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Freedman DE, Oh J, Kiss A, Puopolo J, Wishart M, Meza C, Feinstein A. The influence of depression and anxiety on cognition in people with multiple sclerosis: a cross-sectional analysis. J Neurol 2024; 271:4885-4896. [PMID: 38730098 DOI: 10.1007/s00415-024-12409-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/04/2024] [Accepted: 04/26/2024] [Indexed: 05/12/2024]
Abstract
There are conflicting findings about the relationships between depression, anxiety, and cognitive dysfunction in people with multiple sclerosis (MS), and a paucity of research has examined the cumulative influence on cognition of depression plus anxiety. This study aimed to determine whether elevated symptoms of depression and anxiety alone or in combination are associated with worse cognition in people with MS. In this cross-sectional analysis, people with MS consecutively seen at a tertiary neuropsychiatry clinic completed the Hospital Anxiety and Depression Scale for symptoms of depression (HADS-D) and anxiety (HADS-A), and the Minimal Assessment of Cognitive Function in MS for cognitive indices. Accounting for covariates, regression models predicted cognitive indices from scores for HADS-D, HADS-A, and the interaction. Of 831 people with MS, 72% were female, mean age was 43.2 years, and median Expanded Disability Status Scale score was 2.0. Depressive symptoms were independently predictive of lower verbal fluency (Controlled Oral Word Association Test, p < 0.01), verbal learning (California Verbal Learning Test-II (CVLT-II) total learning, p = 0.02), verbal delayed recall (CVLT-II delayed recall, p < 0.01), and processing speed (Symbol Digit Modalities Test, p < 0.01; three-second Paced Auditory Serial Addition Test (PASAT), p = 0.05; two-second PASAT, p = 0.01). Anxiety in people with depression predicted decreased visuospatial function (Judgment of Line Orientation, p = 0.05), verbal learning (p < 0.01), verbal delayed recall (p < 0.01), visuospatial recall (Brief Visuospatial Memory Test-Revised, p = 0.02), and executive function (Delis-Kaplan Executive Function System, p < 0.01). Anxiety alone was not independently predictive of cognition. In conclusion, depression, especially with comorbid anxiety, is associated with cognitive dysfunction in people with MS.
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Affiliation(s)
- David E Freedman
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
| | - Jiwon Oh
- Division of Neurology, Department of Medicine, Temerty Faculty of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Alex Kiss
- Evaluative Clinical Sciences, Department of Health Policy, Management and Evaluation, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, University of Toronto, Toronto, Canada
| | - Juliana Puopolo
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Margaret Wishart
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Cecilia Meza
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Anthony Feinstein
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Canada
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2
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Carmin CN, Ownby RL, Fontanella C, Steelesmith D, Binkley PF. Impact of Mental Health Treatment on Outcomes in Patients With Heart Failure and Ischemic Heart Disease. J Am Heart Assoc 2024; 13:e031117. [PMID: 38506666 PMCID: PMC11179768 DOI: 10.1161/jaha.123.031117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 01/12/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND There is conflicting evidence as to the impact of mental health treatment on outcomes in patients with heart disease. The aim of this study was to examine whether individuals who received mental health treatment for anxiety or depression after being hospitalized for ischemic disorders or heart failure had a reduced frequency of rehospitalizations, emergency department visits, or mortality compared with those who did not receive treatment. METHODS AND RESULTS A population-based, retrospective, cohort design was used to examine the association between psychotherapy or antidepressant medication prescription and health service utilization and mortality in patients with coronary artery disease or heart failure and comorbid anxiety or depression. Those receiving versus not receiving mental health treatment were compared based on the frequency of rehospitalization, emergency department visits, and mortality. The study sample included 1563 patients who had a mean age of 50.1 years. Individuals who received both forms of mental health treatment for anxiety or depression were 75% less likely to be rehospitalized, 74% less likely to have an emergency department visit, and 66% less likely to die from any cause. CONCLUSIONS Mental health treatment for anxiety or depression has a significant impact on outcomes in patients with cardiovascular disease consisting of reduced hospitalizations, emergency department visits, and in some conditions improved survival.
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Affiliation(s)
- Cheryl N. Carmin
- Department of Psychiatry and Behavioral HealthThe Ohio State University Wexner Medical CenterColumbusOHUSA
| | - Raymond L. Ownby
- Department of Psychiatry and Behavioral MedicineNova Southeastern UniversityFort LauderdaleFLUSA
| | - Cynthia Fontanella
- Department of Psychiatry and Behavioral HealthThe Ohio State University Wexner Medical CenterColumbusOHUSA
| | - Danielle Steelesmith
- Department of Psychiatry and Behavioral HealthThe Ohio State University Wexner Medical CenterColumbusOHUSA
| | - Philip F. Binkley
- Department of Psychiatry and Behavioral HealthThe Ohio State University Wexner Medical CenterColumbusOHUSA
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3
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Zhang L, Wang Q, Cui HS, Luo YY. Assessing myocardial indices and inflammatory factors to determine anxiety and depression severity in patients with chronic heart failure. World J Psychiatry 2024; 14:53-62. [PMID: 38327882 PMCID: PMC10845224 DOI: 10.5498/wjp.v14.i1.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 11/25/2023] [Accepted: 12/21/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Patients with chronic heart failure (CHF) have a progressive disease that is associated with poor quality of life and high mortality. Many patients experience anxiety and depression (A&D) symptoms, which can further accelerate disease progression. We hypothesized that indicators of myocardial function and inflammatory stress may reflect the severity of A&D symptoms in patients with CHF. Changes in these biomarkers could potentially predict whether A&D symptoms will deteriorate further in these individuals. AIM To measure changes in cardiac and inflammatory markers in patients with CHF to determine A&D severity and predict outcomes. METHODS We retrospectively analyzed 233 patients with CHF treated at the Jingzhou Hospital, Yangtze University between 2018-2022 and grouped them according to Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) scores. We compared clinical data in the no-A&D, mild-A&D, moderate-A&D, and severe-A&D groups, the SAS and SDS scores with the New York Heart Association (NYHA) functional classification, and cardiac markers and inflammatory factors between the no/mild-A&D and moderate/severe-A&D groups. Regression analysis was performed on the markers with P < 0.05 to determine their ability to predict A&D severity in patients and the area under the receiver operating characteristic curve (AUROC) was used to evaluate their accuracy. RESULTS In the inter-group comparison, the following variables had an effect on A&D severity in patients with CHF: NYHA class, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter, N-terminal pro-brain natriuretic peptide (NT-proBNP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (P < 0.05). Other variables did not differ significantly between the A&D groups (P > 0.05). In addition, we found that higher NYHA classes were associated with higher the SAS and SDS scores (P < 0.05). Regression analysis showed that LVEF, NT-proBNP, and IL-6 were independent risk factors for A&D severity (P < 0.05). Among them, NT-proBNP had the best predictive ability as a single indicator (AUROC = 0.781). Furthermore, the combination of these three indicators exhibited a good predictive effect toward discriminating the extent of A&D severity among patients (AUROC = 0.875). CONCLUSION Cardiac and inflammatory biomarkers, such as LVEF, NT-proBNP, and IL-6, are correlated with A&D severity in patients with CHF and have predictive value.
