Predictors of suicidal ideation in coronary artery disease

Predicting suicidal ideation using multiple serum biomarkers in patients with acute coronary syndrome

BACKGROUND

Biomarkers for suicidal behavior in patients with acute coronary syndrome (ACS) have yet to be elucidated. This study aimed to identify a panel of serum biomarkers associated with suicidal ideation (SI) in patients with ACS.

METHODS

The study evaluated 969 patients within 2 weeks of ACS (acute phase) and 711 patients 12 months later (chronic phase). The evaluation included 14 serum biomarkers covering 7 functional systems, socio-demographic/clinical characteristics, and SI assessed by the "suicidal thoughts" item of the Montgomery-Åsberg Depression Rating Scale. Logistic regression models were used to analyze the data. The results showed that 195 patients (20.1 %) had SI in the acute phase, and 87 patients (12.2 %) had SI in the chronic phase.

RESULTS

A combination of five serum biomarkers (tumor necrosis factor-α, interleukin-1β, folate, troponin I, and creatine kinase-MB) was significantly associated with SI in the acute phase, and a combination of three serum biomarkers (tumor necrosis factor-α, interleukin-1β, and folate) was significantly associated with SI in the chronic phase in a clear dose-dependent manner (all P-values < 0.001) after adjustment for relevant covariates.

DISCUSSION

These findings suggest that the application of a combination of multiple serum biomarkers could improve the predictability of SI in patients with ACS at both acute and chronic phases.

Effect Modification of Cortisol on the Associations Between Obsessive-Compulsive Symptoms on Suicidality in Patients With Acute Coronary Syndrome

OBJECTIVE

Obsessive-compulsive symptoms (OCS) and suicidal ideation (SI) are common in patients with acute coronary syndrome (ACS). This study investigated the associations of OCS and serum cortisol levels with SI, and further evaluated the possible modifying effects of cortisol on the associations between OCS and SI in acute and chronic phases of ACS.

METHODS

In total, 969 ACS patients were recruited from a tertiary university hospital in Korea within 2 weeks of disease onset and evaluated in terms of OCS (using the OCS dimension of the Symptom Checklist-90-Revised), serum cortisol levels, and SI (using the "suicidal thoughts" item of the Montgomery-Åsberg Depression Rating Scale). Covariates included sociodemographics, depression, vascular risk factors, and disease severity. After 1 year, 711 patients were re-evaluated in terms of SI. Logistic regression analysis was performed with adjustment for covariates.

RESULTS

Higher OCS was significantly associated with SI both at baseline and follow-up. Serum cortisol showed no such association, but modified the association between OCS and SI. That was the associations were significant only in the higher but not in the lower serum cortisol levels, with significant interaction terms after adjusted for relevant covariates.

CONCLUSION

Evaluating OCS and serum cortisol levels at the acute phase could improve the accuracy of clinical predictions of SI both in the acute and chronic phases of ACS.

Associations of systemic inflammation and social support with suicidal ideation in patients with acute coronary syndrome and stroke

BACKGROUND

This study aimed to investigate associations of serum high-sensitivity C-reactive protein (hsCRP) and social support (SS) levels with suicidal ideation (SI), and to evaluate potential modifying effects of SS on the associations between serum hsCRP levels and SI in two longitudinal cohorts with cardio-/cerebrovascular diseases.

METHODS

1152 acute coronary syndrome (ACS) and 423 stroke patients were recruited at baseline within 2 weeks of disease onset, and evaluated for: i) serum hsCRP levels; ii) SS by the Social Support Scale and Social Undermining Scale; iii) SI by the "suicidal thoughts" item of the Montgomery-Åsberg Depression Rating Scale; and iv) covariates including socio-demographics, depression, vascular risk factors, and index disease severity. At 12-month follow-up, SI was re-evaluated. Logistic regression models were used to adjust for potential covariates.

RESULTS

In the ACS cohort, higher serum hsCRP and lower SS levels were significantly associated with SI at baseline; and only lower SS levels were significantly associated with SI at follow-up. In the stroke cohort, lower SS levels were significantly associated with SI at baseline; but no other association was found. Associations of serum hsCRP levels with SI at both baseline and follow-up were only significant at higher SS levels with significant interaction terms in both cohorts.

