Depression and anxiety symptom trajectories in coronary heart disease: Associations with measures of disability and impact on 3-year health care costs

Types of depression in patients with coronary heart disease: Results from the THORESCI study

BACKGROUND

Both coronary heart diseases (CHD) and depression are highly prevalent and bidirectionally related. The precise nature of this relationship remains unclear. Defining depressive subtypes could help unravel this relationship. Therefore, the aim of this study was to explore depressive subtypes in patients with CHD.

METHODS

1530 patients (21.3 % women, mean age: 64.7 years (SD = 10.1)) were included in latent class analysis with nine indicators derived from the PHQ-9 and BDI-II representing symptoms of depression as described in the DSM-5 criteria. The best-fitting latent class model was confirmed with double cross-validation. Classes were characterized using demographic, medical, psychiatric, and cardiovascular (risk) factors.

RESULTS

A 3-class model demonstrated the best fit to the data, resulting in a depressed (5.4 %), fatigued (13.5 %), and non-depressed class (81.1 %). Having medical comorbidities, a history of psychiatric problems, negative affectivity, and anxiety symptoms increased the odds of belonging to the depressed group (OR 3.02, 95%CI 1.19-7.68, OR 3.61, 95%CI 1.44-9.02, OR 1.16, 95%CI 1.04-1.30, and OR 1.89, 95%CI 1.66-2.15, respectively). Belonging to the fatigued group was associated with increased odds of having an elective PCI (OR 2.12, 95%CI 1.27-3.55), insufficient physical activity (OR 2.19, 95%CI 1.20-3.99), comorbid medical conditions (OR 2.15, 95%CI 1.21-3.81), a history of psychiatric problems (OR 2.25, 95%CI 1.25-4.05), and anxiety symptoms (OR 1.48, 95%CI 1.34-1.63) compared with the non-depressed group.

LIMITATIONS

Future studies should include more people with depressive symptoms.

CONCLUSIONS

Patients with CHD and medical or psychiatric risk factors should be offered support to decrease or prevent depressive or fatigue symptoms.

Comparing network structures of depressive and anxiety symptoms between demographically-matched heart disease and heart disease free samples using propensity score matching: Findings from the Chinese Longitudinal Healthy Longevity Survey (CLHLS)

BACKGROUND

Older adults with heart disease often experience higher rates of comorbid anxiety and depression. This study examined depression and anxiety network structures among older adults with heart disease and their heart disease free peers.

METHODS

Network analyses of secondary cross-sectional data from the 2017 to 2018 wave of CLHLS were used to construct groups of older adults with and without heart disease using propensity score matching. Depression and anxiety symptoms were assessed using Center for Epidemiological Studies Depression Scale and Generalized Anxiety Disorder Scale, respectively. Central symptoms and bridge symptoms were identified using expected influence.

RESULTS

1689 older adults with heart disease and matched control sample of 1689 older adults without heart disease were included. The prevalence and severity of depression and anxiety were significantly higher in older adults with heart disease compared to the control group. There was no significant difference in overall structures of depression and anxiety network models between two the groups. Key central symptoms and bridge symptoms within these groups were highly similar; GAD 2 "Uncontrollable worrying" and GAD 4 "Trouble relaxing" were identified as the most central symptoms, while GAD 1 "Nervousness" and CESD 1 "Feeling bothered" were identified as key bridge symptoms across both network models.

CONCLUSION

Depression and anxiety are more prevalent in older adults with heart disease than demographically-matched heart disease free controls. However, network structures of these symptoms do not differ between two groups. Accordingly, depression and anxiety psychosocial interventions developed for older adults without heart disease may also benefit older adults with heart disease.

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.

A comparative analysis of open heart surgery and minimally invasive cardiac surgery in exercise-based cardiac rehabilitation

BACKGROUND

Historically, the majority of patients admitted to inpatient exercise-based cardiac rehabilitation (EBCR) have undergone open heart surgery (OHS). However, with advances in minimally invasive cardiac surgery (MICS), these patient groups are also increasingly referred for inpatient EBCR. Herein, we aimed to compare the progress of these groups during rehabilitation.

METHODS

In this prospective, nonrandomized study, 403 inpatient EBCR patients were recruited from December 2022 until September 2023 and stratified into two groups: OHS, and MICS. Participants completed a 3-4-week certified EBCR program. The primary endpoint was defined as a change in the 6-minute walk test (6MWT). Moreover, a comprehensive panel of quality-of-life (QoL) assessments were performed at admission and discharge.

RESULTS

At baseline, patients with OHS were older (66 years [IQR 59 - 72]), more often male (83%), and underwent emergency/urgent procedures more often (20%) than patients with MICS. Furthermore, patients with MICS showed a better 6MWT at admission (426 meters [IQR 336 - 483]) compared to patients with OHS (381 meters [IQR 299 - 453]). While all patients were able to increase the distance in the 6MWT, regression analyses in fully adjusted models showed no difference in improvements between the two groups (β -5, 95% CI, -26 - 14, p = 0.58). Moreover, during EBCR, we observed significant improvements in all QoL measures in all groups.

CONCLUSIONS

In this study, improvements in fitness, as assessed by the 6WMT were observed in all groups. Furthermore, multiple QoL measures improved equally across all groups. These encouraging results emphasize the importance of EBCR.

Triglyceride-glucose index as a potential predictor of major adverse cardiovascular and cerebrovascular events in patients with coronary heart disease complicated with depression

Background

Triglyceride-glucose (TyG) index is a surrogate marker of insulin resistance and metabolic abnormalities, which is closely related to the prognosis of a variety of diseases. Patients with both CHD and depression have a higher risk of major adverse cardiovascular and cerebrovascular events (MACCE) and worse outcome. TyG index may be able to predict the adverse prognosis of this special population.

Methods

The retrospective cohort study involved 596 patients with both CHD and depression between June 2013 and December 2023. The primary outcome endpoint was the occurrence of MACCE, including all-cause death, stroke, MI and emergent coronary revascularization. The receiver operating characteristic (ROC) curve, Cox regression analysis, Kaplan-Meier survival analysis, and restricted cubic spline (RCS) analysis were used to assess the correlation between TyG index and MACCE risk of in patients with CHD complicated with depression.

Results

With a median follow-up of 31 (15-62) months, MACCE occurred in 281(47.15%) patients. The area under the ROC curve of TyG index predicting the risk of MACCE was 0.765(0.726-0.804) (P<0.01). Patients in the high TyG index group(69.73%) had a significantly higher risk of developing MACCE than those in the low TyG index group(23.63%) (P<0.01). The multifactorial RCS model showed a nonlinear correlation (nonlinear P<0.01, overall P<0.01), with a critical value of 8.80 for the TyG index to predict the occurrence of MACCE. The TyG index was able to further improve the predictive accuracy of MACCE.

Conclusions

TyG index is a potential predictor of the risk of MACCE in patients with CHD complicated with depression.

The psychological well-being index and quality of life after a cardiac rehabilitation program based on aerobic training and psychosocial support

BACKGROUND

This study aimed to investigate the physical and psychological benefits of an alternative cardiac rehabilitation program based on therapeutic groups during physical exercise sessions and to compare the results with those of a conventional cardiac rehabilitation program.

METHOD

The sample included 112 patients from the cardiac rehabilitation unit of a medical center, 91.1 % of whom were male. The control group consisted of 47 subjects, with a mean age of 57.89 ± 12.30 and the experimental group consisted of 65 subjects, with a mean age of M = 58.38 ± 9.86. Quality of life, psychological well-being, health-related quality of life, body mass index, blood pressure, abdominal circumference and resting heart rate were measured before starting and at the end of the cardiac rehabilitation program.

RESULTS

The experimental group improved significantly more than the control group in body mass index, systolic and diastolic blood pressure, abdominal circumference, and resting heart rate (p value < 0.005). In addition, the experimental group had significantly greater improvements in quality of life, psychological well-being, and health-related quality of life than the control group (p-value < 0.001).

CONCLUSIONS

A cardiac rehabilitation program based on simultaneous aerobic training and psychosocial support improved the physical function, health-related quality of life and well-being.

Prevalence and risk factors of depression and anxiety symptoms in intensive care unit patients with cardiovascular disease: A cross-sectional study

AIMS

To investigate the prevalence of anxiety and depression symptoms in intensive care unit (ICU) patients with cardiovascular disease (CVD) and to explore which elements are risk factors for the development of anxiety and depression symptoms.

DESIGN

A cross-sectional study.

METHODS

A total of 1028 ICU patients with CVD were enrolled in this cross-sectional study. Logistic regression was used to assess risk factors and associations between anxiety and depression symptoms, and mediation analysis was used to explore the effect of risk factors on the association between anxiety and depression symptoms. Reporting of the study followed the STROBE checklist.

RESULTS

The results showed that among ICU patients with CVD, 38.1% had anxiety symptoms, 28.7% had depression symptoms and 19.3% had both anxiety and depression symptoms, and there was a significant association between anxiety and depression symptoms. We also identified female gender, hypertension, hyperlipidemia and cardiac function class IV as independent risk factors for anxiety and depression symptoms. Importantly, these factors also mediated the association between anxiety and depression symptoms, emphasising their role in the psychological well-being of this patient group.

CONCLUSION

ICU patients with CVD were prone to anxiety and depression symptoms. Female gender, hypertension, hyperlipidemia and cardiac function class IV were identified as independent risk factors that also served as mediators in the relationship between anxiety and depression symptoms. Especially, cardiac function class IV emerged as a critical factor in this association.