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Affiliation(s)
- Li Zhang
- Department of Cardiology, Jingzhou Hospital, Yangtze University, Jingzhou 434020, Hubei Province, China
| | - Qiang Wang
- Department of Cardiology, Jingzhou Hospital, Yangtze University, Jingzhou 434020, Hubei Province, China
| | - Hong-Sheng Cui
- Department of Cardiology, Jingzhou Hospital, Yangtze University, Jingzhou 434020, Hubei Province, China
| | - Yuan-Yuan Luo
- Department of Intensive Care Unit, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510000, Guangdong Province, China
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4
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Al-Sutari MM, Abdalrahim MS. Symptom Burden and Quality of Life Among Patients With Heart Failure. SAGE Open Nurs 2024; 10:23779608241242023. [PMID: 38559894 PMCID: PMC10981229 DOI: 10.1177/23779608241242023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/16/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction Heart failure is a debilitating condition that is associated with several burdensome symptoms that impede patients' quality of life. However, patients' experience of distressing symptoms and their impacts on their quality of life is not studied in Jordan. Objectives To assess the severity of distressing symptoms and to assess the relationships between these symptoms and the quality of life among patients with heart failure in Jordan. Methods A descriptive cross-sectional design was used. A convenience sampling approach was used to recruit the participants. Heart failure patients (n = 167) who visited the outpatient clinics in three hospitals in Amman between July and November 2021 were included. The Edmonton Symptom Assessment System and Short-Form 36 tool were used. Results Participants were more likely males with a mean age of 55.2 years (SD = 13.7). The most distressing symptoms among patients with heart failure were tiredness (M = 4.56, SD = 3.24), worse well-being (M = 4.34, SD = 2.52), and drowsiness (M = 3.5, SD = 3.06), respectively. Symptoms burden were negatively associated with the physical and the mental components summary of the quality of life. Pain, tiredness, nausea, loss of appetite, anxiety, and poor well-being were significant predictors of the physical components. The predictors of the mental components were tiredness, nausea, loss of appetite, and anxiety. Conclusions This study revealed that patients with heart failure facing significant symptom burden. The patients showed inadequate quality of life in both physical and mental components that were inversely associated with symptom burden. Given the debilitating effects of symptom burden on heart failure patients' quality of life, therefore, symptom assessment and management have to be a priority.
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Affiliation(s)
- Manal Mohammed Al-Sutari
- Acute and Chronic Care Nursing Department, Faculty of Nursing, Al-Ahliyya Amman University, Amman, Jordan
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5
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Sumaqa YA, Hayajneh FA, Alhamory S, Rayan A, Alnaeem M, Al Tarawneh TR, Assaf Alrida NA, Abu-abbas M, Suhemat A, Ayasreh IR. Consequences of Psychological Aspects: From Jordanian Heart Failure Patients' Beliefs. SAGE Open Nurs 2023; 9:23779608231189128. [PMID: 37528905 PMCID: PMC10387668 DOI: 10.1177/23779608231189128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/14/2023] [Accepted: 06/27/2023] [Indexed: 08/03/2023] Open
Abstract
Introduction Psychological aspects are common in patients with heart failure (HF). Psychological aspects have negative consequences in patients with HF. Objective This study was conducted to gain a deeper understanding of the consequences of psychological aspects in Jordanian patients with HF. Methods This study is a qualitative study conducted with the participation of 24 patients with HF. Data were collected using semi-structured interviews. Results The main theme of the findings can be expressed as "Consequences of psychological aspects of HF." The following four sub-themes emerged from the data: social isolation, disturbance of feelings, being non-compliant, and growing burden on the health care system. Conclusion The findings revealed the need for informing healthcare providers about the negative consequences of psychological aspects and develop clinical guidelines to evaluate psychological aspects to support these patients.
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Affiliation(s)
| | | | | | - Ahmad Rayan
- Faculty of Nursing, Zarqa University, Zarqa, Jordan
| | | | | | | | | | - Aida Suhemat
- Faculty of Nursing, University of Mutah, Alkarak, Jordan
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6
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Manolis TA, Manolis AA, Melita H, Manolis AS. Neuropsychiatric disorders in patients with heart failure: not to be ignored. Heart Fail Rev 2022:10.1007/s10741-022-10290-2. [DOI: 10.1007/s10741-022-10290-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
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7
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Yusufov M, Pirl WF, Braun I, Tulsky JA, Lindvall C. Natural Language Processing for Computer-Assisted Chart Review to Assess Documentation of Substance use and Psychopathology in Heart Failure Patients Awaiting Cardiac Resynchronization Therapy. J Pain Symptom Manage 2022; 64:400-409. [PMID: 35716959 DOI: 10.1016/j.jpainsymman.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 06/09/2022] [Accepted: 06/09/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Advanced heart failure (HF) patients often experience distressing psychological symptoms, frequently meeting diagnostic criteria for psychological disorders, including anxiety, depression, and substance use disorder. Patients with device-based HF therapies have added risk for psychological disorders, with consequences for their physiological functioning, including adverse cardiac outcomes. OBJECTIVES This study used natural language processing (NLP) for computer-assisted chart review to assess documentation of mental health and substance use in HF patients awaiting cardiac resynchronization therapy (CRT), a device-based HF therapy. METHODS We applied NLP to clinical notes from electronic health records (EHR) of 965 consecutive patients, with 9821 total clinical notes, at two academic medical centers between 2004 and 2015. We developed and validated a keyword library capturing terms related to mental health and substance use, while balancing specificity and sensitivity. RESULTS Mean age was 71.6 years (SD = 11.8), 78% male, and 87% non-Hispanic White. Of the 544 patients (56.4%) with documentation of mental health history, 9.7% had their mental health assessed and 6.6% had a plan documented. Of the 773 patients (80.1%) with documentation of substance use history, 10 (1.0%) had an assessment, and 3 (0.3%) had a plan. CONCLUSION Despite clinical recommendations and standards of care, clinicians are under documenting assessments and plans prior to CRT. Future research should develop an algorithm to prompt clinicians to document this content. Such quality improvement efforts may ensure adherence to standards of care and clinical guidelines.
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Affiliation(s)
- Miryam Yusufov
- Department of Psychosocial Oncology and Palliative Care (M.Y., W.F.P., I.B., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School (M.Y., W.F.P., I.B., J.A.T., C.L.), Boston, Massachusetts, USA.
| | - William F Pirl
- Department of Psychosocial Oncology and Palliative Care (M.Y., W.F.P., I.B., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School (M.Y., W.F.P., I.B., J.A.T., C.L.), Boston, Massachusetts, USA
| | - Ilana Braun
- Department of Psychosocial Oncology and Palliative Care (M.Y., W.F.P., I.B., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School (M.Y., W.F.P., I.B., J.A.T., C.L.), Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care (M.Y., W.F.P., I.B., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School (M.Y., W.F.P., I.B., J.A.T., C.L.), Boston, Massachusetts, USA
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care (M.Y., W.F.P., I.B., J.A.T., C.L.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Harvard Medical School (M.Y., W.F.P., I.B., J.A.T., C.L.), Boston, Massachusetts, USA
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8
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Chen X, Xu L, Li Z. Autonomic Neural Circuit and Intervention for Comorbidity Anxiety and Cardiovascular Disease. Front Physiol 2022; 13:852891. [PMID: 35574459 PMCID: PMC9092179 DOI: 10.3389/fphys.2022.852891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/21/2022] [Indexed: 11/28/2022] Open
Abstract
Anxiety disorder is a prevalent psychiatric disease and imposes a significant influence on cardiovascular disease (CVD). Numerous evidence support that anxiety contributes to the onset and progression of various CVDs through different physiological and behavioral mechanisms. However, the exact role of nuclei and the association between the neural circuit and anxiety disorder in CVD remains unknown. Several anxiety-related nuclei, including that of the amygdala, hippocampus, bed nucleus of stria terminalis, and medial prefrontal cortex, along with the relevant neural circuit are crucial in CVD. A strong connection between these nuclei and the autonomic nervous system has been proven. Therefore, anxiety may influence CVD through these autonomic neural circuits consisting of anxiety-related nuclei and the autonomic nervous system. Neuromodulation, which can offer targeted intervention on these nuclei, may promote the development of treatment for comorbidities of CVD and anxiety disorders. The present review focuses on the association between anxiety-relevant nuclei and CVD, as well as discusses several non-invasive neuromodulations which may treat anxiety and CVD.
