Characterising acute coronary syndrome-associated depression: Let the data speak

The effect of escitalopram in treating mild to moderate depressive disorder and improving the quality of life in patients undergoing coronary artery bypass grafting - a double-blind randomized clinical trial

Introduction

Chronic depression and anxiety can be a risk factor for coronary aArtery bypass grafting (CABG) and is an emerging factor after coronary artery disease when the patient is admitted to the hospital and after surgery. We aimed to assess the effect of Escitalopram in treating mild to moderate depressive disorder and improving the quality of life in patients undergoing CABG.

Methods

In this randomized clinical trial, 50 patients undergoing CABG referred to Tehran Heart Hospital from January 2021 to May 2021 and were suffering from mild to moderate depression were randomly assigned to one of the two groups of Escitalopram or placebo. The level of depression was assessed based on Beck's depression inventory and the quality-of-life status and its domains were assessed based on the SF-36 questionnaire in 2 groups. Measurements were obtained at baseline and at four and eight weeks after treatment. Chi-square, Fisher's exact, paired, and Wilcoxon tests or ANOVA were used as appropriate.

Results

There was no significant difference between the level of depression between the two study groups at baseline (P=0.312). There was no significant difference between the quality of life and its domains in the two study groups at baseline (P=0.607). However, the most important effect of Escitalopram was reducing depression scores in the intervention group at weeks 4 and 8 after treatment compared to the placebo group (P<0.001). The quality of life and its domains were significantly higher in the Escitalopram group eight weeks after treatment (P=0.004). The amount of drug side effects at 2 and 4 weeks after treatment had no significant difference between the groups (P>0.05).

Conclusion

Escitalopram was effective in treating mild to moderate depressive disorder and improving quality of life in patients undergoing CABG.

Clinical trial registration

https://irct.behdasht.gov.ir/, identifier IRCT20140126016374N2.

Screening for depression and anxiety among patients with acute coronary syndrome in acute care settings: a scoping review

OBJECTIVE

The aim of this review was to scope the literature for publications on the practice of screening for depression and anxiety in acute coronary syndrome patients in acute care by identifying instruments for the screening of anxiety and/or depression; determining if screening for anxiety and/or depression has been integrated into cardiac models of care and clinical pathways; and identifying any evidence practice gap in the screening and management of anxiety and/or depression in this population.

INTRODUCTION

Depression in acute coronary syndrome is bidirectional. Depression is an independent risk factor for cardiovascular disease, and comorbid depression is associated with a twofold greater risk of mortality in patients with cardiovascular disease. The presence of acute coronary syndrome increases the risk of depressive disorders or anxiety during the first one to two years following an acute event, and both depression and anxiety are associated with a higher risk of further acute coronary health concerns. Clinical practice guidelines have previously recommended routine screening for depression following a cardiac event, although many current guidelines do not include recommendations for screening in an acute setting. To date there have been no previous scoping reviews investigating depression and anxiety screening in patients with acute coronary syndrome in the acute care setting.

INCLUSION CRITERIA

Adults (18 years and over) with acute coronary syndrome who are screened for anxiety and/or depression (not anxiety alone) in an acute care setting.

METHODS

A systematic search of the literature was conducted by a research librarian. Research studies of any design published in English from January 1, 2012, to May 31, 2018, were included. Data were extracted from the included studies to address the three objectives. Purposefully designed tables were used to collate information and present findings. Data are also presented as figures and by narrative synthesis.

RESULTS

Fifty-one articles met the inclusion criteria. Primary research studies were from 21 countries and included 21,790 participants; clinical practice guidelines were from two countries. The most common instruments used for the screening of depression and anxiety were: i) the Hospital Anxiety and Depression Scale (n = 18); ii) the Beck Depression Inventory (n = 16); and iii) the nine-item Patient Health Questionnaire (n = 7). Eleven studies included screening for anxiety in 2181 participants (30% female) using the full version of the Hospital Anxiety and Depression Scale. The State-Trait Anxiety Inventory was used to screen 444 participants in three of the studies. Four studies applied an intervention for those found to have depression, including two randomized controlled trials with interventions targeting depression. Of the seven acute coronary syndrome international guidelines published since 2012, three (43%) did not contain any recommendations for screening for depression and anxiety, although four (57%) had recommendations for treatment of comorbidities.