RELEVANCE TO CLINICAL PRACTICE

It is imperative for critical care professionals to recognize the elevated risk of depression and anxiety among ICU patients with severe CVD, especially those with cardiac function class IV, hypertension, hyperlipidemia and females. Proactive and supportive measures are essential for this vulnerable group during their ICU stay to safeguard their mental health and prevent negative outcomes.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

The effects of Solution-Focused Brief Therapy on self-care and mental health among older adults at risk of coronary heart disease: A randomized controlled trial

This study tested the effectiveness of a nursing program developed based on Solution-Focused Brief Therapy (SFBT) in improving self-care skills and mental health among community-dwelling older adults at risk for coronary heart disease (CHD). A total of 120 older adults were randomly assigned to either an SFBT group or a control group. Participants' self-care ability, depressive symptoms, and anxiety at baseline and post-intervention were assessed using the Self-care Ability Scale for the Elderly (SASE), Self-Rating Depression Scale (SDS), and Self-Rating Anxiety Scale (SAS), respectively. The t-test, Mann-Whitney U, and chi-square tests were conducted for group comparisons. After 6 months of intervention, the intervention group had significantly higher self-concept, self-skills, self-care awareness, and health knowledge scores than the baseline and the control group (all P-values < 0.05). The intervention group had significantly lower depression and anxiety scores than the baseline and the control group (all P-values < 0.05). SFBT is effective in improving older adults' self-care and mental health and may be widely applied among older adults to prevent CHD and promote well-being in the future.

Comparing depression, anxiety, and quality of life in individuals with cardiac and non-cardiac chest pain

Background

Psychological factors are often overlooked as potential contributors to cardiovascular disease. This study aimed to investigate the relationship between depression, anxiety, and quality of life with chest pain origin.

Method

This cross-sectional study was performed from 2019 to 2020 and included participants from multiple medical centers across Shahrekord, Iran. Participants were recruited through advertisements in medical centers. Participants were divided into three groups: healthy control (n = 67), chest pain with cardiac origin (CCP) (n = 70), and chest pain with non-cardiac origin (NCCP) (n = 73). Data were collected using the Beck's Anxiety scale, Beck's Depression scale, and Short-Form Health Survey questionnaires. The chi-square, exact test, t-test, Kruskal-Wallis, and logistic regression models were used for statistical analysis. All analysis was performed using SPSS 26.

Results

The mean scores of depression and anxiety in the NCCP group (depression = 17.03 ± 11.93, anxiety = 17.18 ± 11.37) were significantly higher than those in the CCP (depression = 9.73 ± 5.76, anxiety = 8.77 ± 5.96) and healthy (depression = 7.00 ± 7.61, anxiety = 6.18 ± 7.63) groups (p < 0.05). The mean score of quality of life in the NCCP group (54.87 ± 12.66) was significantly lower than that in the CCP (76.31 ± 12.49) and healthy (80.94 ± 15.78) groups (p < 0.05). Patients with NCCP had higher odds of having depression (adjusted OR = 4.39, 95% CI: 1.25, 15.35) and lower odds for having mental quality of life scores than the CCP and health groups, respectively (adjusted OR = 0.90, 95% CI: 0.87, 0.94).

Conclusion

Our findings suggest that collaboration between psychiatrists and other specialists may be necessary to improve patients' health conditions and quality of life.

Improving mental well-being in psychocardiology-a feasibility trial for a non-blended web application as a brief metacognitive-based intervention in cardiovascular disease patients

Background

Many patients with cardiovascular disease also show a high comorbidity of mental disorders, especially such as anxiety and depression. This is, in turn, associated with a decrease in the quality of life. Psychocardiological treatment options are currently limited. Hence, there is a need for novel and accessible psychological help. Recently, we demonstrated that a brief face-to-face metacognitive therapy (MCT) based intervention is promising in treating anxiety and depression. Here, we aim to translate the face-to-face approach into digital application and explore the feasibility of this approach.

Methods

We translated a validated brief psychocardiological intervention into a novel non-blended web app. The data of 18 patients suffering from various cardiac conditions but without diagnosed mental illness were analyzed after using the web app over a two-week period in a feasibility trial. The aim was whether a non-blended web app based MCT approach is feasible in the group of cardiovascular patients with cardiovascular disease.

Results

Overall, patients were able to use the web app and rated it as satisfactory and beneficial. In addition, there was first indication that using the app improved the cardiac patients' subjectively perceived health and reduced their anxiety. Therefore, the approach seems feasible for a future randomized controlled trial.

Conclusion

Applying a metacognitive-based brief intervention via a non-blended web app seems to show good acceptance and feasibility in a small target group of patients with CVD. Future studies should further develop, improve and validate digital psychotherapy approaches, especially in patient groups with a lack of access to standard psychotherapeutic care.

Effectiveness of Shuxuening injection in coronary heart disease: a systematic review and meta-analysis

Background: Coronary heart disease (CHD) poses a serious threat to public health, and the current medical management still faces significant challenges. Reliable evidence on the efficacy of Shuxuening injection (SXNI) in CHD is still lacking, even though it is widely used in China. Purpose: To evaluate the efficacy of SXNI combination therapy in treating CHD. Methods: A systematic search of eight databases was conducted to identify relevant randomized controlled trials (RCTs) from the inception of each database until June 2023. ROB 2.0, RevMan 5.4, and Stata 15.1 were used for quality evaluation and data analysis. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the quality of evidence. Results: A total of 3,779 participants from 39 studies were included. The results showed SXNI combination therapy increased the clinical efficacy and decreased the frequency and duration of angina. Furthermore, SXNI combination therapy improved cardiac function of patients by decreasing LVEDD, and increased CI, CO, and LVEF. It also improved blood lipid profiles by increasing HDL, decreasing TC, TG, and LDL. The thrombosis factors of patients were also improved by decreasing FIB, PV, HCT, and HS. Moreover, SXNI combination therapy was superior to the conventional treatment in improving CRP levels, increasing ECG efficacy and BNP. However, due to the limited safety information, reliable safety conclusions could not be drawn. Furthermore, the levels of evidence ranged from very low to moderate due to publication bias and heterogeneity. Conclusion: SXNI can effectively improve angina symptoms, clinical efficacy, cardiac function, blood lipid indicators, and thrombosis factors of patients with CHD. However, more multi-center and large-sample studies are needed to confirm the conclusions due to the limitations of this study. Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=399606; Identifier: CRD42023433292.

Xinkeshu for coronary heart disease complicated with anxiety or depression: A meta-analysis of randomized controlled trials

ETHNOPHARMACOLOGICAL RELEVANCE

The incidence of coronary heart disease (CHD) complicated with anxiety or depression is increasing year by year. However, many anti-anxiety drugs or antidepressants have a certain degree of adverse reactions and are not easily accepted by patients. Xinkeshu (XKS), as a proprietary Chinese patent medicine with "psycho-cardiology" effect, is one of the commonly used drugs in the treatment of CHD complicated with anxiety or depression in China.

AIM OF THE STUDY

To systematically evaluate the efficacy and safety of XKS for CHD complicated with anxiety or depression.

METHODS

Nine different electronic databases were independently searched to include randomized controlled trials (RCTs) of XKS for CHD complicated with anxiety or depression published from inception to February 2022, and the methodological quality was evaluated using the bias risk assessment tool from Cochrane Handbook 5.0 and the modified Jadad scale. Meta-analysis was performed using RevMan 5.3 and Stata 16.0 software. The GRADE Profiler 3.6.1 and TSA 0.9.5.10 beta were adopted to evaluate the certainty and conclusiveness of the evidence.

RESULTS

A total of 18 RCTs involving 1907 subjects were included. There were 956 subjects in the XKS group and 951 subjects in the control group. Baseline conditions were consistent and comparable between the groups. Compared with single-use western medicine (WM), XKS combined with WM significantly reduced scores of Hamilton Anxiety Scale (HAMA) [Mean difference (MD) = -7.60, 95% confidence interval (95% CI) (-10.37, -4.83), P < 0.000 01], Zung Self-rating Anxiety Scale (SAS) [MD = -10.05, 95% CI (-12.70, -7.41), P < 0.000 01], Hamilton Depression Scale (HAMD) [MD = -6.74, 95% CI (-11.58, -1.90), P = 0.006], and Zung Self-rating Depression Scale (SDS) [MD = -10.75, 95% CI (-17.05,-4.45), P = 0.000 8], as well as improved clinical effective rate [odds ratio (OR) = 4.24, 95% CI (2.47, 7.27), P < 0.000 01]. In terms of safety, 4 studies reported the adverse reactions in detail. The severity was mild and symptoms disappeared after treatment.

CONCLUSION

Current evidence indicates that XKS may be effective and safe in the treatment of patients with CHD complicated with anxiety or depression. Since the quality of the literature included in this study was generally low, there is an urgent need for more RCTs with high quality, low bias risk and sufficient sample size to validate our conclusions.

Machine learning models in predicting health care costs in patients with a recent acute coronary syndrome: A prospective pilot study

Background

Health care budgets are limited, requiring the optimal use of resources. Machine learning (ML) methods may have an enormous potential for effective use of health care resources.

Objective

We assessed the applicability of selected ML tools to evaluate the contribution of known risk markers for prognosis of coronary artery disease to predict health care costs for all reasons in patients with a recent acute coronary syndrome (n = 65, aged 65 ± 9 years) for 1-year follow-up.

Methods

Risk markers were assessed at baseline, and health care costs were collected from electronic health registries. The Cross-decomposition algorithms were used to rank the considered risk markers based on their impacts on variances. Then regression analysis was performed to predict costs by entering the first top-ranking risk marker and adding the next-best markers, one by one, to build up altogether 13 predictive models.

Results

The average annual health care costs were €2601 ± €5378 per patient. The Depression Scale showed the highest predictive value (r = 0.395), accounting for 16% of the costs (P = .001). When the next 2 ranked markers (LDL cholesterol, r = 0.230; and left ventricular ejection fraction, r = -0.227, respectively) were added to the model, the predictive value was 24% for the costs (P = .001).

Conclusion

Higher depression score is the primary variable forecasting health care costs in 1-year follow-up among acute coronary syndrome patients. The ML tools may help decision-making when planning optimal utilization of treatment strategies.