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Affiliation(s)
- Xuanzhao Chen
- The Center of Pathological Diagnosis and Research, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Li Xu
- Department of Rheumatology and Immunology, General Hospital of Central Theater Command, Wuhan, China
| | - Zeyan Li
- The Center of Pathological Diagnosis and Research, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
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9
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Nikbakht Nasrabadi A, Mardanian Dehkordi L, Taleghani F. Nurses’ Experiences of Transitional Care in Multiple Chronic Conditions. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2021. [DOI: 10.1177/10848223211002166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transitional care is a designed plan to ensure the continuity of care received by patients as they transfer between different locations or levels of care. The aim of this paper is to explore nurses’ experiences of transitional care in multiple chronic conditions. A qualitative method with a conventional content analysis approach was utilized. The study was conducted at university hospitals in 2 big cities (Isfahan and Tehran) of Iran. This study is performed from November 2018 to December 2019 using deep, semi-structured, and face-to-face interviews which are focused on nurses’ experiences of transitional care. Data collection continued until saturation was reached. Finally, 15 nurses take part in this study. Data collection and data analysis were conducted concurrently. Data were analyzed using Graneheim and Lundman’s techniques. Two main themes providing a descriptive summary of the major elements of transitional care identified: “threat to patient safety” and “Care breakdown”. Findings showed an exclusive image of unsafe transitional care which was done unplanned without appropriate delegating care to family and threat patient safety. There is still a gap in the transition from hospital to home. Nursing managers can address this issue by creating a culture of teamwork, training competent nurses by continuum education, and more supervision of nursing care. Policymakers can ensure continuity of care by developing policies and programs about transitional care.
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Affiliation(s)
| | - Leila Mardanian Dehkordi
- School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
- Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fariba Taleghani
- Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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10
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Abstract
BACKGROUND An estimated 6.5 million American adults live with heart failure (HF). Elevated anxiety symptoms may worsen HF symptoms and contribute to decreases in overall quality of life (QOL). Mindfulness has been associated with better psychological health with lower levels of anxiety symptoms. Mindfulness may be a modifiable target for reducing anxiety symptoms and increasing QOL in patients with HF. OBJECTIVE The objective of this study is to examine the relationships among anxiety symptoms, dispositional mindfulness, and QOL in patients with symptomatic HF. METHODS In this cross-sectional study, we conducted a secondary analysis of baseline data from 70 participants. We performed descriptive statistics, bivariate Pearson correlations, and multiple linear regression. RESULTS The sample included 70 individuals with a mean age of 65 ± 10.5 years, 89% male, mean left ejection fraction of 45.7 ± 13.6, mean total QOL of 36.9 ± 21.7, mean total mindfulness of 82.2 ± 12.8, and mean anxiety of 4.8 ± 2.9. In multiple regression analyses, total mindfulness was significantly associated with lower anxiety (β = -0.491, P < .01), greater observational mindfulness was significantly associated with lower anxiety (β = -0.377, P < .01), and greater nonreactivity to inner experience was significantly associated with lower anxiety (β = -0.320, P < .05). Lower anxiety was associated with greater total QOL (β = 0.488, P < .01), greater physical QOL (β = 0.381, P < .01), and greater emotional QOL (β = 0.639, P < .01). CONCLUSIONS Mindfulness may be a way of improving both anxiety symptoms and QOL in this population.
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11
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Suksatan W, Tankumpuan T. Depression and Rehospitalization in Patients With Heart Failure After Discharge From Hospital to Home: An Integrative Review. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2021. [DOI: 10.1177/1084822320986965] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients with heart failure are known to be particularly vulnerable to depression resulting in adverse health outcomes. However, there has been no literature review on current evidence regarding the relationship between depression and rehospitalization. This review aims to explore the relationship between depression and rehospitalization in patients with heart failure. A systematic review employing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines included articles published between 2001 and 2019 taken from Scopus, PubMed, CINAHL, and PsycINFO databases. We identified 12 relevant studies with participants ranging from 115 to 160,169 patients. Heart failure patients with depression were more likely to be rehospitalized than those without. To explain this, few reasons have been proposed. First, depression could disrupt the regulation of autonomic nervous system, neurohormonal activation, and body’s natural rhythm. Second, depressed patients tend to have poor adherence to medication. Healthcare providers should not only focus on drug and dietary management but also on implementing effective interventions to manage depression, in order to reduce the risk of rehospitalization. Moreover, palliative care should start at the stage of heart failure diagnosis to improve quality of life, better outcomes, and lower cost of care for the patients.
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Affiliation(s)
- Wanich Suksatan
- HRH Princess Chulabhorn College of Medical Science Faculty of Nursing, Chulabhorn Royal Academy, Bangkok, Thailand
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12
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Hill L, Prager Geller T, Baruah R, Beattie JM, Boyne J, de Stoutz N, Di Stolfo G, Lambrinou E, Skibelund AK, Uchmanowicz I, Rutten FH, Čelutkienė J, Piepoli MF, Jankowska EA, Chioncel O, Ben Gal T, Seferovic PM, Ruschitzka F, Coats AJS, Strömberg A, Jaarsma T. Integration of a palliative approach into heart failure care: a European Society of Cardiology Heart Failure Association position paper. Eur J Heart Fail 2020; 22:2327-2339. [PMID: 32892431 DOI: 10.1002/ejhf.1994] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 12/18/2022] Open
Abstract
The Heart Failure Association of the European Society of Cardiology has published a previous position paper and various guidelines over the past decade recognizing the value of palliative care for those affected by this burdensome condition. Integrating palliative care into evidence-based heart failure management remains challenging for many professionals, as it includes the identification of palliative care needs, symptom control, adjustment of drug and device therapy, advance care planning, family and informal caregiver support, and trying to ensure a 'good death'. This new position paper aims to provide day-to-day practical clinical guidance on these topics, supporting the coordinated provision of palliation strategies as goals of care fluctuate along the heart failure disease trajectory. The specific components of palliative care for symptom alleviation, spiritual and psychosocial support, and the appropriate modification of guideline-directed treatment protocols, including drug deprescription and device deactivation, are described for the chronic, crisis and terminal phases of heart failure.