CONCLUSIONS

This review has identified a lack of consistency in how depression and anxiety screening tools are integrated into cardiac models of care and clinical pathways. Guidelines for acute coronary syndrome are not consistent in their recommendations for screening for depression and/or anxiety, or in identifying the best screening tools.

The well-being of medical students: A biopsychosocial approach

OBJECTIVE

Mental health problems among medical students have been widely reported, but the predisposing and perpetuating factors and biological concomitants are poorly understood. Adopting a biopsychosocial approach, we studied well-being in a group of Australian medical students, focusing on sleep, autonomic and immune mechanisms, as well as mental, social and physical well-being, health-related behaviours, and daily functioning.

METHODS

Fourth-year medical students (N = 151) completed comprehensive assessments, including laboratory-based and nocturnal autonomic monitoring via ambulatory bioharness, a psychiatric diagnostic interview, and questionnaires assessing sleep quality and psychosocial and physical well-being. A blood sample was taken to quantify the inflammatory marker C-reactive protein. Sleep, mood and activity was additionally monitored daily for 7 days.

RESULTS

A sizable minority of students reported diminished physical, mental and psychosocial well-being. We also found concerning levels of sleep disturbance and social and occupational impairment in a subset of students. The strong co-occurrence of problems across symptom domains supported a biopsychosocial interdependence of health and well-being states. Maladaptive coping behaviours were apparent, notably hazardous alcohol consumption, which was associated with a clinically significant elevation in C-reactive protein levels (> 3 mg/L). We documented, for the first time, significantly diminished nocturnal heart rate variability in medical students with a mental health diagnosis. Nocturnal heart rate variability was strongly associated with sleep quality, daytime autonomic stress reactivity, as well as occupational and social functioning.

CONCLUSION

Well-being is a multifaceted phenomenon firmly interlinked with sleep, autonomic and immune function, health behaviours and functional outcomes. Our novel findings supported a key role for nocturnal autonomic function in promoting sleep quality and mental well-being. Interventions could focus on sleep hygiene and health behaviours as a buffer for well-being and teach more adaptive strategies for coping with the stresses of medical training.

Acute coronary syndrome-associated depression: Getting to the heart of the data

OBJECTIVES

We sought to identify and consider methodological issues that may have limited or confounded investigations into links between depression and acute coronary syndrome (ACS) events.

METHODS

We reviewed salient research studies to identify such issues.

RESULTS

Against previous conclusions, we found that lifetime depression is unlikely to have any primary ACS impact, while we clarify that 'incident depression' (depression commencing at variable periods around the time of the ACS event) appears to confer a greater risk than non-incident depression. As the time periods of incident depressions are likely to have quite differing causes, evaluating any consolidated risk period appears unwise. It remains unclear whether it is 'depression' that provides the risk for ACS events or a higher order factor. Variable use of depression measures and failure to evaluate depressive sub-types have further limited clarification. The response by ACS patients to antidepressant medication appears limited, and it remains to be determined whether exposure to an antidepressant might be a contributing factor. Finally, studies may have focused on an excessively refined association, and neglected to recognise that depression is associated with a wide range of vascular events, suggesting that a broader conceptual model may be required.

LIMITATIONS

The authors have considered only a limited set of studies in preparing this review, with the critique relying at times on subjective interpretation.

CONCLUSIONS

After decades of research pursuing links between depression and ACS events explanatory links remain obscure, presumably reflecting a range of methodological issues that we have discussed in this paper .

Depression and poor outcome after an acute coronary event: Clarification of risk periods and mechanisms

OBJECTIVE

Lifetime depression and depression around the time of an acute coronary syndrome event have been associated with poor cardiac outcomes. Our study sought to examine the persistence of this association, especially given modern cardiac medicine's successes.