Case report: specific phobia of vaginal penetration in a pregnant patient

Specific phobia is frequently unrecognized or untreated unless it causes significant impairment. In this report, we documented a rare case of a pregnant patient who had a specific fear related to vaginal penetration. Due to abnormal fetal cardiac development in the second trimester, the patient was admitted for termination of pregnancy. The patient's persistent request for surgical termination via cesarean delivery prompted the obstetrician to seek psychiatric consultation for tokophobia, a labor- and childbirth-related phobia. The consulting psychiatrist discovered that the patient had developed a significant fear of vaginal penetration during adolescence. Throughout the extended period of this specific phobia, the patient established a range of avoidance strategies. Had it not been for the unforeseen need for abortion, her phobia may not have been identified. Psychoeducation on specific phobias, exposure therapy, muscle relaxation techniques, and the administration of anxiolytics were implemented. The pregnancy was terminated through a vaginal labor induction procedure 2 days later. Collaboration across disciplines is necessary to support a thorough assessment of obstetric patients who express hesitancy toward vaginal delivery.

Efficacy and safety of non-pharmacological therapy under the guidance of TCM theory in the treatment of anxiety in patients with myocardial infarction: A protocol for systematic review and meta-analysis

BACKGROUND

With the increasing pressures of modern life and work, combined with a growing older population, the incidence of comorbid anxiety and myocardial infarction (MI) is increasing. Anxiety increases the risk of adverse cardiovascular events in patients with MI and significantly affects their quality of life. However, there is an ongoing controversy regarding the pharmacological treatment of anxiety in patients with MI. The concomitant use of commonly prescribed selective serotonin reuptake inhibitors (SSRIs) and antiplatelet medications such as aspirin and clopidogrel may increase the risk of bleeding. Conventional exercise-based rehabilitation therapies have shown limited success in alleviating anxiety symptoms. Fortunately, non-pharmacological therapies based on traditional Chinese medicine (TCM) theory, such as acupuncture, massage, and qigong, have demonstrated promising efficacy in treating MI and comorbid anxiety. These therapies have been widely used in community and tertiary hospital settings in China to provide new treatment options for patients with anxiety and MI. However, current studies on non-pharmacological TCM-based therapies have predominantly featured small sample sizes. This study aims to comprehensively analyze and explore the effectiveness and safety of these therapies in treating anxiety in patients with MI.

METHOD

We will systematically search six English and four Chinese databases by employing a pre-defined search strategy and adhering to the unique rules and regulations of each database to identify studies that fulfilled our inclusion criteria, to qualify for inclusion, patients must be diagnosed with both MI and anxiety, and they must have undergone non-pharmacological TCM therapies, such as acupuncture, massage, or qigong, whereas the control group received standard treatments. The primary outcome measure will be alterations in anxiety scores, as assessed using anxiety scales, with secondary outcomes encompassing the evaluations of cardiopulmonary function and quality of life. We will utilize RevMan 5.3 to conduct a meta-analysis of the collected data, and subgroup analyses will be executed based on distinct types of non-pharmacological TCM therapies and outcome measures.

RESULTS

A narrative summary and quantitative analysis of the existing evidence on the treatment of anxiety patients with MI using non-pharmacological therapies guided by Traditional Chinese Medicine theory.

CONCLUSION

This systematic review will investigate whether non-pharmacological interventions guided by TCM theory are effective and safe for anxiety in patients with MI, and provide evidence-based support for their clinical application.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022378391.

Remote cardiac rehabilitation program during the COVID-19 pandemic for patients with stable coronary artery disease after percutaneous coronary intervention: a prospective cohort study

OBJECTIVE

The coronavirus disease-19 (COVID-19) pandemic restricts rapid implementation of in-person delivery of cardiac rehabilitation (CR) at the center for coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI), thus enabling a cohort comparison of in-person vs. remote CR program. This study aims to investigate outcomes of exercise capacity, health-related quality of life (HRQL), mental health, and family burden of stable CAD patients undergoing PCI in low-to-moderate risk after different delivery models of CR program.

METHODS

The study included a cohort of stable CAD patients undergoing PCI who had experienced two naturally occurring modes of CR program after hospital discharge at two time periods, January 2019 to December 2019 (in-person CR program) and May 2020 to May 2021 (remote CR program). The exercise capacity was assessed by means of 6-min walk test (6MWT), maximal oxygen uptake (VO₂max) and the respiratory anaerobic threshold (VO_2AT) before discharge, at the end of the 8-week and 12-week in-person or remote CR program after discharge.

RESULTS

No adverse events occurred during the CR period. CAD patients had a longer distance walked in 6 min with a higher VO_2max after 8-week and 12-week CR program whether in-person or remote model (p < 0.05). The distance walked in 6 min was longer and the maximal oxygen uptake (VO₂max) was higher at the end of the 12-week in-person or remote CR program than 8-week in-person or remote CR program (p < 0.05). The respiratory anaerobic threshold (VO_2AT) of CAD patients was decreased after 8-week CR program whether in-person or remote model (p < 0.05). CAD patients receiving remote CR program exhibited higher HRQL scores in domains of vitality (p = 0.048), role emotional (p = 0.039), mental health (p = 0.014), and the summary score of the mental composite (p = 0.048) compared to in-person CR program after 8 weeks. The anxiety and depression scores of CAD patients undergoing PCI were decreased after 8-week CR program whether in-person or remote model (p < 0.05). The CAD patients receiving remote delivery showed lower anxiety and depression scores compared to those receiving in-person delivery at the end of the 8-week CR program (p < 0.05). It was found that the family burden scores of CAD patients undergoing PCI were reduced after 8-week and 12-week CR program whether in-person or remote model (p < 0.05). The CAD patients receiving remote CR program showed lower family burden scores than those receiving in-person CR program after whether 8 weeks or 12 weeks (p < 0.05).

CONCLUSION

These data indicate that a properly designed and monitored remote delivery represents a feasible and safe model for low-to-moderate-risk, stable CAD patients undergoing PCI inaccessible to in-person CR during the COVID-19 pandemic.

Prevalence of post-traumatic stress and tests of metacognition as a PTSD risk marker in patients with coronary heart disease and elevated HADS scores: analysis of data from the PATHWAY RCT's in UK cardiac rehabilitation

Introduction

Anxiety and depression in coronary heart disease (CHD) are associated with poorer health outcomes, greater healthcare use and reduced quality of life. Post-traumatic stress symptoms may be a particular concern as they are associated with increased mortality at follow-up. We examined prevalence of PTSD in patients with elevated anxiety/depression scores referred for cardiac rehabilitation (CR) across seven NHS sites in North-West England. We tested a possible mechanism (metacognition) linking CHD to PTSD symptom severity as implicated in the metacognitive model.

Methods

Data was collected at baseline as part of the NIHR funded PATHWAY trial of metacognitive therapy for anxiety and depression in CHD. Patients (n = 572) with at least mild symptoms of anxiety and depression under routine screening (assessed with the Hospital Anxiety and Depression Scale) and attending CR were eligible for the study. A battery of questionnaires, including assessment of demographic variables, PTSD symptoms (using the IES-R) and metacognitive beliefs was administered prior to random allocation and intervention delivery.

Results

Rates of PTSD were high, with 48% of patients meeting threshold for PTSD and a further 15% partial PTSD. All five metacognition subscales were positively associated with PTSD vs. no PTSD, with beliefs about the uncontrollability and danger of worry and beliefs about need to control thoughts being most strongly related. For every unit increase in uncontrollability and danger metacognitions the odds of being in the PTSD group increased 30%, whilst the odds of partial PTSD increased 16%. Stepwise regression analysis using the metacognitive subscales along with demographic and health-related covariates found that uncontrollability/danger and need for control metacognitions explained unique variation in PTSD symptom severity, with unique contributions also for age, sex, and number of comorbidities.

Conclusion

PTSD symptoms appeared highly prevalent in the current CR sample. Metacognitive beliefs were individually associated with symptom severity with the strongest positive relationship observed for beliefs about uncontrollability and dangerousness of worry, followed by need to control thoughts. The results highlight the importance in assessing PTSD in CR patients and add support to implementing metacognitive therapy in CHD to target particular metacognition risk factors in anxiety, depression and PTSD.

Predictors of health-related quality of life in outpatients with coronary heart disease

Introduction

Health-related quality of life (HRQoL) is an important treatment target in patients with coronary heart disease (CHD) and is associated with poor outcomes. Therefore, it is of clinical importance to identify the key determinants of HRQoL among these patients. There is, however, limited knowledge of how a comprehensive set of psychosocial factors influence HRQoL. We aimed to determine the relative associations of clinical and psychosocial factors with mental and physical components of HRQoL in a sample of CHD outpatients.

Methods

This cross-sectional study included 1,042 patients 2-36 (mean 16) months after a CHD event recruited from two general Norwegian hospitals with a combined catchment area making up 7% of the Norwegian population, representative with regards to demographic and clinical factors. We collected data on HRQoL, demographics, comorbidities, coronary risk factors, and psychosocial factors. HRQoL was assessed using the Short Form 12 (SF12), which comprises a Mental Component Scale (MCS), and the Physical Component Scale (PCS). Crude and multi-adjusted linear regression analyses were used to investigate the association between covariates and MCS and PCS.

Results

Mean age was 61 [standard deviation (SD) 10] years, 20% were females, 18% had type D personality, 20% significant depression symptoms, 14% significant symptoms of anxiety whereas 45% reported insomnia. The presence of type D personality (β: -0.19), significant symptoms of depression (β: -0.15), and the presence of insomnia (β: -0.13) were negatively associated with MCS, but not PCS in multi-adjusted analyses. The presence of chronic kidney disease (β: -0.11) was associated with reduced MCS, whereas the presence of chronic obstructive pulmonary disease (β: -0.08) and low physical activity (β: -0.14) were negatively associated with PCS. Younger age was associated with lower MCS, whereas older age was associated with lower PCS.

Discussion

We conclude that Type D personality, depressive symptoms, insomnia, and chronic kidney disease were the strongest determinants of the mental component of HRQoL. Assessing and managing these psychological factors among CHD outpatients may improve their mental HRQoL.