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Affiliation(s)
- Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Tal Prager Geller
- Palliative Care Ward at Dorot Health Centre, Heart Failure Unit at Rabin Medical Center, Netanya, Israel
| | - Resham Baruah
- Chelsea and Westminster NHS Foundation Trust, London, UK
| | - James M Beattie
- Cicely Saunders Institute, King's College London, London, UK
| | - Josiane Boyne
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Giuseppe Di Stolfo
- Cardiovascular Department, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | | | | | - Izabella Uchmanowicz
- Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland.,Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Massimo Francesco Piepoli
- Heart Failure Unit, Cardiology, Guglielmo da Saliceto Hospital, Piacenza, Italy.,University of Parma, Parma, Italy
| | - Ewa A Jankowska
- Centre for Heart Diseases, University Hospital, Wroclaw, Poland.,Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania.,University of Medicine Carol Davila, Bucharest, Romania
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Petar M Seferovic
- Cardiology Department, Clinical Centre Serbia, Medical School Belgrade, Belgrade, Serbia
| | - Frank Ruschitzka
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Anna Strömberg
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
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13
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Kewcharoen J, Tachorueangwiwat C, Kanitsoraphan C, Saowapa S, Nitinai N, Vutthikraivit W, Rattanawong P, Banerjee D. Association between depression and increased risk of readmission in patients with heart failure: a systematic review and meta-analysis. Minerva Cardiol Angiol 2020; 69:389-397. [PMID: 32996309 DOI: 10.23736/s2724-5683.20.05346-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Heart failure (HF) is one of the world leading causes of admission and readmission. Recent studies have shown that the presence of depression is associated with hospital readmission in patients after an index admission for heart failure (HF). However, there is disagreement between published studies regarding this finding. We performed a systematic review and meta-analysis to evaluate the effect of depression on readmission rates in HF patients. EVIDENCE ACQUISITION We searched the databases of MEDLINE and EMBASE from inception to March 2020. Included studies were published study evaluating readmission rate of HF patients, with and without depression. Data from each study were combined using a random-effects model, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. EVIDENCE SYNTHESIS Ten studies were included in the meta-analysis with a total of 53,165 patients (6194 patients with depression). The presence of depression was associated with an increased risk of readmission in patients with HF (pooled HR=1.54, 95% CI: 1.22-1.94, P<0.001, I2=55.4%). In a subgroup analysis, depression was associated with an increased risk of readmission in patients with HF in both short-term (≤90 days) follow-up (pooled HR=1.75, 95% CI: 1.07-2.85, P=0.025, I2=76.0%) and long-term (>90 days) follow-up (pooled HR=1.58, 95% CI: 1.32-1.90, P<0.001, I2=0.0%). CONCLUSIONS Our meta-analysis demonstrated that depression is associated with an increased risk of hospital readmission in patients with HF.
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Affiliation(s)
- Jakrin Kewcharoen
- Internal Medicine Residency Program, University of Hawaii, Honolulu, HI, USA -
| | | | | | - Sakditad Saowapa
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nattapat Nitinai
- Faculty of Medicine, Chulalongkorn University Hospital, Bangkok, Thailand
| | - Wasawat Vutthikraivit
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Pattara Rattanawong
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Dipanjan Banerjee
- Queens Heart Physician Practice, Queen's Medical Center, Honolulu, HI, USA.,John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
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14
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Psychomotor speed as a predictor of functional status in older chronic heart failure (CHF) patients attending cardiac rehabilitation. PLoS One 2020; 15:e0235570. [PMID: 32614895 PMCID: PMC7332048 DOI: 10.1371/journal.pone.0235570] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/18/2020] [Indexed: 01/14/2023] Open
Abstract
Background The association among psychological, neuropsychological dysfunctions and functional/clinical variables in Chronic Heart Failure (CHF) has been extensively addressed in literature. However, only a few studies investigated those associations in the older population. Purpose To evaluate the psychological/neuropsychological profile of older CHF patients, to explore the interrelation with clinical/functional variables and to identify potential independent predictors of patients’ functional status. Methods This study was conducted with a multi-center observational design. The following assessments were performed: anxiety (Hospital Anxiety and Depression Scale, HADS), depression (Geriatric Depression Scale, GDS), cognitive impairment (Addenbrooke’s Cognitive Examination Revised, ACE-R), executive functions (Frontal Assessment Battery, FAB), constructive abilities (Clock Drawing Test, CDT), psychomotor speed and alternated attention (Trail Making Test, TMT-A/B), functional status (6-minute walking test, 6MWT) and clinical variables (New York Heart Association, NYHA; Brain Natriuretic Peptide, BNP; left ventricular ejection fraction, LVEF; left ventricular end diastolic diameter, LVEDD; left ventricular end diastolic volume, LVEDV; tricuspid annular plane systolic excursion, TAPSE). Results 100 CHF patients (mean age: 74.9±7.1 years; mean LVEF: 36.1±13.4) were included in the study. Anxious and depressive symptoms were observed in 16% and 24,5% of patients, respectively. Age was related to TMT-A and CDT (r = 0.49, p<0.001 and r = -0.32, p = 0.001, respectively), Log-BNP was related to ACE-R-Fluency subtest, (r = -0.22, p = 0.034), and 6MWT was related to ACE-R-Memory subtest and TMT-A (r = 0.24, p = 0.031 and r = -0.32, p = 0.005, respectively). Both anxiety and depression symptoms were related to ACE-R-Total score (r = -0.25, p = 0.013 and r = -0.32, p = 0.002, respectively) and depressive symptoms were related to CDT (r = -0.23, p = 0.024). At multiple regression analysis, Log-BNP and TMT-A were significant and independent predictors of functional status: worse findings on Log-BNP and TMT-A were associated with shorter distance walked at the 6MWT. Conclusions Psychological and neuropsychological screening, along with the assessment of psychomotor speed (TMT-A), may provide useful information for older CHF patients undergoing cardiac rehabilitation.
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15
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Freedland KE, Steinmeyer BC, Carney RM, Skala JA, Rich MW. Antidepressant use in patients with heart failure. Gen Hosp Psychiatry 2020; 65:1-8. [PMID: 32361659 PMCID: PMC7350278 DOI: 10.1016/j.genhosppsych.2020.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE There is little evidence that antidepressants are efficacious for depression in patients with heart failure (HF), and equivocal evidence that they are safe. This study identified characteristics that are associated with antidepressant use in hospitalized patients with HF. METHOD Logistic regression models were used to identify independent correlates of antidepressant use in 400 patients hospitalized with HF between 2014 and 2016. The measure of depression in the primary analysis was a DSM-5 diagnosis based on a structured interview; this was replaced by a PHQ-9 depression score in a secondary analysis. RESULTS In the primary analysis, there were positive associations between antidepressant use and white race, younger age, unemployment, non-ischemic HF, number of other prescribed medications, current minor depression, history of major depression, and functional impairment. In the secondary analysis, there were positive associations with white race, unemployment, number of other prescribed medications, and functional impairment; the effect of current severity of depression differed between patients with vs. without a history of major depression. CONCLUSIONS Current depression is only one of several factors that influence the use of antidepressant medications in patients with HF. Further research is needed to ensure that these agents are being used appropriately in this patient population.
