pattern for our participant. Clinicians could be trained to identify these categories of words in the context of a discussion of feelings to better detect and understand subtle emotional problems in patients who have difficulty talking openly about their feelings. Next steps include furthering face and construct validity and test-retest reliability, examining the prevalence of these patterns in a larger sample, and assessing correlates of patterns.

Exercise Counteracts the Cardiotoxicity of Psychosocial Stress

Physical inactivity and psychosocial stress are prevalent in residents of the United States. The purpose of this article is to review the interaction between these 2 conditions and examine the effects of exercise on stress and cardiovascular (CV) health. A query of scientific references between 1974 to 2018 was performed using the PubMed search engine accessing the MEDLINE database using the search terms psychosocial stress, CV disease (CVD), physical activity, exercise, cardiac rehabilitation, and team sports. Psychosocial stress is a strong independent risk factor for adverse CV events. Conversely, people who experience CV events subsequently have drastically elevated rates of new-onset mental health disorders, including depression and anxiety. Psychosocial stress and CVD often trigger self-reinforcing feedback loops that can worsen mental health and cardiac prognosis. Exercise predictably improves CV health and prognosis and also is effective at lowering levels of psychosocial stress. Group exercise in particular seems to provide social support while at the same time boosting fitness levels and, thus, may be the single most important intervention for patients with concomitant CVD and emotional stress. Collaborative physical activity, such as group exercise, team sports, interactive physical play, and cardiac rehabilitation programs, have the potential to improve mental health and CV prognosis.

Impact of anxiety and depression on morbidity and mortality of patients with coronary syndrome

ABSTRACT Objective: Evaluate the impact of anxiety and depression on morbidity and mortality of patients with acute coronary syndrome. Method: Retrospective cohort study, with follow-up of two years, conducted with 94 patients. The morbidity and mortality (readmission, myocardial revascularization, and death) was evaluated immediately after discharge and after one and two years. Anxiety and depression were evaluated by the State-Trait Anxiety Inventory and by Beck’s Depression Inventory. The Kaplan-Meier estimator and the Logrank test were used. The significance level adopted was 0.05. Results: We observed that 76.6% of the patients did not present symptoms of depression or had mild signs, while 78.8% had low to moderate anxiety. The symptoms of depression and anxiety were not related to morbidity (need for MR p=0.098 and 0.56, respectively; readmission p=0.962 and 0.369, respectively) and mortality (p=0.434 and 0.077, respectively). Conclusion: No relationship was found between levels of anxiety and depression with the morbidity and mortality of patients.

Death anxiety in patients with myocardial infarction or cancer

OBJECTIVE

The aim of this study was to find out the level of death anxiety among 3 groups: patients with acute myocardial infarction, patients with cancer and healthy individuals in two training and research hospitals; also to evaluate its relationship with several sociodemographic and clinical variables.

MATERIALS AND METHOD

This study was conducted with one hundred and eighty persons (108 male, 72 female) who have been referred to cardiology or oncology departments and the healthy individuals. Participants completed sociodemographic and clinical data form, State and Trait Anxiety Inventory (STAI-I, STAI-II), Thorson Powell Death Anxiety Scale (TPDAS), Death Depression Scale (DDS).

RESULTS

Participants included in the present study were 40% female with an average age of 53.48 for whole group. The mean TPDAS score for patients with AMI was 51.60 ± 16.40, for patients with cancer 37.10 ± 10.23 and for healthy individuals 43.40 ± 13.35. In AMI group there were positive correlations between STAI-I and TPDAS, DDS scores and also between STAI-II and DDS. In cancer group positive correlations were between STAI-I, II and TPDAS, DDS. TPDAS and DDS were positively correlated in all three groups. Women and participants who were unemployed scored higher on DDS.

CONCLUSION

In this study patients with AMI had higher death anxiety than patients with cancer or healthy individuals. Generally death anxiety was related with education, employment and socioeconomic status. Prospective studies carefully searching for different variables in different medical groups would reveal and help us to understand the importance of death anxiety and its impact on courses of physical and mental disorders.

Symptoms of depression and anxiety and 11-year all-cause mortality in men and women undergoing coronary artery bypass graft (CABG) surgery

OBJECTIVES

To investigate the overall and the sex-specific association of preoperative and one-year post coronary artery bypass (CABG) surgery symptoms of depression and anxiety with 11-year all-cause mortality.

METHODS

A multicenter prospective study including 1125 patients who completed the Hospital Anxiety and Depression Scale (HADS) before an elective CABG surgery, of whom 850 completed the HADS again at one-year follow-up. Information on all-cause mortality was obtained through the Israeli Ministry of Internal Affairs Register. Multivariable adjusted Cox regression models quantified the association of symptoms of depression and anxiety with all-cause mortality.