Exploring the Role of Irrational Beliefs, Lifestyle Behaviors, and Educational Status in 10-Year Cardiovascular Disease Risk: the ATTICA Epidemiological Study

BACKGROUND

Irrational beliefs, maladaptive emotions, and unhealthy lifestyle behaviors can adversely affect health status. However, limited research has examined the association between irrational beliefs and cardiovascular disease (CVD). The aim of this study was to evaluate the association between irrational beliefs and the 10-year CVD incidence among apparently healthy adults, considering the potential moderating or mediating role of particular social and lifestyle factors.

METHODS

The ATTICA study is a population-based, prospective cohort (2002-2012), in which 853 participants without a history of CVD [453 men (aged 45 ± 13 years) and 400 women (aged 44 ± 18 years)] underwent psychological evaluations. Among other tools, participants completed the irrational beliefs inventory (IBI, range 0-88), a self-reported measure consistent with the Ellis model of psychological disturbance. Demographic characteristics, detailed medical history, dietary, and other lifestyle habits were also evaluated. Incidence of CVD (i.e., coronary heart disease, acute coronary syndromes, stroke, or other CVD) was defined according to the International Coding Diseases (ICD)-10 criteria.

RESULTS

Mean IBI score was 53 ± 2 in men and 53 ± 3 in women (p = 0.88). IBI score was positively associated with 10-year CVD risk (hazard ratio 1.07, 95%CI 1.04, 1.13), in both men and women, and more prominently among those with less healthy dietary habits and lower education status; specifically, higher educational status leads to lower IBI score, and in conjunction they lead to lower 10-year CVD risk (HR for interaction 0.98, 95%CI 0.97, 0.99).

CONCLUSIONS

The findings of this study underline the need to build new, holistic approaches in order to better understand the inter-relationships between irrational beliefs, lifestyle behaviors, social determinants, and CVD risk in individuals.

Cognitive-behavioural therapy reduces psychological distress in younger patients with cardiac disease: a randomized trial

AIMS

To test whether usual outpatient cardiac rehabilitation (CR) supplemented by a cognitive-behavioural therapy (CBT) intervention may reduce anxiety and depression compared with usual CR.

METHODS AND RESULTS

In this multicentre randomized controlled trial, 147 cardiac patients (67% men, mean age 54 years, 92% with coronary artery disease) with psychological distress defined as a hospital anxiety and depression scale (HADS) anxiety or depression score ≥8 were randomized to five sessions of group CBT plus usual CR (intervention, n = 74) or CR alone (control, n = 73). Patients with severe distress or a psychiatric diagnosis were excluded. The intervention was delivered by cardiac nurses with CBT training and supervised by a psychologist. A reference, non-randomized group (background, n = 41) of consecutive patients without psychological distress receiving usual CR was included to explore the effect of time on HADS score. The primary outcome, total HADS score after 3 months, improved more in the intervention than in the control group [the mean total HADS score improved by 8.0 (standard deviation 5.6) vs. 4.1 (standard deviation 7.8), P < 0.001]. Significant between-group differences were maintained after 6 months. Compared with the control group, the intervention group also had greater adherence to CR (P = 0.003), more improvement in the heart-related quality of life (HeartQoL) at 6 months (P < 0.01), and a significant reduction in cardiac readmissions at 12 months (P < 0.01). The background group had no significant change in HADS score over time.

CONCLUSION

Brief CBT provided by cardiac nurses in relation to CR reduced anxiety and depression scores, improved HeartQoL and adherence to CR, and reduced cardiovascular readmissions. The programme is simple and may be implemented by CR nurses.

Irrational beliefs, depression and anxiety, in relation to 10-year cardiovascular disease risk: the ATTICA Epidemiological Study

BACKGROUND AND OBJECTIVES

Various bio-psychosocial mechanisms underlying the link between anxiety, depression and cardiovascular disease risk, remain unknown. We investigated the role of irrational beliefs in conjunction with anxiety and depression in the 10-year cardiovascular disease (CVD) incidence, and the effect of biochemical and socio-behavioral factors.

DESIGN

853[453 men (45 ± 13 years) and 400 women (44 ± 18 years)] from the ATTICA study (2002-2012) and without evidence of CVD were assessed.

METHODS

The Irrational Beliefs Inventory (IBI), the Zung Self-Rating-Depression-Scale (ZDRS) and the State-Trait-Anxiety-Inventory (STAI) were used for the assessments. Incidence of CVD was defined according to the International Coding Diseases (ICD)-10 criteria.

RESULTS

Participants with high irrational beliefs and anxiety symptoms had a 138% greater risk of developing CVD during the 10-year follow-up (2.38; 95%CI 1.75, 3.23) as compared to those without anxiety. Among others, C-reactive protein, interleukin-6 and total antioxidant capacity were mediators in the tested association. Interaction of irrational beliefs and depression was not associated with the 10-year CVD in all models.

CONCLUSIONS

Inflammation and oxidative stress, partially explained the associations between irrational beliefs and anxiety in predicting CVD risk. These findings advance psychological research in the area of primary prevention of mental health and cardiovascular diseases.

Cardiovascular disease burden is associated with worsened depression symptoms in the U.S. general population

BACKGROUND

Cardiovascular disease (CVD) and depression are the leading causes of disability in the U.S. Using five cycles (2009-2018) of the U.S. National Health and Nutrition Examination Survey, we examined the cross-sectional association between CVD risk factor burden and depression severity in nonpregnant adults with no history of CVD events.

METHODS

With at least 3000 participants per cycle, the overall N was 18,175. CVD risk factors were ascertained through self-report, lab tests, or medications. The sum of hypertension, diabetes, dyslipidemia, and current smoking represented a CVD risk score variable (range: 0-4). Depression severity was assessed using scores on the 9-item patient health questionnaire: 0-9 (none-mild) and 10-27 (moderate-to-severe). Logistic regression models were performed to investigate the association between CVD risk score categories and moderate-to-severe depression. Cycle-specific odds ratios (OR) were meta-analyzed to obtain a pooled OR (95 % CI) (Q-statistic p > 0.05).

RESULTS

Compared to participants with no CVD risk factors, participants with risk scores of 1, 2, 3, and 4, had 1.28 (0.92-1.77), 2.18 (1.62-2.94), 2.53 (1.86-3.49), 2.97 (1.67-5.31) times higher odds of moderate-to-severe depression, respectively, after adjusting for socio-demographics and antidepressant use (linear trend p < 0.0001). This relationship persisted after additionally adjusting for lifestyle variables.

LIMITATIONS

NHANES data is cross-sectional and self-reported, thus preventing causal assessments and leading to potential recall bias.

CONCLUSIONS

Among U.S. adults, CVD risk factor burden was associated with worsened depression symptoms. Integrated mental and physical healthcare services could improve risk stratification among persons with CVD and depression, possibly reducing long-term disability and healthcare costs.

Characteristics and Effect of Anxiety and Depression Trajectories in Inflammatory Bowel Disease

INTRODUCTION

Symptoms of common mental disorders, such as anxiety or depression, are associated with adverse clinical outcomes in inflammatory bowel disease (IBD). We report trajectories of these symptoms in IBD, patient characteristics associated with different trajectories, and effects on healthcare utilization and prognosis.

METHODS

We collected demographic, symptom, psychological, and quality-of-life data, with questionnaires at 3-month intervals, over 12 months of follow-up. We collected healthcare utilization and IBD outcomes through notes review. We compared characteristics of those with persistently normal or improving anxiety or depression scores with those with persistently abnormal or worsening scores and the number of flares, glucocorticosteroid prescriptions, escalations of therapy, hospitalizations, or intestinal resections due to IBD activity.

RESULTS

Among 771 and 777 patients, respectively, worsening or persistently abnormal anxiety or depression scores were associated with increased antidepressant (28.6% vs 12.3% anxiety, 35.8% vs 10.1% depression, P < 0.001) and opiate use (19.0% vs 7.8% anxiety, P = 0.001 and 34.0% vs 7.4% depression, P < 0.001), compared with those with persistently normal or improving scores. These individuals were also more likely to have been diagnosed with IBD in the last 12 months (16.3% vs 5.0% anxiety, P = 0.001, and 15.1% vs 5.5% depression, P = 0.006), to have clinically active disease at baseline (57.1% vs 26.6% anxiety and 71.7% vs 29.1% depression, P < 0.001) and lower quality-of-life scores ( P < 0.001). Individuals with worsening or persistently abnormal trajectories of anxiety or depression required significantly more outpatient appointments, radiological investigations, and endoscopic procedures for IBD-related symptoms.

DISCUSSION

In this 12-month follow-up study, patients with IBD with worsening or persistently high anxiety or depression scores were higher utilizers of health care but were not at an increased risk of future adverse disease outcomes.

Hospital variability in modifiable factors driving coronary artery bypass charges

OBJECTIVE

Coronary artery bypass grafting is associated with significant interhospital variability in charges. Drivers of hospital charge variability remain elusive. We identified modifiable factors associated with statewide interhospital variability in hospital charges for coronary artery bypass grafting.

METHODS

Charge data were used as a surrogate for cost. Society of Thoracic Surgeons data from Maryland institutions and charge data from the Maryland Health Care Commission were linked to characterize interhospital charge variability for coronary artery bypass grafting. Multivariable linear regression was used to identify perioperative factors independently related to coronary artery bypass grafting charges. Of the factors independently associated with charges, we analyzed which factors varied between hospitals.

RESULTS

A total of 10,337 patients underwent isolated coronary artery bypass grafting at 9 Maryland hospitals from 2012 to 2016, of whom 7532 patients were available for analyses. Mean normalized charges for isolated coronary artery bypass grafting varied significantly among hospitals, ranging from $30,000 to $57,000 (P < .001). Longer preoperative length of stay, operating room time, and major postoperative morbidity including stroke, renal failure, prolonged ventilation, reoperation, and deep sternal wound infection were associated with greater hospital charges. Incidence of major postoperative events, except stroke and deep sternal wound infection, was variable between hospitals. In a univariate linear regression model, patient risk profile only accounted for approximately 10% of statistical variance in charges.