LIMITATIONS

This study evaluated SI, but not suicide attempts or death; it also used a single-center design.

CONCLUSIONS

By considering SS evaluations with routine serum hsCRP levels in cardio-/cerebrovascular disease, clinical prediction of SI both at acute and chronic phases of the diseases might be improved.

Interaction effects of diabetes and brain-derived neurotrophic factor on suicidal ideation in patients with acute coronary syndrome

Acute coronary syndrome (ACS) is related to an increased risk of suicide. Although both diabetes and the brain-derived neurotrophic factor (BDNF) pathway are closely associated with ACS and suicide, the effects of these factors on suicidal behavior in ACS patients have not been assessed. We investigated the individual and interaction effects of diabetes and BDNF-related markers, namely the serum BDNF (sBDNF) level and the BDNF Val66Met polymorphism, on suicidal ideation (SI) in ACS patients. The presence of diabetes was ascertained, and sBDNF levels and the presence of the BDNF Val66Met polymorphism were measured in 969 patients within 2 weeks after an ACS episode. 711 patients were followed up at 1 year after the ACS episode. SI was assessed using the relevant items of the Montgomery–Åsberg Depression Rating Scale at baseline (acute SI) and the 1-year follow-up (chronic SI). Significant individual effects of low sBDNF levels were found on acute SI. The presence of both diabetes and a low sBDNF level or the BDNF Met/Met genotype was associated with acute SI, with multivariate logistic regression analyses revealing significant interaction effects. The highest frequency of chronic SI was seen in diabetic patients with an sBDNF level in the lowest tertile or with the BDNF Met/Met genotype, although the interaction terms were not statistically significant. Our study suggests that the combination of diabetes and BDNF-related markers, such as the sBDNF level and the BDNF Val66Met polymorphism, might provide a useful predictor of acute SI in ACS patients.

Serotonin modifies the impact of sleep disturbance on suicidality in patients with acute coronary syndrome

BACKGROUND

This study investigated the associations of sleep disturbance and serum serotonin levels with suicidal ideation, and evaluated the potential modifying effects of serotonin on these associations in patients with the acute coronary syndrome (ACS).

METHODS

In total, 969 ACS patients were recruited from a tertiary university hospital in Korea within 2 weeks of disease onset and evaluated in terms of sleep disturbance (using the Leeds Sleep Evaluation Questionnaire), serum serotonin levels, and suicidal ideation (using the "suicidal thoughts" item of the Montgomery-Åsberg Depression Rating Scale). Covariates included sociodemographics, depression, vascular risk factors, and disease severity. After 1 year, 711 patients were re-evaluated in terms of suicidal ideation. Logistic regression analysis was performed with adjustment for covariates.

RESULTS

Sleep disturbance was significantly associated with suicidal ideation at baseline and follow-up. Serum serotonin showed no such association but modified the association of sleep disturbance with suicidal ideation such that it was significant only in the lower serum serotonin group, with significant interaction terms obtained after adjustment for relevant covariates.

CONCLUSION

Evaluating sleep disturbance and serum serotonin levels could improve the accuracy of clinical predictions of suicidal ideation in the acute and chronic phases of ACS.

Suicide in obstructive lung, cardiovascular and oncological disease

Healthcare institutions face increasing demands stemming from the burden of noncommunicable diseases. The personal, social, financial and societal impact of these diseases are well-documented. However, the mental health concerns and trajectories of patients afflicted by chronic medical diseases have been under-recognized and are under-resourced. Despite that chronic diseases are associated with substantially increased risk of suicide, the medical world has largely failed to properly address suicide in the medically ill. Considering their high prevalence and mortality rate, this review article will highlight the mental health burden and suicide risk in obstructive lung, cardiovascular (including stroke) and oncological disease, in light of relevant data and conceptual models of suicide. Finally, general evidence-based suicide intervention strategies and potential selective adaptation of these strategies to the chronic medically ill patient populations and medical settings will be reviewed.