RESULTS

Females comprised 22.7% of the cohort and were 5.5years older than males (70.0±9.3 and 64.4±10.3years, respectively). Controlling for sociodemographic and lifestyle factors, illness severity and post-surgery participation in cardiac rehabilitation, there was little evidence of an association between preoperative symptoms of depression and mortality in males [adjusted hazard ratio (aHR_males)=1.03, 95% CI 0.99-1.07, p=0.21] or females (aHR_females=1.01, 95% CI 0.95-1.08, p=0.7). One-year postoperative symptoms of depression were associated with mortality in both males (aHR_males=1.05, 95% CI 1.01-1.10, p=0.03) and females (aHR_females=1.07, 95% CI 1.02-1.13, p=0.013). Preoperative symptoms of anxiety were unrelated to mortality overall, but among females postoperative symptoms of anxiety predicted 11-year mortality (aHR_females=1.07, 95% CI 1.00-1.14, p=0.049). There was no HADS by sex interaction (p for interaction=0.12-0.99).

CONCLUSIONS

Symptoms of depression one-year after surgery were positively related to mortality with little evidence for sex differences. These findings underscore the need for identification and treatment of psychiatric symptoms in patients undergoing CABG surgery.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT00356863.

Anxiety and anger immediately prior to myocardial infarction and long-term mortality: Characteristics of high-risk patients

OBJECTIVE

Acute high levels of anger and anxiety are associated with an elevated risk of myocardial infarction (MI) in the following two hours. MIs preceded by these acute negative emotions may also have a poor long-term prognosis, but information about high-risk patients is lacking. We examined whether young age and female sex are associated with MIs that are preceded by negative emotions and whether age and sex moderate the subsequent increased mortality risk following MI preceded by negative emotions.

METHODS

We conducted a secondary analysis of the Determinants of Myocardial Infarction Onset Study (N=2176, mean age=60.1±12.3years, 29.2% women). Anxiety and anger immediately prior to (0-2h) MI and the day before (24-26h) MI were assessed using a structured interview. Subsequent 10-year all-cause mortality was determined using the US National Death Index.

RESULTS

Anxiety during the 0-2h pre-MI period was associated with younger age (OR=0.98,95% CI=0.96-0.99 per year) and female sex (OR=1.50,95% CI=1.11-2.02). Anger in the 0-2h pre-MI period was also associated with younger age (OR=0.95,95% CI=0.94-0.96) but not with sex (OR=0.93,95% CI=0.67-1.28). During follow-up, 580 (26.7%) patients died. Mortality rate was higher if MI occurred immediately after high anxiety, particularly in patients ≥65years (HR=1.80,95% CI=1.28-2.54) vs. younger patients (HR=0.87,95% CI=0.55-1.40; p-interaction=0.015). Other interactions with sex or anger were not significant.

CONCLUSIONS

Patients with high anxiety or anger levels in the critical 2-hour period prior to MI are younger than those without such emotional precipitants. In addition, pre-MI anxiety is associated with an elevated 10-year mortality risk in patients aged ≥65years.

Risk of anxiety and depressive disorders in patients with myocardial infarction: A nationwide population-based cohort study

Anxiety and depressive symptoms are associated with adverse cardiovascular events after an acute myocardial infarction (MI). However, most studies focusing on anxiety or depression have used rating scales or self-report methods rather than clinical diagnosis. This study aimed to investigate the association between psychiatrist-diagnosed psychiatric disorders and cardiovascular prognosis.We sampled data from the National Health Insurance Research Database; 1396 patients with MI were recruited as the study cohort and 13,960 patients without MI were recruited as the comparison cohort. Cox proportional hazard regression models were used to examine the effect of MI on the risk of anxiety and depressive disorders.During the first 2 years of follow-up, patients with MI exhibited a significantly higher risk of anxiety disorders (adjusted hazard ratio [HR] = 5.06, 95% confidence interval [CI]: 4.61-5.54) and depressive disorders (adjusted HR = 7.23, 95% CI: 4.88-10.88) than those without MI did. Greater risk for anxiety and depressive disorders was observed among women and patients aged 45 to 64 years following an acute MI. Patients with post-MI anxiety had a 9.37-fold (95% CI: 4.45-19.70) higher risk of recurrent MI than those without MI did after adjustment for age, sex, socioeconomic status, and comorbidities.This nationwide population-based cohort study provides evidence that MI increases the risk of anxiety and depressive disorders during the first 2 years post-MI, and post-MI anxiety disorders are associated with a higher risk of recurrent MI.

Effect of simulated patient death on emergency worker's anxiety: a cluster randomized trial

Objective

Simulation-based teaching offers promising and diverse teaching possibilities. We aim to assess whether the death of the manikin increased anxiety amongst learner compared to similar simulation-based course where the manikin stays alive.