METHODS

For 332 patients admitted for an acute coronary syndrome, a baseline interview assessed major depression status, and psychological measures were administered. At 1 and 12 months post-acute coronary syndrome event, telephone interviews collected rates of hospital readmission and/or death and major depression status, while biomarker information was examined using medical records.

RESULTS

The 12-month mortality rate was 2.3% and cardiac readmission rate 21.0%. Depression subsequent to an acute coronary syndrome event resulted in a threefold and 2.5-fold increase in 1-month and 12-month odds of cardiac readmission or death, respectively. No relationship with past depressive episodes was found. Poor sleep was associated with higher trait anxiety and neuroticism scores and with more severe depression.

CONCLUSION

Lifetime depression may increase the risk of depression around the time of an acute coronary syndrome but not influence cardiac outcomes. We suggest that poor sleep quality may be causal or indicate high anxiety/neuroticism, which increases risk to depression and contributes to poor cardiac outcomes rather than depression being the primary causal factor.

Morning and afternoon serum cortisol level in patients with post-myocardial infarction depression

BACKGROUND

Post-myocardial depression is a highly prevalent condition which worsens the course and prognosis of coronary artery disease. One possible pathogenetic factor is dysregulation of the hypothalamic-pituitary-adrenal axis, resulting in cortisol profile disturbances.

METHODS

Thirty seven patients hospitalized due to a first myocardial infarction (MI) were enrolled in this study. The Beck Depression Inventory (BDI) was used to rate the severity of their depressive symptoms. Morning and afternoon serum cortisol samples were taken on the fifth day of the MI.

RESULTS

Depression, defined as BDI ≥ 10, was present in 34.4% of the patients. A statistically significant difference was observed between the mean morning and the evening plasma concentrations in patients with depression compared to the no-depression group: F (1.29) = 5.0405, p = 0.0328.

CONCLUSIONS

Patients with depressive symptoms directly after MI have a flattened diurnal serum cortisol profile. This is particularly expressed in patients with longer lasting symptoms.

The health and well-being of Australia's future medical doctors: protocol for a 5-year observational cohort study of medical trainees

INTRODUCTION

Clinical training in the undergraduate medical course places multiple stressors on trainees, which have been held to lead to heightened distress, depression, suicide, substance misuse/abuse and poor mental health outcomes. To date, evidence for morbidity in trainees is largely derived from cross-sectional survey-based research. This limits the accuracy of estimates and the extent to which predispositional vulnerabilities (biological and/or psychological), contextual triggers and longer-term consequences can be validly identified. Longitudinal clinical assessments embedded within a biopsychosocial framework are needed before effective preventative and treatment strategies can be put in place.

METHODS AND ANALYSIS

This study is an observational longitudinal cohort study of 330 students enrolled in the undergraduate medicine course at the University of New South Wales (UNSW) Sydney, Australia. Students will be recruited in their fourth year of study and undergo annual assessments for 4 consecutive years as they progress through increasingly demanding clinical training, including internship. Assessments will include clinical interviews for psychiatric morbidity, and self-report questionnaires to obtain health, psychosocial, performance and functioning information. Objective measures of cognitive performance, sleep/activity patterns as well as autonomic and immune function (via peripheral blood samples) will be obtained. These data will be used to determine the prevalence, incidence and severity of mental disorder, elucidate contextual and biological triggers and mechanisms underpinning psychopathology and examine the impact of psychopathology on performance and professional functioning.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the UNSW human research ethics committee (reference HC16340). The findings will be disseminated through peer-reviewed publications and conference presentations, and distributed to key stakeholders within the medical education sector. The outcomes will also inform targeted preventative and treatment strategies to enhance stress resilience in trainee doctors.

Major Depression and Acute Coronary Syndrome-Related Factors

Background

Major Depressive Disorder (MDD) is one of the most common mental illnesses in psychiatry, being considered a risk factor for Acute Coronary Syndrome (ACS).

Objective

To assess the prevalence of MDD in ACS patients, as well as to analyze associated factors through the interdependence of sociodemographic, lifestyle and clinical variables.