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Affiliation(s)
- Kenneth E Freedland
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA.
| | - Brian C Steinmeyer
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Robert M Carney
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Judith A Skala
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael W Rich
- Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
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16
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Ely AV, Alio C, Bygrave D, Burke M, Walker E. Relationship Between Psychological Distress and Cognitive Function Differs as a Function of Obesity Status in Inpatient Heart Failure. Front Psychol 2020; 11:162. [PMID: 32116957 PMCID: PMC7033423 DOI: 10.3389/fpsyg.2020.00162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/21/2020] [Indexed: 01/19/2023] Open
Abstract
Heart failure (HF) is a chronic medical condition rapidly growing in prevalence. Evidence links HF to cognitive decline, obesity, and psychological distress. The current study examined the association between cognitive function and ejection fraction (EF%), anxiety, depression, and obesity in inpatient HF. Patients completed the Generalized Anxiety Disorder 7-Item Scale (GAD-7), Patient Health Questionnaire 9-Item Scale (PHQ-9), and Mini-Cog while hospitalized for HF. Additional demographic and medical information was gathered via chart review. All models controlled for age. Of 117 patients assessed (49% male), 55% (n = 64) were obese. ANCOVA analyses were conducted comparing those with obesity and without on cognitive function: model A included EF%, model B included depression, and model C included anxiety. All three models were significantly related to cognitive function. There was a significant interaction effect of EF% and obesity and of anxiety and obesity to predict Mini-Cog scores. Post hoc partial correlational analyses revealed that anxiety was negatively associated with Mini-Cog scores among only patients without obesity. Depression was not significantly related to cognitive function in either group. However, patients with obesity demonstrated higher depression and anxiety than patients without. Results suggest that at lower EF%, and with higher anxiety, patients without obesity may be at greater risk of cognitive dysfunction than those with obesity. Cognitive dysfunction among HF patients with obesity may be independent of psychological distress. These findings may reflect the “obesity paradox” observed among HF patients, in that patients with obesity may have a different biopsychosocial presentation, which may lead to unexpected clinical outcomes. Further research is necessary to articulate the relationship of obesity and cognitive function in HF.
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Affiliation(s)
- Alice V Ely
- Department of Psychiatry, Christiana Care, Newark, DE, United States.,Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, United States
| | - Courtney Alio
- Department of Psychiatry, Christiana Care, Newark, DE, United States
| | - Desiree Bygrave
- Department of Psychiatry, Christiana Care, Newark, DE, United States.,School of Nursing, University of Delaware, Newark, DE, United States
| | - Marykate Burke
- Department of Psychiatry, Christiana Care, Newark, DE, United States
| | - Earl Walker
- Department of Psychiatry, Christiana Care, Newark, DE, United States
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17
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Ichijo Y, Kono S, Yoshihisa A, Misaka T, Kaneshiro T, Oikawa M, Miura I, Yabe H, Takeishi Y. Impaired Frontal Brain Activity in Patients With Heart Failure Assessed by Near-Infrared Spectroscopy. J Am Heart Assoc 2020; 9:e014564. [PMID: 31973606 PMCID: PMC7033895 DOI: 10.1161/jaha.119.014564] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background The prevalence of depression and/or anxiety disorders is reported to be higher in patients with heart failure (HF) than in the general population, and patients with HF also have coexisting cognitive problems. Recently, the development of near-infrared spectroscopy (NIRS) has enabled noninvasive measurements of regional cerebral blood volume and brain activity, in terms of cerebral oxyhemoglobin in the cerebral cortex, with a high time resolution. The aim of the current study was to determine the associations between frontal brain activity and depressive symptoms, anxiety status, and cognitive function in patients with HF. Methods and Results We measured and compared frontal brain activity determined by NIRS during a verbal fluency task in patients with HF (n=35) and control subjects (n=28). The Center for Epidemiologic Studies Depression Scale for assessment of depressive symptoms, State-Trait Anxiety Inventory for assessment of anxiety status, Mini-Mental State Examination for assessment of cognitive function, and NIRS were simultaneously conducted. NIRS showed that frontal brain activity was significantly lower in the HF group than in the control subjects (28.5 versus 88.0 mM·mm; P<0.001). Next, we examined the associations between frontal brain activity and the findings of Center for Epidemiologic Studies Depression Scale, State-Trait Anxiety Inventory, Mini-Mental State Examination, and verbal fluency task. There were significant correlations between frontal brain activity and State-Trait Anxiety Inventory (R=-0.228, P=0.046), Mini-Mental State Examination (R=0.414, P=0.017), and verbal fluency task (R=0.338, P=0.007), but not with Center for Epidemiologic Studies Depression Scale (R=-0.160, P=0.233). Conclusions Frontal brain activity assessed by NIRS is reduced and is associated with high anxiety status and low cognitive function in patients with HF.
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Affiliation(s)
- Yasuhiro Ichijo
- Department of Cardiovascular Medicine Fukushima Medical University Fukushima Japan
| | - Soichi Kono
- Department of Neuropsychiatry Fukushima Medical University Fukushima Japan
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine Fukushima Medical University Fukushima Japan
| | - Tomofumi Misaka
- Department of Cardiovascular Medicine Fukushima Medical University Fukushima Japan
| | - Takashi Kaneshiro
- Department of Cardiovascular Medicine Fukushima Medical University Fukushima Japan
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine Fukushima Medical University Fukushima Japan
| | - Itaru Miura
- Department of Neuropsychiatry Fukushima Medical University Fukushima Japan
| | - Hirooki Yabe
- Department of Neuropsychiatry Fukushima Medical University Fukushima Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine Fukushima Medical University Fukushima Japan
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18
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Cognitive behavioural therapy for co-morbid anxiety and depression in heart failure: a case report. COGNITIVE BEHAVIOUR THERAPIST 2020. [DOI: 10.1017/s1754470x20000197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Heart failure increases the likelihood of an individual experiencing co-morbid anxiety and depression, which can affect their physical as well as mental health. There is a need to develop non-pharmacological interventions for the psychological consequences of heart failure. Evidence shows that cognitive behavioural therapy (CBT) can be helpful, but there is less clarity about CBT’s effectiveness for people with heart failure who have complex multi-morbid difficulties.
This paper presents a case report of a man with heart failure. He was part of a research trial for cardiac resynchronisation therapy with defibrillation (CRT-D), after other physical procedures had been unsuccessful, and was experiencing severe anxiety and moderately severe depression. The intervention used was based on transdiagnostic CBT, provided at home over six sessions. Self-report measures were completed at each session and at 3-month follow-up. A measure of his use of clinical services was also carried out at pre-, post- and 3-month follow up. Post-intervention, the client showed non-clinical levels of depression and anxiety and these improvements were maintained at 3 months. Use of clinical services also reduced, with fewer admissions to hospital and fewer visits by specialist nurses and GPs.
This case suggests that CBT, and particularly transdiagnostic CBT, can be helpful in reducing anxiety and depression in people with heart failure. Further work evaluating the impact on quality of life and the utility of this approach with a wider group of people with heart failure and psychological distress would be advantageous.
Key learning aims
(1)
Depression and anxiety are prevalent in people with heart failure.
(2)
Cognitive behavioural therapy can be an effective intervention for reducing depression and anxiety in people living with heart failure.
(3)
There are benefits to integrating care with this population because they present with interlinked physical and psychological needs.