Methods

We conducted a cluster randomized study amongst multidisciplinary teams of emergency workers. Teams of physicians, nurses, and healthcare assistants were randomly assigned to participate in a simulation-based course where the simulated patient died (death group) or not (life group). We assessed anxiety at 1 month after the teaching using Spielberger STAI-state anxiety questionnaire. We compared reduction of anxiety when facing a life-threatening situation in both groups.

Results

We included 25 teams for a total of 129 participants. We analysed 63 participants in the death group and 57 in the life group. Baseline characteristics were similar in both groups, including baseline anxiety (STAI-state score 39.6 (7.8) in the death group vs 38.6 (7.1) in the life group). We report a significant reduction in both groups 1 month after the training: 6.6 (7.8) vs 6 (8.0), mean difference 0.5 (−2.4; 3.4). At 3 months, we report a significant greater reduction of anxiety in the death group (mean difference 4 [0.1; 7.9]).

Conclusion

We observed in our sample that unexpected simulated patient death did not increase anxiety amongst multidisciplinary emergency workers.

Treatment of anxiety in patients with coronary heart disease: Rationale and design of the UNderstanding the benefits of exercise and escitalopram in anxious patients WIth coroNary heart Disease (UNWIND) randomized clinical trial

BACKGROUND

Anxiety is highly prevalent among patients with coronary heart disease (CHD), and there is growing evidence that high levels of anxiety are associated with worse prognosis. However, few studies have evaluated the efficacy of treating anxiety in CHD patients for reducing symptoms and improving clinical outcomes. Exercise and selective serotonin reuptake inhibitors have been shown to be effective in treating patients with depression, but have not been studied in cardiac patients with high anxiety.

METHODS

The UNWIND trial is a randomized clinical trial of patients with CHD who are at increased risk for adverse events because of comorbid anxiety. One hundred fifty participants with CHD and elevated anxiety symptoms and/or with a diagnosed anxiety disorder will be randomly assigned to 12 weeks of aerobic exercise (3×/wk, 35 min, 70%-85% VO2peak), escitalopram (5-20 mg qd), or placebo. Before and after 12 weeks of treatment, participants will undergo assessments of anxiety symptoms and CHD biomarkers of risk, including measures of inflammation, lipids, hemoglobin A1c, heart rate variability, and vascular endothelial function. Primary outcomes include post-intervention effects on symptoms of anxiety and CHD biomarkers. Secondary outcomes include clinical outcomes (cardiovascular hospitalizations and all-cause death) and measures of quality of life.

CONCLUSIONS

The UNWIND trial (ClinicalTrials.gov NCT02516332) will evaluate the efficacy of aerobic exercise and escitalopram for improving anxiety symptoms and reducing risk for adverse clinical events in anxious CHD patients.

Depression and Anxiety as Risk Factors for Morbidity and Mortality After Organ Transplantation: A Systematic Review and Meta-Analysis

BACKGROUND

Depression and anxiety are common mental health problems in transplant populations. There is mixed evidence concerning whether they increase morbidity and mortality risks after transplantation. If such associations exist, additional risk reduction strategies may be needed.

METHODS

Four bibliographic databases were searched from 1981 through September 2014 for studies prospectively examining whether depression or anxiety (determined with diagnostic evaluations or standardized symptom scales) affected risk for posttransplant mortality, graft loss, acute graft rejection, chronic rejection, cancer, infection, and rehospitalization.

RESULTS

Twenty-seven studies (10 heart, total n = 1738; 6 liver, n = 1063; 5 kidney, n = 49515; 4 lung, n = 584; 1 pancreas, n = 80; 1 mixed recipient sample, n = 205) were identified. In each, depression and/or anxiety were typically measured before or early after transplantation. Follow-up for outcomes was a median of 5.8 years (range, 0.50-18.0). Depression increased the relative risk (RR) of mortality by 65% (RR, 1.65; 95% confidence interval [95% CI], 1.34-2.05; 20 studies). Meta-regression indicated that risk was stronger in studies that did (vs did not) control for potential confounders (P = .032). Risk was unaffected by type of transplant or other study characteristics. Depression increased death-censored graft loss risk (RR, 1.65; 95% CI, 1.21-2.26, 3 studies). Depression was not associated with other morbidities (each morbidity was assessed in 1-4 studies). Anxiety did not significantly increase mortality risk (RR, 1.39; 95% CI, 0.85-2.27, 6 studies) or morbidity risks (assessed in single studies).

CONCLUSIONS

Depression increases risk for posttransplant mortality. Few studies considered morbidities; the depression-graft loss association suggests that linkages with morbidities deserve greater attention. Depression screening and treatment may be warranted, although whether these activities would reduce posttransplant mortality requires study.