Methods

Observational, descriptive, cross-sectional, case-series study conducted on patients hospitalized consecutively at the coronary units of three public hospitals in the city of Rio de Janeiro over a 24-month period. All participants answered a standardized questionnaire requesting sociodemographic, lifestyle and clinical data, as well as a structured diagnostic interview for the DSM-IV regarding ongoing major depressive episodes. A general log-linear model of multivariate analysis was employed to assess association and interdependence with a significance level of 5%.

Results

Analysis of 356 patients (229 men), with an average and median age of 60 years (SD ± 11.42, 27-89). We found an MDD point prevalence of 23%, and a significant association between MDD and gender, marital status, sedentary lifestyle, Killip classification, and MDD history. Controlling for gender, we found a statistically significant association between MDD and gender, age ≤ 60 years, sedentary lifestyle and MDD history. The log-linear model identified the variables MDD history, gender, sedentary lifestyle, and age ≤ 60 years as having the greatest association with MDD.

Conclusion

Distinct approaches are required to diagnose and treat MDD in young women with ACS, history of MDD, sedentary lifestyle, and who are not in stable relationships.

Omega-3/omega-6 fatty acid ratios in different phospholipid classes and depressive symptoms in coronary artery disease patients

Depressive symptoms are highly incident among coronary artery disease (CAD) patients and increase mortality. Reduced ratios of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) (omega-3 fatty acids) to arachidonic acid (AA, omega-6 fatty acid) concentrations have been linked with depressive symptoms in CAD. It remains unclear whether depressive symptoms are differentially associated with that ratio in different phospholipid classes, and this may have mechanistic implications. This study investigated associations between depressive symptoms in CAD patients and the EPA+DHA to AA ratio in the major phospholipid classes. This was a cross-sectional study of stable CAD patients. Sociodemographic, medical, medication, and cardiopulmonary fitness data were collected from each patient. Each patient was assessed for depressive symptoms using the 17-item Hamilton Depression Rating Scale (HAM-D). The percentage of EPA, DHA, and AA in each erythrocyte phospholipid class was determined using gas chromatography from fasting blood. Relationships between EPA+DHA to AA ratios and depressive symptoms were assessed using linear regression and were corrected for multiple comparisons. Seventy-six CAD patients were included (age=61.9 ± 8.5, 74% male, HAM-D=7.2 ± 5.9). In a backward elimination linear regression model, lower EPA+DHA to AA in erythrocyte phosphatidylinositol (B=-12.71, β=-0.33, p<.01) and sphingomyelin (B=-2.52, β=-0.37, p<.01) was associated with greater depressive symptom severity, independently of other known predictors. Other phospholipid classes were not associated with depressive symptoms. In conclusion, the relationship between EPA+DHA to AA ratios and depressive symptoms in CAD may not be consistent across phospholipid classes. Continued investigation of these potentially differential relationships may clarify underlying disease mechanisms.

On the heart, the mind, and how inflammation killed the Cartesian dualism. Commentary on the 2015 Named Series: Psychological Risk Factors and Immune System Involvement in Cardiovascular Disease

The 2015 Named Series on "Psychological Risk Factors and Immune System Involvement in Cardiovascular Disease" was conceived with the idea of drawing attention to the interdisciplinary work aimed at investigating the relationships between the heart, metabolic system, brain, and mental health. In this commentary, we provide a brief overview of the manuscripts included in this Named Series and highlight how a better understanding of immune regulation will help us to move forward from the current "dualistic" perspective of the heart as separate from the mind to a more comprehensive understanding of the physiological links between cardiovascular and mental disorders. The manuscripts included in this Named Series range across a wide spectrum of topics, from understanding biological mechanisms explaining comorbidity between cardiovascular disease and psychiatric disorders to new insights into the dysregulation of inflammation associated with cardiovascular risk factors. Clearly, inflammation emerges as a cross-cutting theme across all studies. Data presented in this Series contribute to putting an end to an era in which the heart and the mind were considered to be separate entities in which the responses of one system did not affect the other.