Time-Specific Associations of Tumor Necrosis Factor-α Levels and Polymorphisms (-850 C/T or -308 G/A) With Suicidal Ideation in Acute Coronary Syndrome Patients

Background: Considering the association of inflammation with suicide and acute coronary syndrome (ACS), we investigated the individual and interactive effects of serum tumor necrosis factor-alpha (sTNFα) levels and two polymorphisms (-850 C/T and -308 G/A) on suicidal ideation (SI) after ACS. Methods: The SI status using items on the Montgomery-Åsberg Depression Rating Scale (MADRS), related covariates including sociodemographic and clinical characteristics, sTNFα levels, and tumor necrosis factor-alpha (TNF-α) polymorphisms were evaluated in 969 patients within 2 weeks after ACS. Of the patients, 711 were evaluated 1 year later for SI. Multivariate logistic regression models were used to calculate individual and interactive associations after adjusting for the covariates. Results: Higher (vs. lower) sTNFα levels and the -850 C/T or T/T (vs. C/C) polymorphism were significantly associated with SI 2 weeks after ACS, while only higher sTNFα levels were significantly associated with SI after 1 year. Significant interactive effects were detected between sTNFα (higher) levels and the -850 C/T (C/C or C/T) polymorphism on SI 2 weeks after ACS and between the two (-850 CC or CT and -308 G/A or AA) polymorphisms on SI 1 year after ACS. Conclusions: The sTNFα level and two polymorphisms (-850C/T and -308 G/A), separately or in combination, could be time-specific biomarkers for SI in ACS. Focused interventions for ACS patients at risk of SI might reduce the suicidal burden in patients with ACS.

Psychological Distress and Suicidal Ideation in Patients With Atrial Fibrillation: Prevalence and Response to Management Strategy

Background

An association between atrial fibrillation (AF), anxiety, and depression is recognized, but the spectrum of psychological distress remains unclear. We aimed to characterize the severity and predictors of distress associated with AF in a tertiary population and its response to AF management.

Methods and Results

Seventy‐eight patients with symptomatic AF underwent evaluation, including of AF symptom severity, health‐related quality of life, psychological distress, suicidal ideation, and specific personality traits. Twenty participants underwent AF ablation and 58 were managed medically, with repeat assessments at 4, 8, and 12 months. Severe distress (Hospital Anxiety and Depression Scale score, ≥15/42) was identified in 27 of 78 (35%). Independent predictors were a personality marked by vulnerability to stress (Perceived Stress Scale: R², 0.54; β=0.7±0.1; t=7.8; P<0.001) and 1 marked by negativity/social inhibition (Type D Personality Scale: R², 0.47; β=0.7±0.1; t=6.7; P<0.001). Suicidal ideation was reported by 16 of 78 (20%) and was predicted by personality traits (Perceived Stress Scale score: R², 0.35; odds ratio, 1.22±0.06; P<0.001; Type D Personality Scale score: R², 0.48; odds ratio, 1.43±0.14; P<0.001). Effective AF ablation (median AF burden 1% [0–1%] over 12 months) was associated with significant reductions in distress (Hospital Anxiety and Depression Scale score, 13.9±1.8 to 4.3±1.8; P<0.05) and prevalence of suicidal ideation (30–5%; P=0.02).

Conclusions

There was a high prevalence of severe psychological distress (35%) and of suicidal ideation (20%) in a tertiary AF population, with personality traits predicting both. Effective AF ablation was associated with significant improvements, suggesting AF itself may be a treatable causative factor of distress.

Gerontological social work and cardiac rehabilitation

Cardiac rehabilitation is a setting in which integrating social work services can benefit older adults. Many cardiac rehabilitation patients endorse symptoms of stress and depression following a cardiac event, impeding their ability to participate fully in cardiac rehabilitation services or recover from a heart attack. Gerontologically trained social workers can improve the care of older adults with heart disease in a variety of ways and this paper discusses the potential roles social workers can play in enhancing care. Two examples demonstrating how community academic partnerships can lead to improved options for older adults following a heart attack are discussed. First, using a microsystems approach, social workers embedded within cardiac rehabilitation may improve patient quality of life, address social service needs, provide mental health treatment, and assist in the completion of standard cardiac rehabilitation assessments. Second, using a macrosystems approach, social workers can help communities by developing partnerships to establish infrastructure for new cardiac rehabilitation clinics that are integrated with mental health services in rural areas. Social workers can serve an important role in addressing the psychological or social service needs of cardiac rehabilitation patients while increasing access to care.