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19
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Lin TK, Hsu BC, Li YD, Chen CH, Lin JW, Chien CY, Weng CY. Prognostic Value of Anxiety Between Heart Failure With Reduced Ejection Fraction and Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2019; 8:e010739. [PMID: 31181979 PMCID: PMC6645644 DOI: 10.1161/jaha.118.010739] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Evidence suggests differences in clinical characteristics, causes, and prognoses between heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Most studies have failed to support the prognostic relevance of anxiety in HFrEF or unclassified HF with mean left ventricular ejection fraction <40%. Meanwhile, the association between anxiety and prognoses in HFpEF remains unexamined. This study compared the prognostic value of anxiety between HFrEF and HFpEF. Methods and Results A total of 158 patients with HFrEF (left ventricular ejection fraction=28.51±7.53%) and 108 patients with HFpEF (left ventricular ejection fraction=64.53±9.67%) were recruited between May 2012 and December 2014. Demographic and clinical characteristics, Spielberger State‐Trait Anxiety Inventory, Beck Depression Inventory‐II scale, and 18‐month follow‐up outcomes were recorded during the hospital stay. There were significant differences in age, sex, comorbidities, laboratory biomarkers, discharge medications, and unhealthy behaviors, which supported the contention that HFrEF and HFpEF represent 2 distinct phenotypes, although there were no significant differences in anxiety and 18‐month outcomes. Multiple logistic regression yielded no significant associations between anxiety and 18‐month outcomes in HFrEF. By contrast, trait anxiety could predict 18‐month all‐cause mortality (odds ratio, 1.429; 95% CI, 1.020–2.000; P=0.038), all‐cause readmission or death (odds ratio, 1.147; 95% CI, 1.036–1.271; P=0.008), and cardiac readmission or death (odds ratio, 1.133; 95% CI, 1.031–1.245; P=0.010) in HFpEF after adjusting for possible confounders. Conclusions Trait anxiety was independently associated with 18‐month all‐cause mortality, all‐cause readmission or death, and cardiac readmission or death in HFpEF, but not in HFrEF.
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Affiliation(s)
- Tin-Kwang Lin
- 1 School of Medicine Tzu Chi University Hualien Taiwan.,2 Department of Internal Medicine Dalin Tzu Chi Hospital Buddhist Tzu Chi Medical Foundation Chiayi Taiwan
| | - Bo-Cheng Hsu
- 3 Department of Psychology National Chung Cheng University Chiayi Taiwan
| | - Yi-Da Li
- 1 School of Medicine Tzu Chi University Hualien Taiwan.,2 Department of Internal Medicine Dalin Tzu Chi Hospital Buddhist Tzu Chi Medical Foundation Chiayi Taiwan
| | - Chi-Hsien Chen
- 2 Department of Internal Medicine Dalin Tzu Chi Hospital Buddhist Tzu Chi Medical Foundation Chiayi Taiwan
| | - Jiunn-Wen Lin
- 2 Department of Internal Medicine Dalin Tzu Chi Hospital Buddhist Tzu Chi Medical Foundation Chiayi Taiwan
| | - Chen-Yu Chien
- 2 Department of Internal Medicine Dalin Tzu Chi Hospital Buddhist Tzu Chi Medical Foundation Chiayi Taiwan
| | - Chia-Ying Weng
- 3 Department of Psychology National Chung Cheng University Chiayi Taiwan
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20
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Abstract
LEARNING OBJECTIVES After participating in this activity, learners should be better able to:• Identify the relationships between depression, anxiety, and heart failure (HF).• Assess methods for accurately diagnosing depression and anxiety disorders in patients with HF.• Evaluate current evidence for treatment of anxiety and depression in patients with HF. BACKGROUND In patients with heart failure (HF), depression and anxiety disorders are common and associated with adverse outcomes such as reduced adherence to treatment, poor function, increased hospitalizations, and elevated mortality. Despite the adverse impact of these disorders, anxiety and depression remain underdiagnosed and undertreated in HF patients. METHODS We performed a targeted literature review to (1) identify associations between depression, anxiety, and HF, (2) examine mechanisms mediating relationships between these conditions and medical outcomes, (3) identify methods for accurately diagnosing depression and anxiety disorders in HF, and (4) review current evidence for treatments of these conditions in this population. RESULTS Both depression and anxiety disorders are associated with the development and progression of HF, including increased rates of mortality, likely mediated through both physiologic and behavioral mechanisms. Given the overlap between cardiac and psychiatric symptoms, accurately diagnosing depression or anxiety disorders in HF patients can be challenging. Adherence to formal diagnostic criteria and utilization of a clinical interview are the best courses of action in the evaluation process. There is limited evidence for the efficacy of pharmacologic and psychotherapy in patients with HF. However, cognitive-behavioral therapy has been shown to improve mental health outcomes in patients with HF, and selective serotonin reuptake inhibitors appear safe in this cohort. CONCLUSIONS Depression and anxiety disorders in HF patients are common, underrecognized, and linked to adverse outcomes. Further research to improve detection and develop effective treatments for these disorders in HF patients is badly needed.
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Affiliation(s)
- Christopher M. Celano
- Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Ana C. Villegas
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | | | - Hanna K. Gaggin
- Harvard Medical School, Boston, MA
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Jeff C. Huffman
- Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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21
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Affiliation(s)
- Kathryn A Wood
- 1 Emory University Nell Hodgson Woodruff School of Nursing Atlanta GA
| | | | - Holli A DeVon
- 3 University of Illinois at Chicago College of Nursing Chicago IL
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22
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Ma C. Rehospitalisation rates and associated factors within 6 months after hospital discharge for patients with chronic heart failure: A longitudinal observational study. J Clin Nurs 2019; 28:2526-2536. [DOI: 10.1111/jocn.14830] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 01/21/2019] [Accepted: 02/09/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Chunhua Ma
- School of Nursing; Guangzhou Medical University; Guangzhou China
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23
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24
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Pino EC, Zuo Y, Borba CP, Henderson DC, Kalesan B. Clinical depression and anxiety among ST-elevation myocardial infarction hospitalizations: Results from Nationwide Inpatient Sample 2004-2013. Psychiatry Res 2018; 266:291-300. [PMID: 29615266 DOI: 10.1016/j.psychres.2018.03.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 02/13/2018] [Accepted: 03/13/2018] [Indexed: 10/17/2022]
Abstract
Depression and anxiety are common among patients who have a major cardiovascular event. However, despite their frequency, there is a lack of evidence regarding the relationship between depression and/or anxiety and receiving revascularization in ST-elevation myocardial infarction (STEMI) hospitalizations. Using data from the Nationwide Inpatient Sample (NIS) from the years 2004 to 2013, we assessed whether a clinical co-diagnosis of depression and/or anxiety decreases the likelihood of revascularization among STEMI hospitalizations. Our central finding is that, paradoxically, the odds of in-hospital mortality were lower among STEMI hospitalizations with a clinical co-diagnosis of depression and/or anxiety as compared to those without. We further discovered that clinical diagnoses of depression and/or anxiety were less prevalent among revascularized as compared to non-revascularized STEMI hospitalizations. However, the percentage of clinical diagnoses of depression and/or anxiety among STEMI hospitalizations increased at a similar rate over a 10-year period irrespective of revascularization status. In conclusion, these results are suggestive of the potentially underdiagnosed mental health issues surrounding major cardiovascular events, and indeed, chronic disease as a whole. To our knowledge, this is the first study to document and examine the "depression paradox" among a population of cardiac patients.
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Affiliation(s)
- Elizabeth C Pino
- Center for Clinical Translational Epidemiology and Comparative Effectiveness Research, Department of Medicine, Boston University School of Medicine, Boston, MA, United States
| | - Yi Zuo
- Center for Clinical Translational Epidemiology and Comparative Effectiveness Research, Department of Medicine, Boston University School of Medicine, Boston, MA, United States
| | - Christina Pc Borba
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States
| | - David C Henderson
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States
| | - Bindu Kalesan
- Center for Clinical Translational Epidemiology and Comparative Effectiveness Research, Department of Medicine, Boston University School of Medicine, Boston, MA, United States.