CONCLUSIONS

There is significant charge variability for coronary artery bypass grafting among hospitals within the same state. By targeting variation in preoperative length of stay, operating room time, postoperative renal failure, prolonged ventilation, and reoperation, cardiac surgery programs can realize cost savings while improving quality of care for this resource-intense patient population.

Patient-reported outcome is associated with health care costs in patients with ischaemic heart disease and arrhythmia

AIMS

Systematic use of patient-reported outcomes (PROs) have the potential to improve quality of care and reduce costs of health care services. We aimed to describe whether PROs in patients diagnosed with heart disease are directly associated with health care costs.

METHODS AND RESULTS

A national cross-sectional survey including PROs at discharge from a heart centre with 1-year follow-up using data from national registers. We included patients with either ischaemic heart disease (IHD), arrhythmia, heart failure (HF), or valvular heart disease (VHD). The Hospital Anxiety and Depression Scale, the heart-specific quality of life, the EuroQol five-dimensional questionnaire, and the Edmonton Symptom Assessment Scale were used. The economic analysis was based on direct costs including primary, secondary health care, and medical treatment. Patient-reported outcomes were available from 13 463 eligible patients out of 25.241 [IHD (n = 7179), arrhythmia (n = 4322), HF (n = 987), or VHD (n = 975)]. Mean annual total direct costs in all patients were €23 228 (patients with IHD: €19 479, patients with arrhythmia: €21 076, patients with HF: €34 747, patients with VDH: €48 677). Hospitalizations contributed overall to the highest part of direct costs. For patients discharged with IHD or arrhythmia, symptoms of anxiety or depression, worst heart-specific quality of life or health status, and the highest symptom burden were associated with increased economic expenditure. We found no associations in patients with HF or VHD.

CONCLUSION

Patient-reported outcomes at discharge from a heart centre were associated with direct health care costs in patients with IHD and arrhythmia.

REGISTRATION

ClinicalTrials.gov: NCT01926145.

Metacognitive therapy home-based self-help for anxiety and depression in cardiovascular disease patients in the UK: A single-blind randomised controlled trial

BACKGROUND

Anxiety and depression in cardiac rehabilitation (CR) are associated with greater morbidity, mortality, and increased healthcare costs. Current psychological interventions within CR have small effects based on low-quality studies of clinic-based interventions with limited access to home-based psychological support. We tested the effectiveness of adding self-help metacognitive therapy (Home-MCT) to CR in reducing anxiety and depression in a randomised controlled trial (RCT).

METHODS AND FINDINGS

We ran a single-blind, multi-centre, two-arm RCT. A total of 240 CR patients were recruited from 5 NHS-Trusts across North West England between April 20, 2017 and April 6, 2020. Patients were randomly allocated to Home-MCT+CR (n = 118, 49.2%) or usual CR alone (n = 122, 50.8%). Randomisation was 1:1 via randomised blocks within hospital site, balancing arms on sex and baseline Hospital Anxiety and Depression Scale (HADS) scores. The primary outcome was the HADS total score at posttreatment (4-month follow-up). Follow-up data collection occurred between August 7, 2017 and July 20, 2020. Analysis was by intention to treat. The 4-month outcome favoured the MCT intervention group demonstrating significantly lower end of treatment scores (HADS total: adjusted mean difference = -2.64 [-4.49 to -0.78], p = 0.005, standardised mean difference (SMD) = 0.38). Sensitivity analysis using multiple imputation (MI) of missing values supported these findings. Most secondary outcomes also favoured Home-MCT+CR, especially in reduction of post-traumatic stress symptoms (SMD = 0.51). There were 23 participants (19%) lost to follow-up in Home-MCT+CR and 4 participants (3%) lost to follow-up in CR alone. No serious adverse events were reported. The main limitation is the absence of longer term (e.g., 12-month) follow-up data.

CONCLUSION

Self-help home-based MCT was effective in reducing total anxiety/depression in patients undergoing CR. Improvement occurred across most psychological measures. Home-MCT was a promising addition to cardiac rehabilitation and may offer improved access to effective psychological treatment in cardiovascular disease (CVD) patients.

TRIAL REGISTRATION

NCT03999359.

Bidirectional brain-gut axis effects influence mood and prognosis in IBD: a systematic review and meta-analysis

OBJECTIVE

The role of the brain-gut axis is of increasing interest in IBD, as the link between common mental disorders and GI inflammation may be bidirectional. We performed a systematic review examining these issues.

DESIGN

We searched EMBASE Classic and EMBASE, Medline, and APA PsychInfo (to 11 July 2021) for longitudinal follow-up studies examining effect of symptoms of anxiety or depression on subsequent adverse outcomes in IBD, or effect of active IBD on subsequent development of symptoms of anxiety or depression. We pooled relative risks (RRs) and HRs with 95% CIs for adverse outcomes (flare, escalation of therapy, hospitalisation, emergency department attendance, surgery or a composite of any of these) according to presence of symptoms of anxiety or depression at baseline, or RRs and HRs with 95% CIs for new onset of symptoms of anxiety or depression according to presence of active IBD at baseline.

RESULTS

We included 12 separate studies, recruiting 9192 patients. All 12 studies examined brain-to-gut effects. Anxiety at baseline was associated with significantly higher risks of escalation of therapy (RR=1.68; 95% CI 1.18 to 2.40), hospitalisation (RR=1.72; 95% CI 1.01 to 2.95), emergency department attendance (RR=1.30; 95% CI 1.21 to 1.39), or a composite of any adverse outcome. Depression at baseline was associated with higher risks of flare (RR=1.60; 95% CI 1.21 to 2.12), escalation of therapy (RR=1.41; 95% CI 1.08 to 1.84), hospitalisation (RR=1.35; 95% CI 1.17 to 1.57), emergency department attendance (RR=1.38; 95% CI 1.22 to 1.56), surgery (RR=1.63; 95% CI 1.19 to 2.22) or a composite of any of these. Three studies examined gut-to-brain effects. Active disease at baseline was associated with future development of anxiety or depression (RR=2.24; 95% CI 1.25 to 4.01 and RR=1.49; 95% CI 1.11 to 1.98, respectively).

CONCLUSION

Bidirectional effects of the brain-gut axis are present in IBD and may influence both the natural history of the disease and psychological health.

The role of sense of coherence in reducing anxiety and depressive symptoms among patients at the first acute coronary event: A three-year longitudinal study

OBJECTIVE

Although several studies suggest an association between psychological distress and increased morbidity and mortality in various cardiac populations, little is known about positive psychological resources, like Sense of Coherence (SOC), that may reduce distress. This longitudinal observational study aimed to test the hypothesis that a strong SOC predicted a longitudinal decrease in anxiety and depression in a sample of patients after their first acute coronary event.

METHODS

A sample of 275 patients completed the Hospital Anxiety Depression Scale (HADS) and the SOC Scale at five time-points (at the baseline and after 6, 12, 24, and 36 months). Longitudinal trajectories of anxiety, depression, and SOC were examined through hierarchical (generalized) linear models, controlling for sociodemographic and clinical indicators.

RESULTS

38.6% of patients experienced clinically relevant anxiety symptoms soon after the cardiovascular event, whereas only 20.8% experienced clinically relevant depressive symptoms. Anxiety symptoms decreased over time, plateaued, and then slightly increased, whereas depressive symptoms tended to be stable; these variables were positively associated during all time points. The SOC did not change over time; a strong SOC at baseline predicted decreased anxiety and depression.

CONCLUSION

Findings showed a strong relationship between SOC and symptoms of anxiety and depression, and they suggested the importance of a salutogenic approach in clinical practice and the relevance of interventions aimed at increasing resilience resources like the SOC in patients with cardiovascular diseases.

Associations of Cardiovascular Agents and Metformin with Depression Symptoms: A Cross-Sectional Analysis from the HUNT Study, Norway

BACKGROUND

Cardiovascular agents, including angiotensin-converting enzyme inhibitors, angiotensin II receptor inhibitors, acetylsalicylic acid, statins, and metformin, have demonstrated benefits for depression. However, there is scant evaluation of these drugs' antidepressant properties in large population settings.

OBJECTIVE

This study aimed to examine cross-sectional associations between depression symptoms and the use of cardiovascular agents and metformin in populations with cardiovascular diseases or diabetes mellitus.

METHODS

Participants in the Trøndelag Health Study 2006-08 (HUNT3, n = 40,516) and 2017-19 (HUNT4, n = 42,103) were included and data on their drug use from 2006 to 2019 was retrieved from the Norwegian Prescription Database. The outcome was self-reported depression symptoms defined by the Hospital Anxiety and Depression Scale. Associations between cardiovascular agents or metformin use and self-reported depression were analyzed by multi-level logistic regression in sex-stratified samples.

RESULTS

Among men with cardiovascular diseases, use of acetylsalicylic acid was associated with reduced depression symptoms compared with acetylsalicylic acid non-users (reference) in HUNT3 and HUNT4 [risk ratio = 0.76; 95% confidence interval 0.59-0.94, risk ratio = 0.67; 95% CI 0.52-0.82, respectively]. Similarly, male statin users had a lower likelihood of reporting depression than statin non-users in HUNT3 (risk ratio = 0.70; 95% confidence interval 0.54-0.86) and HUNT4 (risk ratio = 0.67; 95% confidence interval 0.51-0.84). Associations between statins or acetylsalicylic acid use and reduced depression symptoms were detected in women with cardiovascular diseases in HUNT4. We found no statistical support for associations between other cardiovascular agents or metformin use and a reduced or increased depression symptom risk.

CONCLUSIONS

Results suggest negative associations between acetylsalicylic acid or statin use and depression symptoms. However, longitudinal cohort studies and randomized controlled trials are required to confirm the antidepressant effects of these drugs.