Suicidal Ideation Predicts Functioning and Quality of Life Over One Year after Acute Coronary Syndrome

OBJECTIVE

This study investigated the associations of suicidal ideation (SI) evaluated within 2 weeks after an acute coronary syndrome (ACS) episode with functioning, disability, and quality of life (QOL) at a 1-year follow-up assessment.

METHODS

This study recruited 1152 consecutive patients within 2 weeks of a confirmed ACS episode; 828 of these patients who were followed up 1 year later comprised the study sample. SI was determined at baseline using the "suicidal thoughts" item of the MontgomeryÅsberg Depression Rating Scale. At both examinations, social and occupational functioning were measured by the Social and Occupational Functioning Assessment Scale (SOFAS), disability was estimated by World Health Organization Disability Assessment Schedule-12 (WHODAS-12), and QOL was assessed using the World Health Organization Quality of Life-Abbreviated form (WHOQOL-BREF). Baseline covariates included sociodemographic data, depression characteristics, cardiovascular risk factors, and current cardiac status.

RESULTS

SI at baseline was independently associated with less improved or decreased scores on the SOFAS, WHODAS-12, and WHOQOL-BREF over 1 year after adjusting for relevant covariates.

CONCLUSION

SI within 2 weeks of an ACS episode predicted poorer functioning and QOL at a 1-year follow-up assessment. Thus, the simple evaluation of SI in patients with recently developed ACS could be helpful in screening for functioning and QOL during the chronic phase of this disease.

Genetic predisposition toward suicidal ideation in patients with acute coronary syndrome

The genetic predisposition toward suicidal ideation has been explored to identify subgroups at high risk and to prevent suicide. Acute coronary syndrome (ACS) is associated with an increased risk of suicide, but few studies have explored the genetic predisposition toward suicide in ACS populations. Therefore, this longitudinal study explored the genetic predisposition toward suicidal ideation in ACS patients. In total, of 969 patients within 2 weeks after ACS, 711 were followed at 1 year after ACS. Suicidal ideation was evaluated with the relevant items on the Montgomery-Åsberg Depression Rating Scale. Ten genetic polymorphisms associated with serotonergic systems, neurotrophic factors, carbon metabolism, and inflammatory cytokines were examined. Associations between genetic polymorphisms and suicidal ideation within 2 weeks and 1 year of ACS were investigated using logistic regression models. The 5-HTTLPR s allele was significantly associated with suicidal ideation within 2 weeks of ACS after adjusting for covariates and after the Bonferroni correction. TNF-α -308G/A, IL-1β -511C/T, and IL-1β + 3953C/T were significantly associated with suicidal ideation within 2 weeks after ACS, but these associations did not reach significance after the Bonferroni correction in unadjusted analyses and after adjusting for covariance. However, no significant association between genetic polymorphisms and suicidal ideation was found at 1 year. Genetic predisposition, 5-HTTLPR s allele in particular, may confer susceptibility to suicidal ideation in ACS patients during the acute phase of ACS.

Determinants and escitalopram treatment effects on suicidal ideation in patients with acute coronary syndrome: Findings from the K-DEPACS and EsDEPACS studies

BACKGROUND

This study is aimed to investigate the determinants of suicidal ideation as well as to assess escitalopram treatment effects on suicidal ideation in patients with acute coronary syndrome (ACS).

METHODS

A total of 1152 patients were consecutively recruited at baseline, 2 to 14weeks after a confirmed ACS episode. Of 446 baseline participants with comorbid depressive disorders, 300 were randomized to a 24-week double-blind trial of escitalopram or placebo treatment. Suicidal ideation was determined using the "suicidal thoughts" item of the Montgomery and Asberg Depression Rating Scale. Socio-demographic and clinical characteristics, including depressive and anxiety symptoms, cardiovascular risk factors, and current cardiac status, were assessed.

RESULTS

Suicidal ideation was independently associated with past history of depression, depressive and anxiety disorders, and higher troponin I levels. Escitalopram treatment was significantly more efficacious in reducing and treating suicidal ideation than placebo treatment over a 24-week period. These effects were largely explained by remission status of depressive and anxiety disorders.

CONCLUSIONS

Suicidal ideation is associated with unfavorable psychiatric and ACS status during the acute phase of ACS. Successful treatment of depression and anxiety with escitalopram had significant beneficial effects on suicidal ideation in these patients.