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Bangalore S, Shah R, Pappadopulos E, Deshpande CG, Shelbaya A, Prieto R, Stephens J, McIntyre RS. Cardiovascular hazards of insufficient treatment of depression among patients with known cardiovascular disease: a propensity score adjusted analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 4:258-266. [DOI: 10.1093/ehjqcco/qcy023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/06/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Sripal Bangalore
- Cardiovascular Outcomes Group, Leon H. Charney Division of Cardiology, New York University School of Medicine, 550 First Avenue, SKI 9R/109, New York, NY, USA
| | - Ruchitbhai Shah
- Pharmerit International, LP, 4350 East West Hwy, Suite #1110, Bethesda, MD, USA
| | | | - Chinmay G Deshpande
- Pharmerit International, LP, 4350 East West Hwy, Suite #1110, Bethesda, MD, USA
| | - Ahmed Shelbaya
- Pfizer Inc., 235 E 42nd St, New York, NY, USA
- Mailman School of Public Health, Columbia University, 722 W 168th St, New York, NY, USA
| | - Rita Prieto
- Pfizer GEP, S.L.U., AVENIDA DE EUROPA (PQ EMP LA MORALEJA), 20 - B, ALCOBENDAS, MADRID, Spain
| | - Jennifer Stephens
- Pharmerit International, LP, 4350 East West Hwy, Suite #1110, Bethesda, MD, USA
| | - Roger S McIntyre
- MDPU, UHN University of Toronto, 399 Bathurst Street, MP 9-325, Toronto, Ontario, Canada
- Brain and Cognition Discovery Foundation, University Health Network, 399 Bathurst Street, MP 9-325, Toronto, Ontario, Canada
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26
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Alhurani AS, Dekker R, Ahmad M, Miller J, Yousef KM, Abdulqader B, Salami I, Lennie TA, Randall DC, Moser DK. Stress, cognitive appraisal, coping, and event free survival in patients with heart failure. Heart Lung 2018; 47:205-210. [PMID: 29627073 DOI: 10.1016/j.hrtlng.2018.03.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 03/16/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe self-reported stress level, cognitive appraisal and coping among patients with heart failure (HF), and to examine the association of cognitive appraisal and coping strategies with event-free survival. METHODS This was a prospective, longitudinal, descriptive study of patients with chronic HF. Assessment of stress, cognitive appraisal, and coping was performed using Perceived Stress Scale, Cognitive Appraisal Health Scale, and Brief COPE scale, respectively. The event-free survival was defined as cardiac rehospitalization and all-cause death. RESULTS A total of 88 HF patients (mean age 58 ± 13 years and 53.4% male) participated. Linear and cox regression showed that harm/loss cognitive appraisal was associated with avoidant emotional coping (β = -0.28; 95% CI: -0.21 - 0.02; p = 0.02) and event free survival (HR = 0.53; 95% CI: 0.28 - 1.02; p = 0.05). CONCLUSIONS The cognitive appraisal of the stressors related to HF may lead to negative coping strategies that are associated with worse event-free survival.
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Affiliation(s)
| | | | | | | | | | - Basel Abdulqader
- California School for Health Sciences, Garden Grove, United States
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Chang WH, Lee IH, Chen WT, Chen PS, Yang YK, Chen KC. Coexisting geriatric anxiety and depressive disorders may increase the risk of ischemic heart disease mortality-a nationwide longitudinal cohort study. Int J Geriatr Psychiatry 2017; 32:e25-e33. [PMID: 27966781 DOI: 10.1002/gps.4646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 11/09/2016] [Accepted: 11/16/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVES In the elderly, the risk of mortality because of physical illnesses related to anxiety disorders varies with potential confounding influences, including comorbidity with depressive disorders. Our study aimed to explore (i) whether anxiety disorders increase the risk of mortality in the elderly, and (ii) whether the risk of mortality mediated by anxiety and depressive disorders differs between physical illnesses. METHODS Our longitudinal cohort study included subjects aged over 60 years from the National Health Insurance Research Database. One thousand and eighty-six subjects with anxiety disorders and 50 554 control subjects without anxiety disorders were included. Propensity score-matched cohorts were analyzed. Rate ratios (RRs) were calculated for the risk of mortality associated with different physical illnesses with comorbidities of either anxiety disorders only or both anxiety and depressive disorders. RESULTS The risk of mortality in patients with anxiety disorders was significantly higher than controls, and was even higher when subjects had both anxiety and depressive disorder comorbidities. Furthermore, the co-occurrence of anxiety and depressive disorders increased the risk of mortality in elderly patients with ischemic heart diseases (RR = 1.60; 95% CI: 1.14-2.24). CONCLUSIONS Coexisting anxiety and depressive disorders could increase the risk of mortality in elderly patients with ischemic heart diseases. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Wei Hung Chang
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan.,Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - I Hui Lee
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Addiction Research Center, National Cheng Kung University, Tainan, Taiwan
| | - Wei Tseng Chen
- Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan.,Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po See Chen
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Addiction Research Center, National Cheng Kung University, Tainan, Taiwan
| | - Yen Kuang Yang
- Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan.,Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Addiction Research Center, National Cheng Kung University, Tainan, Taiwan.,Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kao Chin Chen
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Addiction Research Center, National Cheng Kung University, Tainan, Taiwan
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Aggelopoulou Z, Fotos NV, Chatziefstratiou AA, Giakoumidakis K, Elefsiniotis I, Brokalaki H. The level of anxiety, depression and quality of life among patients with heart failure in Greece. Appl Nurs Res 2017; 34:52-56. [DOI: 10.1016/j.apnr.2017.01.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 12/14/2016] [Accepted: 01/31/2017] [Indexed: 11/26/2022]
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29
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Taylor JB, Stern TA. Meeting Its Mission: Does Psychosomatics Align With the Mission of Its Parent Organization, the Academy of Psychosomatic Medicine? PSYCHOSOMATICS 2017; 58:375-385. [PMID: 28449827 DOI: 10.1016/j.psym.2017.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/05/2017] [Accepted: 03/06/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The vision and mission statements of the Academy of Psychosomatic Medicine (APM) indicate that the APM should promote excellence in clinical care for patients with comorbid psychiatric and general medical conditions by seeking to influence research, public policy, and interdisciplinary education. OBJECTIVE As the APM owns the journal, Psychosomatics, we sought to assess whether the APM's journal was fulfilling the vision and mission of its parent organization by reviewing the content of articles published in the journal to determine whether it sufficiently addresses the various clinical care knowledge areas it seeks to influence. METHODS We categorized content in all review articles, case reports, and original research articles published in Psychosomatics in 2015 and 2016. Each article was assigned to as many categories that it covered. RESULTS In the 163 articles reviewed, the most frequently covered fund of knowledge area was psychiatric morbidity in medical populations (44.2%); among psychiatric disorders, mood disorders (22.1%), psychiatric disorders due to a general medical condition or toxic substance (21.5%), anxiety disorders (14.7%), and delirium (13.5) were the most frequently covered. Of the medical and surgical topics, neurology (19.6%), coping with chronic illness/psychological response to illness (17.8%), toxicology (11.7%), outpatient medicine (10.4%), and cardiology (9.8%) appeared most often. CONCLUSIONS Psychosomatics appears to be successfully providing content relevant to the APM's vision and mission statements and to practitioners of psychosomatic medicine.