Relative Contribution of Disease Activity and Psychological Health to Prognosis of Inflammatory Bowel Disease During 6.5 Years of Longitudinal Follow-Up

BACKGROUND & AIMS

Symptoms of common mental disorders, such as anxiety or depression, are common in inflammatory bowel disease (IBD) and may affect prognosis. However, unlike clinical or biochemical markers of disease activity, psychological health is not a recommended therapeutic target. We assessed relative contribution of poor psychological health and clinical or biochemical activity to prognosis.

METHODS

Demographic features, IBD subtype, treatments, and anxiety and depression scores were recorded at baseline for 760 adults, with clinical activity determined using validated scoring systems. Fecal calprotectin was analyzed in 379 (49.9%) patients (≥250 μg/g used to define biochemical activity). Glucocorticosteroid prescription or flare, escalation, hospitalization, intestinal resection, or death were assessed during 6.5 years of follow-up. Occurrence was compared using multivariate Cox regression across 4 patient groups according to presence of disease remission or activity, with or without symptoms of a common mental disorder, at baseline.

RESULTS

In total, 718 (94.5%) participants provided data. Compared with clinical remission without symptoms of a common mental disorder at baseline, need for glucocorticosteroid prescription or flare (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.58-3.54), escalation (HR, 1.65; 95% CI, 1.14--2.40), and death (HR, 4.99; 95% CI, 1.80-13.88) were significantly higher in those with clinical activity and symptoms of a common mental disorder. Rates in those with clinical remission and symptoms of a common mental disorder at baseline or those with clinical activity without symptoms of a common mental disorder were not significantly higher. Similarly, with biochemical activity and symptoms of a common mental disorder, rates of glucocorticosteroid prescription or flare (HR, 2.48; 95% CI, 1.38-4.46), escalation (HR, 2.97; 95% CI, 1.74-5.06), hospitalization (HR, 3.10; 95% CI, 1.43-6.68), and death (HR, 6.26; 95% CI, 2.23-17.56) were significantly higher.

CONCLUSIONS

Psychological factors are important determinants of poor prognostic outcomes in IBD and should be considered as a therapeutic target.

Multimorbidity and fit note receipt in working-age adults with long-term health conditions

BACKGROUND

Research on sickness absence has typically focussed on single diagnoses, despite increasing recognition that long-term health conditions are highly multimorbid and clusters comprising coexisting mental and physical conditions are associated with poorer clinical and functional outcomes. The digitisation of sickness certification in the UK offers an opportunity to address sickness absence in a large primary care population.

METHODS

Lambeth Datanet is a primary care database which collects individual-level data on general practitioner consultations, prescriptions, Quality and Outcomes Framework diagnostic data, sickness certification (fit note receipt) and demographic information (including age, gender, self-identified ethnicity, and truncated postcode). We analysed 326 415 people's records covering a 40-month period from January 2014 to April 2017.

RESULTS

We found significant variation in multimorbidity by demographic variables, most notably by self-defined ethnicity. Multimorbid health conditions were associated with increased fit note receipt. Comorbid depression had the largest impact on first fit note receipt, more than any other comorbid diagnoses. Highest rates of first fit note receipt after adjustment for demographics were for comorbid epilepsy and rheumatoid arthritis (HR 4.69; 95% CI 1.73-12.68), followed by epilepsy and depression (HR 4.19; 95% CI 3.60-4.87), chronic pain and depression (HR 4.14; 95% CI 3.69-4.65), cardiac condition and depression (HR 4.08; 95% CI 3.36-4.95).

CONCLUSIONS

Our results show striking variation in multimorbid conditions by gender, deprivation and ethnicity, and highlight the importance of multimorbidity, in particular comorbid depression, as a leading cause of disability among working-age adults.

Severity of psychological distress over five years differs as a function of sex and presence of coronary artery disease

BACKGROUND

Psychological distress is more prevalent and severe among patients with coronary artery disease (CAD) compared to healthy individuals. Little is known regarding its time course, and whether these differences extend to individuals with non-cardiovascular (CV) illnesses. This study examined the presence, severity, and time course of psychological distress in men and women with CAD and those of similarly aged individuals suffering from non-CV conditions.

METHODS

1229 individuals (61% men; mean_age = 60.4 ± 7.0 years) with stable CAD or non-CV illnesses reported on social support, hostility, stress, anxiety and depression at baseline as well as 4.8 ± 0.8 years later. Analyses involved mixed (Sex*CAD status*Time) repeated measures analyses (controlling for relevant covariates), as well as Chi-square and McNemar analyses.

RESULTS

Women with CAD reported more symptoms of depression compared to other participants at both evaluations (p's < 0.01), and reported more symptoms of anxiety and stress compared to others at T1 (p's < 0.05). At T2, perceived stress remained significantly greater among women with CAD compared to men (p's < 0.01), though differences in anxiety were no longer significant. Men reported more hostility than women (p = 0.001). CAD women fell within the clinical range for depression (p < 0.001), anxiety (p = 0.001), and stress (p = 0.030) more frequently compared to others at T1, and for depression (p = 0.009) and stress (p = 0.002) at T2.

CONCLUSIONS

The evolution of patient distress differed as a function of the measure examined, their sex, and/or CV status. While psychological distress was prevalent among these patients with diverse health conditions, women with CAD were particularly and chronically vulnerable.

Gender-based depression trajectories following heart disease onset: significant predictors and health outcomes

BACKGROUND

Using a nationally representative sample of U.S. older adults (50+), this study investigates gender-based depression trajectories following heart disease onset and associated risk of disability and mortality over an 8-year period.

METHOD

Six waves of longitudinal data from the Health and Retirement Study (2006-2016) were used (n = 1787). Heart disease onset was defined as self-reporting no heart disease at baseline but reporting a positive diagnosis in a subsequent wave. Growth Mixture Modelling identified depression trajectories. Multinomial logistic regression models determined significant predictors of depression trajectories. Cox proportional-hazards models examined the associated disability and mortality risks.

RESULTS

Three distinct depression trajectories were identified, including persistent minimal depression (men: 68.65%; women: 60.17%), moderate depression (women: 29.70%; men: 17.97%), and chronic depression (women: 10.12%) or emerging depression (men: 13.38%). Younger age and depression status at baseline were associated with women's chronic depression and men's emerging depression. Chronic/emerging and moderate depression were associated with higher disability risks than was minimal depression among both women and men (hazard ratios [HR] ranged from 2.12 to 3.92, p < 0.001). Only men's emerging depression was linked to higher mortality risk compared to minimal depression (HR = 2.03, p < 0.001).

CONCLUSION

Longitudinal course of depression following onset of heart disease is heterogeneous in later life. Unfavorable depression trajectories (i.e. moderate, chronic, and emerging) were associated with higher disability risk compared to the minimal depression trajectory. Study findings characterize risk stratification regarding depression after heart disease onset, which can inform the development of interventions to improve health outcomes among older adults with heart conditions.

Evaluating Metacognitive Therapy to Improve Treatment of Anxiety and Depression in Cardiovascular Disease: The NIHR Funded PATHWAY Research Programme

BACKGROUND

Anxiety and depression contribute to poorer physical and mental health outcomes in cardiac patients. Psychological treatments are not routinely offered in cardiac care and have mixed and small effects. We conducted a series of studies under the PATHWAY research programme aimed at understanding and improving mental health outcomes for patients undergoing cardiac rehabilitation (CR) through provision of metacognitive therapy (MCT).

METHODS

PATHWAY was a series of feasibility trials, single-blind, multicenter, randomized controlled trials (RCTs), qualitative, stated preferences for therapy and health economics studies.

FINDINGS

Patients felt their psychological needs were not met in CR and their narratives of distress could be parsimoniously explained by the metacognitive model. Patients reported they would prefer therapy over no therapy as part of CR, which included delivery by a cardiac professional. Two feasibility studies demonstrated that RCTs of group-based and self-help MCT were acceptable, could be embedded in CR services, and that RCTs of these interventions were feasible. A definitive RCT of group-MCT within CR (n = 332) demonstrated significantly greater reductions in the severity of anxiety and depression, exceeding CR alone, with gains maintained at 12 month follow-up (SMD HADS total score = 0.52 at 4 months and 0.33 at 12 months). A definitive trial of self-help MCT is ongoing.

CONCLUSION

There is a need to better meet the psychological needs of CR patients. Embedding MCT into CR demonstrated high acceptability and improved efficacy on psychological outcomes. Results support roll-out of MCT in CR with evaluation of national implementation.

REGISTRATION

URL: NCT02420431; ISRCTN74643496; NCT03129282.

Prevalence trends of depression and anxiety symptoms in adults with cardiovascular diseases and diabetes 1995-2019: The HUNT studies, Norway

Background

Symptoms of depression and anxiety are common in adults with cardiovascular diseases (CVDs) and diabetes mellitus (DM). The literature on depression and anxiety in CVDs and DM populations is extensive; however, studies examining these relationships over time, directly compared to adults without these conditions, are still lacking. This study aimed to investigate trends in depression and anxiety symptom prevalence over more than 20 years in adults with CVDs and DM compared to the general population.

Methods

We used data from the population-based Trøndelag Health Study (HUNT), Norway, including adults (≥ 20 years) from three waves; the HUNT2 (1995–97; n = 65,228), HUNT3 (2006–08; n = 50,800) and HUNT4 (2017–19; n = 56,042). Depressive and anxiety symptom prevalence was measured independently by the Hospital Anxiety and Depressions scale (HADS) in sex-stratified samples. We analyzed associations of these common psychological symptoms with CVDs and DM over time using multi-level random-effects models, accounting for repeated measurements and individual variation.

Results

Overall, the CVDs groups reported higher levels of depression than those free of CVDs in all waves of the study. Further, depressive and anxiety symptom prevalence in adults with and without CVDs and DM declined from HUNT2 to HUNT4, whereas women reported more anxiety than men. Positive associations of depression and anxiety symptoms with CVDs and DM in HUNT2 declined over time. However, associations of CVDs with depression symptoms remained over time in men. Moreover, in women, DM was associated with increased depression symptom risk in HUNT2 and HUNT4.

Conclusions

Depression and anxiety symptoms are frequent in adults with CVDs. Further, our time trend analysis indicates that anxiety and depression are differentially related to CVDs and DM and sex. This study highlights the importance of awareness and management of psychological symptoms in CVDs and DM populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00636-0.

Depression and anxiety in cardiac rehabilitation: differential associations with changes in exercise capacity and quality of life

BACKGROUND

Cardiac rehabilitation (CR) has been successful in improving exercise capacity (EC) and quality of life (QoL). However, depression and anxiety are highly prevalent among cardiac patients and might represent risk factors for rehabilitation outcomes. The aim of this study was to investigate the role of depression and anxiety as possible independent risk factors for CR outcomes.

METHODS

The study applied a pre-post-design. The sample comprised N = 3'434 cardiac disease patients taking part in a Swiss inpatient CR center. Variables measured at the beginning (T1) and end of rehabilitation (T2) included depression and anxiety (HADS), EC, and QoL (MacNew). A path analysis was conducted.

RESULTS

Depression at T1 had a significant negative relationship with improvements in EC and in all aspects of QoL during rehabilitation. Anxiety at T1 was positively related to improvements in EC and in emotional and physical QoL. Improvements in depression during CR were positively related with improvements in all outcomes. Improvements in anxiety showed no significant association with the outcomes.

CONCLUSION

Depression and anxiety should be screened for during CR. Depression should be treated due to the negative association found with rehabilitation outcomes. Underlying mechanisms of the positive association of anxiety with rehabilitation outcomes need further investigation.

Cardiac rehabilitation patients experiences and understanding of group metacognitive therapy: a qualitative study

OBJECTIVE

Depression and anxiety are up to three times more prevalent in cardiac patients than the general population and are linked to increased risks of future cardiac events and mortality. Psychological interventions for cardiac patients vary in content and are often associated with weak outcomes. A recent treatment, metacognitive therapy (MCT) has been shown to be highly effective at treating psychological distress in mental health settings. This is the first study to explore qualitatively, cardiac rehabilitation (CR) patients' experiences and understanding of group MCT with the aim of examining aspects of treatment that patients experienced as helpful.

METHODS

In-depth qualitative interviews were conducted with 24 purposively sampled CR patients following group MCT. Data were analysed using thematic analysis.

RESULTS

Two main themes were identified: (1) general therapy factors that were seen largely as beneficial, where patients highlighted interaction with other CR patients and CR staff delivery of treatment and their knowledge of cardiology; (2) group MCT-specific factors that were seen as beneficial encompassed patients' understanding of the intervention and use of particular group MCT techniques. Most patients viewed MCT in a manner consistent with the metacognitive model. All the patients who completed group MCT were positive about it and described self-perceived changes in their thinking and well-being. A minority of patients gave specific reasons for not finding the treatment helpful.

CONCLUSION

CR patients with anxiety and depression symptoms valued specific group MCT techniques, the opportunity to learn about other patients, and the knowledge of CR staff. The data supports the transferability of treatment to a CR context and advantages that this might bring.

Improving the Effectiveness of Psychological Interventions for Depression and Anxiety in Cardiac Rehabilitation: PATHWAY-A Single-Blind, Parallel, Randomized, Controlled Trial of Group Metacognitive Therapy

BACKGROUND

Depression and anxiety in cardiovascular disease are significant, contributing to poor prognosis. Unfortunately, current psychological treatments offer mixed, usually small improvements in these symptoms. The present trial tested for the first time the effects of group metacognitive therapy (MCT; 6 sessions) on anxiety and depressive symptoms when delivered alongside cardiac rehabilitation (CR).

METHODS

A total of 332 CR patients recruited from 5 National Health Service Trusts across the North-West of England were randomly allocated to MCT+CR (n=163, 49.1%) or usual CR alone (n=169, 50.9%). Randomization was 1:1 via minimization balancing arms on sex and Hospital Anxiety and Depression Scale scores within hospital site. The primary outcome was Hospital Anxiety and Depression Scale total after treatment (4-month follow-up). Secondary outcomes were individual Hospital Anxiety and Depression Scales, traumatic stress symptoms, and psychological mechanisms including metacognitive beliefs and repetitive negative thinking. Analysis was intention to treat.

RESULTS

The adjusted group difference on the primary outcome, Hospital Anxiety and Depression Scale total score at 4 months, significantly favored the MCT+CR arm (-3.24 [95% CI, -4.67 to -1.81], P<0.001; standardized effect size, 0.52 [95% CI, 0.291 to 0.750]). The significant difference was maintained at 12 months (-2.19 [95% CI, -3.72 to -0.66], P=0.005; standardized effect size, 0.33 [95% CI, 0.101 to 0.568]). The intervention improved outcomes significantly for both depression and anxiety symptoms when assessed separately compared with usual care. Sensitivity analysis using multiple imputation of missing values supported these findings. Most secondary outcomes favored MCT+CR, with medium to high effect sizes for psychological mechanisms of metacognitive beliefs and repetitive negative thinking. No adverse treatment-related events were reported.

CONCLUSIONS

Group MCT+CR significantly improved depression and anxiety compared with usual care and led to greater reductions in unhelpful metacognitions and repetitive negative thinking. Most gains remained significant at 12 months. Study strengths include a large sample, a theory-based intervention, use of longer-term follow-up, broad inclusion criteria, and involvement of a trials unit. Limitations include no control for additional contact as part of MCT to estimate nonspecific effects, and the trial was not intended to assess cardiac outcomes. Nonetheless, results demonstrated that addition of the MCT intervention had broad and significant beneficial effects on mental health symptoms. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: ISRCTN74643496.

Effects of Teaching Resourcefulness in Patients with Coronary Heart Disease

This cluster randomized controlled trial aimed to investigate the effects of an intervention to teach resourcefulness on depression and coping style of patients with coronary heart disease (CHD). A convenience sample of 72 patients in community settings took part. Participants in the intervention group (n = 36) received an 8-week intervention based on the concept of resourcefulness, plus routine health education. Participants in the control group (n = 36) received routine health education only. After the intervention, participants in the intervention group had significantly higher scores on resourcefulness and coping styles, and lower scores on depression than those in the control group (both ps < .001). The findings suggest that a well-developed intervention to teach resourcefulness could help patients with CHD to be more resourceful, improve their level of depression, and choose more effective strategies to cope with stress.

Time-dependent cognitive and somatic symptoms of depression as predictors of new cardiac-related events in at-risk patients: the UPBEAT-UK cohort

BACKGROUND

Evidence suggests that somatic rather than cognitive depressive symptoms are risk factors for recurrent cardiac events in at-risk patients. However, this has never been explored using a time-dependent approach in a narrow time-frame, allowing a cardiac event-free time-window.

METHODS

The analysis was performed on 595 participants [70.6% male, median age 72 (27-98)] drawn from the UPBEAT-UK heart disease patient cohort with 6-monthly follow-ups over 3 years. Depressive symptomatology was measured using the Patient Health Questionnaire-9 (PHQ-9) (four somatic, five cognitive items). New cardiac events (NCEs) including cardiac-related mortality were identified by expert examination of patient records. Analyses were performed using Cox proportional hazard models with delayed entry, with time-dependent depressive dimensions and covariates measured 12-18 months (median: 14.1, IQR: 3.5) prior to the event, with a 12-month cardiac event-free gap.

RESULTS

There were 95 NCEs during the follow-up [median time-to-event from baseline: 22.3 months (IQR: 13.4)]. Both the somatic (HR 1.12, 95% CI 1.05-1.20, p = 0.001) and cognitive dimensions (HR 1.11, 95% CI 1.03-1.18, p = 0.004) were time-dependent risk factors for an NCE in the multi-adjusted models. Specific symptoms (poor appetite/overeating for the somatic dimension, hopelessness and feeling like a failure for the cognitive dimension) were also significantly associated.

CONCLUSION

This is the first study of the association between depressive symptom dimensions and NCEs in at-risk patients using a time-to-event standardised approach. Both dimensions considered apart were independent predictors of an NCE, along with specific items, suggesting regular assessments and tailored interventions targeting specific depressive symptoms may help to prevent NCEs in at-risk populations.

Lessons learned from an attempted randomized-controlled feasibility trial on "WIDeCAD" - An internet-based depression treatment for people living with coronary artery disease (CAD)

Despite the high prevalence of comorbid depression in people living with coronary artery disease (CAD), uptake of psychological treatment is generally low. This study was designed to investigate the feasibility of an internet-based cognitive-behavioral (iCBT) depression intervention for people with CAD and depressive symptoms.

METHODS

People with CAD and depressive symptoms (PHQ-9 ≥ 5) were randomly assigned to the eight modules comprising iCBT (N = 18), or waitlist-control (N = 16). Measures were taken at baseline (t1) and at post-treatment (eight weeks after randomization, t2). Feasibility-related outcomes were recruitment strategy, study attrition, intervention dropout, satisfaction, negative effects as well as the potential of the intervention to affect likely outcomes in a future full-scale trial (depression, anxiety, quality of life, fear of progression). Data analyses were based on intention-to-treat principles. Linear regression models were used to detect between group differences. Linear Mixed Models were used to model potential changes over time.

RESULTS

This trial was terminated prior to a-priori defined sample size has been reached given low recruitment success as well as high intervention dropout (88%) and study attrition (23%). On average, participants in the intervention group completed M = 2.78 (SD = 3.23) modules. Participants in the waitlist control group barely started one module (M = 0.82, SD = 1.81). The satisfaction with the intervention was low (M = 20.6, SD = 0.88). Participants reported no negative effects attributed to the iCBT. Differences between groups with regard to depression, anxiety, fear of progression and quality of life remained non-significant (p > 0.05).

CONCLUSION

This trial failed to recruit a sufficient number of participants. Future work should explore potential pitfalls with regards to the reach and persuasiveness of internet interventions for people living with CAD. The study gives important indications for future studies with regard to the need for new ideas to reach and treat people with CAD and depression.

Common mental disorders in irritable bowel syndrome: pathophysiology, management, and considerations for future randomised controlled trials

The frequent co-occurrence of irritable bowel syndrome and the common mental disorders of anxiety and depression is well established. A range of biological and psychosocial disease mechanisms are common to both disorders, many of which contribute to a dysregulated gut-brain axis. Clinical and subthreshold psychological comorbidity adds to the functional impairment and disease burden in individuals with irritable bowel syndrome. Progress is being made with regard to understanding irritable bowel syndrome in the clinical setting from a biopsychosocial perspective. However, until now, most trials of irritable bowel syndrome treatment still consider the disease as a gut disorder in isolation, which leaves major gaps in knowledge about disease-disease interactions and treatment outcomes in irritable bowel syndrome. In this Viewpoint, we review the epidemiology, pathophysiology, and management of anxiety and depression in individuals with irritable bowel syndrome. We also provide methodological recommendations for future randomised controlled trials and outline guidance for research that better incorporates psychiatric comorbidity into its design, with a view to improve treatment outcomes for individuals with irritable bowel syndrome.

Effectiveness of e-Health cardiac rehabilitation program on quality of life associated with symptoms of anxiety and depression in moderate-risk patients

Exploring new models of medical care requires evaluating the impact of new care strategies not only on physiological parameters but also on the quality of life of the patient. On the other hand the presence of anxiety together with depression requires further consideration when planning appropriate management strategies. The aim of this study was to examine the effectiveness of a home-based cardiac rehabilitation program incorporating an e-Health technology on health-related quality of life associated with symptoms of anxiety and depression in moderate-risk patients. A multicenter, randomized controlled clinical trial was designed to compare a traditional hospital based cardiac rehabilitation program (n = 38, 35 male) with a mixed home surveillance program where patients exercised at home with a remote electrocardiographic monitoring device (n = 33, 31 male). The Short Form-36 (SF-36) Health Survey and the Goldberg questionnaire were used to evaluate quality of life and the presence of symptoms of anxiety and depression respectively. The results of this study show that the type of cardiac rehabilitation program did not influence the improvement in quality of life (p = 0.854), but the presence of symptoms of anxiety and depression did (p = 0.001). Although both programs achieved a decrease in anxiety and depression symptoms and improved functional capacity (p ≤ 0.001), a significant interaction effect was found between the group with or without anxiety and depression symptoms and the type of program in the bodily pain dimension (p = 0.021). Trial registration: Retrospectively registered NCT02796404 (10/06/2016) in clinialtrials.gov.

Time-dependent depression and anxiety symptoms as risk factors for recurrent cardiac events: findings from the UPBEAT-UK study

BACKGROUND

Depression is a well-known risk factor for recurrent cardiac events (RCEs) but findings are less consistent for anxiety, not previously reported on using a time-dependent approach. We aimed to study the prognostic effect of anxiety and depression symptom levels on RCEs.

METHODS

Data (N = 595) were drawn from the UPBEAT-UK heart disease patient cohort with 6-monthly follow-ups over 3 years. Hospital Anxiety and Depression Scale symptoms were grouped into: agitation (three items), anxiety (four items), and depression (seven items) subscales. We performed two types of multivariate analyses using Cox proportional hazard models with delayed entry: with baseline variables (long-term analysis), and with variables measured 12-to-18 months prior to the event (short-term time-dependent analysis), as RCE risk factors.

RESULTS

In the baseline analysis, both anxiety and depression, but not agitation, were separate RCE risk factors, with a moderating effect when considered jointly. In the short-term time-dependent analysis, elevated scores on the anxiety subscale were associated with increased RCE risk even when adjusted for depression [hazard ratio (95% confidence interval) 1.22 (1.05-1.41), p = 0.009]. Depression was no longer a significant predictor when adjusted for anxiety [1.05 (0.87-1.27), p = 0.61]. For anxiety, individual items associated with RCEs differed between the two approaches: item 5 'worrying thoughts' was the most significant long-term risk factor [1.52 (1.21-1.91), p = 0.0004] whereas item 13 'feelings of panic' was the most significant time-dependent short-term risk factor [1.52 (1.18-1.95), p = 0.001].

CONCLUSIONS

Anxiety is an important short-term preventable and potentially causal risk factor for RCEs, to be targeted in secondary cardiac disease prevention programmes.

Association Between Disability Trajectory and Health Care Service Utilization Among Older Adults in China

OBJECTIVES

This study aimed to identify the heterogeneous disability trajectories among older Chinese adults and examine the association between disability trajectories and health care service utilization.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

A community-based study including older adults aged ≥65 years from the Chinese Longitudinal Healthy Longevity Survey.

METHODS

Disability was assessed by the difficulties in activities of daily living and instrumental activities of daily living between 2002 and 2018. Health care utilization was measured by the expenditures on outpatient and inpatient services in 2018. Growth mixture modeling was conducted to estimate heterogeneous disability trajectories. A 2-part model was used to analyze the association of disability trajectories and health care utilization. Covariates were included based on Andersen's behavioral model.

RESULTS

Three classes of disability trajectories were identified: the progressive (7.9%), late-onset (13.7%), and normal classes (78.4%). Older adults who followed the late-onset trajectory of disability were more likely to use inpatient services compared with the normal class (odds ratio = 1.47, P < .010), after controlling potential confounders. Compared with the normal class, the progressive class on average spent US$145.94 more annually (45.2% higher) on outpatient services (P < .010) and $738.99 more annually (72.6% higher) on inpatient services (P < .001); the late-onset class reported higher annual expenditures on outpatient and inpatient services of $215.94 (66.9% higher) and $1405.00 (138.0% higher), respectively (all P < .001).

CONCLUSIONS AND IMPLICATIONS

Heterogeneous disability trajectories exhibited distinct health care service utilization patterns among older Chinese adults. Older adults affected by late-onset disability incurred the highest health care needs. These findings provide valuable policy-relevant evidence for reducing health care burden among older adults.

Detection and treatment of mental disorders in patients with coronary heart disease (MenDis-CHD): A cross-sectional study

Mental disorders (MD) are associated with an increased risk of developing coronary heart disease (CHD) and with higher CHD-related morbidity and mortality. There is a strong recommendation to routinely screen CHD patients for MDs, diagnosis, and treatment by recent guidelines. The current study aimed at mapping CHD patients' (1) state of diagnostics and, if necessary, treatment of MDs, (2) trajectories and detection rate in healthcare, and (3) the influence of MDs and its management on quality of life and patient satisfaction. The design was a cross-sectional study in three settings (two hospitals, two rehabilitation clinics, three cardiology practices). CHD patients were screened for MDs with the Hospital Anxiety and Depression Scale (HADS), and, if screened-positive, examined for MDs with the Structured Clinical Interview for DSM-IV (SCID-I). Quality of Life (EQ-5D), Patient Assessment of Care for Chronic Conditions (PACIC), and previous routine diagnostics and treatment for MDs were examined. Descriptive statistics, Chi-squared tests, and ANOVA were used for analyses. Analyses of the data of 364 patients resulted in 33.8% positive HADS-screenings and 28.0% SCID-I diagnoses. The detection rate of correctly pre-diagnosed MDs was 49.0%. Physicians actively approached approximately thirty percent of patients on MDs; however, only 6.6% of patients underwent psychotherapy and 4.1% medication therapy through psychotherapists/psychiatrists. MD patients scored significantly lower on EQ-5D and the PACIC. The state of diagnostic and treatment of comorbid MDs in patients with CHD is insufficient. Patients showed a positive attitude towards addressing MDs and were satisfied with medical treatment, but less with MD-related advice. Physicians in secondary care need more training inadequately addressing mental comorbidity.

Psychiatric and Psychosomatic Consultation-Liaison Services in General Hospitals: A Systematic Review and Meta-Analysis of Effects on Symptoms of Depression and Anxiety

BACKGROUND

Psychiatric and psychosomatic consultation-liaison services (CL) are important providers of diagnosis and treatment for hospital patients with mental comorbidities and psychological burdens.

OBJECTIVE

To perform a systematic review and meta-analysis investigating the effects of CL on depression and anxiety.

METHODS

Following PRISMA guidelines, a systematic literature search was conducted until 2017. Included were published randomized controlled trials using CL interventions with adults in general hospitals, treatment as usual as control groups, and depression and/or anxiety as outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Level of integration was assessed using the Standard Framework for Levels of Integrated Healthcare. Meta-analyses were performed using random effects models and meta-regression for moderator effects.

RESULTS

We included 38 studies (9,994 patients). Risk of bias was high in 17, unclear in 15, and low in 6 studies. Studies were grouped by type of intervention: brief interventions tailored to the patients (8), interventions based on specific treatment manuals (19), and integrated, collaborative care (11). Studies showed small to medium effects on depression and anxiety. Meta-analyses for depression yielded a small effect (d = -0.19, 95% CI: -0.30 to -0.09) in manual studies and a small effect (d = -0.33, 95% CI: -0.53 to -0.13) in integrated, collaborative care studies, the latter using mostly active control groups with the possibility of traditional consultation.

CONCLUSIONS

CL can provide a helpful first treatment for symptoms of depression and anxiety. Given that especially depressive symptoms in medically ill patients are long-lasting, the results underline the benefit of integrative approaches that respect the complexity of the illness.

IMPORTANCE OF SOCIAL FACTORS IN HEALTH: CAUSES OF THE CAUSES

The industrial revolution in 1830 led to the urbanization resulting in creation of urban slums. More complex health problems ultimately steered the concept of public health. The social revolution during the Second World War emphasized that health could only be achieved through socioeconomic improvement. Progress in the field of social sciences rediscovered that man is a social being, not only a biological animal. Social services for the improvement of life conditions have been the major factors in reducing mortality, morbidity and improving the standard of life of an individual, family and society.