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Affiliation(s)
- John B Taylor
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
| | - Theodore A Stern
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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30
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31
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Zhao W, Wu Z, Chen J, Jia H, Huang Z, Chen M, Gu X, Liu M, Zhang Z, Wang H, Wang P, Cheng W. Survival prediction of anxious emotion in advanced cancer patients receiving palliative care. Psychooncology 2016; 26:1463-1469. [DOI: 10.1002/pon.4314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 10/11/2016] [Accepted: 11/11/2016] [Indexed: 12/27/2022]
Affiliation(s)
- Weiwei Zhao
- Department of Integrated Therapy; Fudan University Shanghai Cancer Center; Shanghai China
- Department of Oncology, Shanghai Medical College; Fudan University; Shanghai China
| | - Zhenyu Wu
- Department of Biostatistics, School of Public Health, Key Laboratory of Public Health Safety; Ministry of Education; Fudan University; Shanghai China
| | - Jianhua Chen
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center; Shanghai Jiao Tong University School of Medicine; Shanghai China
| | - Huixun Jia
- Department of Oncology, Shanghai Medical College; Fudan University; Shanghai China
| | - Zhe Huang
- Department of Integrated Therapy; Fudan University Shanghai Cancer Center; Shanghai China
| | - Menglei Chen
- Department of Integrated Therapy; Fudan University Shanghai Cancer Center; Shanghai China
| | - Xiaoli Gu
- Department of Integrated Therapy; Fudan University Shanghai Cancer Center; Shanghai China
| | - Minghui Liu
- Department of Integrated Therapy; Fudan University Shanghai Cancer Center; Shanghai China
| | - Zhe Zhang
- Department of Integrated Therapy; Fudan University Shanghai Cancer Center; Shanghai China
| | - Huaping Wang
- Department of Integrated Therapy; Fudan University Shanghai Cancer Center; Shanghai China
| | - Peng Wang
- Department of Oncology, Shanghai Medical College; Fudan University; Shanghai China
- Department of Integrative Oncology; Fudan University Shanghai Cancer Center; Shanghai China
| | - Wenwu Cheng
- Department of Integrated Therapy; Fudan University Shanghai Cancer Center; Shanghai China
- Department of Oncology, Shanghai Medical College; Fudan University; Shanghai China
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32
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Celano CM, Villegas A, Albanese A, Huffman JC. Heart Failure: Psychological and Pharmacological Considerations. Psychiatr Ann 2016. [DOI: 10.3928/00485713-20161102-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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33
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Moser DK, Arslanian-Engoren C, Biddle MJ, Chung ML, Dekker RL, Hammash MH, Mudd-Martin G, Alhurani AS, Lennie TA. Psychological Aspects of Heart Failure. Curr Cardiol Rep 2016; 18:119. [DOI: 10.1007/s11886-016-0799-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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34
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Ramos S, Prata J, Bettencourt P, Gonçalves FR, Coelho R. Depression predicts mortality and hospitalization in heart failure: A six-years follow-up study. J Affect Disord 2016; 201:162-70. [PMID: 27235819 DOI: 10.1016/j.jad.2016.05.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 05/17/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND The aim of this study is to evaluate the prevalence of depressive symptoms (DS) and its relation on hospitalization for cardiovascular (CV) causes and all-cause mortality risk among outpatients with HF. METHODS A prospective study was conducted on 130 adult outpatients with HF. The Beck Depression Inventory Scale-second edition (BDI-II) was used to screen for DS. All-cause mortality and hospitalization for CV causes were registered over 6 years. Logistic regression and multinomial logistic regression analysis were used to evaluate the independent prognostic value of DS on mortality and hospitalization for CV causes after adjustment for clinical risk factors. RESULTS During a mean follow-up of 6 years, 44% of patients were classified as having DS. Sixty-two participants died for all causes, representing 61% of those with DS and 37% of those without (p=0.006); Forty-nine participants (38%) were hospitalized for CV causes, representing 49% of those with DS and 29% of those without (p=0.027). Logistic regression analysis indicated that DS predicted all-cause mortality (OR: 2.905; 95% CI:1.228-6.870; p=0.006) and multinomial logistic regression indicated that DS were predictive of hospitalization for CV causes (OR: 3.169; 95% CI: 1.230-8.164; p=0.027). These associations were independent of conventional risk factors. LIMITATIONS Only outpatient sample; measure of DS only at baseline; cause of death was not known. CONCLUSION This study, first held in a portuguese population, showed that DS are independent predictors of death and hospitalization for CV causes among HF patients and its impact persists over 6 years.
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Affiliation(s)
- Sónia Ramos
- Cardiovascular Research Unit, Faculty of Medicine, University of Porto, Portugal.
| | - Joana Prata
- Cardiovascular Research Unit, Faculty of Medicine, University of Porto, Portugal
| | - Paulo Bettencourt
- Cardiovascular Research Unit, Faculty of Medicine, University of Porto, Portugal
| | | | - Rui Coelho
- i3S - Instituto de Investigação e Inovação em Saúde, University of Porto, Portugal; Department of Clinical Neuroscience and Mental Health, Faculty of Medicine, University of Porto, Portugal
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Depression and anxiety as predictors of mortality among heart failure patients: systematic review and meta-analysis. Heart Fail Rev 2015; 21:49-63. [DOI: 10.1007/s10741-015-9517-4] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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36
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Alhurani AS, Dekker R, Tovar E, Bailey A, Lennie TA, Randall DC, Moser DK. Examination of the potential association of stress with morbidity and mortality outcomes in patient with heart failure. SAGE Open Med 2014; 2. [PMID: 26246898 PMCID: PMC4523379 DOI: 10.1177/2050312114552093] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objectives: The high mortality and morbidity rates associated with heart failure are still not well explained. A few psychosocial factors have been studied and explain some of this risk, but other factors, like stress, remain largely unexplored in heart failure. This study aimed to (1) examine the association of stress with 6-month cardiac event-free survival, (2) examine the relationship of stress with salivary cortisol, and (3) examine the association of salivary cortisol level with 6-month cardiac event-free survival. Method: A total of 81 heart failure patients participated. Stress was measured using the brief Perceived Stress Scale. Cortisol was measured from unstimulated whole expectorated saliva. Cox regression analyses were used to determine whether stress predicted event-free survival, and if salivary cortisol predicted event-free survival. Linear and multiple regressions were used to determine the association of stress with salivary cortisol. Results: Stress was not a significant predictor of event-free survival in heart failure (heart rate = 1.06; 95% confidence interval = 0.95–1.81; p = 0.32). Salivary cortisol was a significant predictor of event-free survival in the unadjusted model (heart rate = 2.30; 95% confidence interval = 0.99–5.927; p = 0.05), but not in the adjusted model. Stress (β 1.06; 95% confidence interval = 0.95–1.18; p = 0.32) was not a significant predictor of salivary cortisol level. Conclusion: Stress is a complex phenomenon, and our measure of stress may not have captured it well. Alternatively, the physical stressors acting in heart failure produce levels of neurohormonal activation that mask the effects of psychosocial stressors or an indirect association of stress with outcomes that is mediated through another construct. Future studies are needed to investigate stress in patients with heart failure to provide definitive answers.
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Affiliation(s)
- Abdullah S Alhurani
- College of Nursing, University of Kentucky, Lexington, KY, USA
- The University of Jordan, Amman, Jordan
| | - Rebecca Dekker
- College of Nursing, University of Kentucky, Lexington, KY, USA
| | - Elizabeth Tovar
- College of Nursing, University of Kentucky, Lexington, KY, USA
| | - Alison Bailey
- College of Nursing, University of Kentucky, Lexington, KY, USA
| | - Terry A Lennie
- College of Nursing, University of Kentucky, Lexington, KY, USA
| | - David C Randall
- College of Nursing, University of Kentucky, Lexington, KY, USA
| | - Debra K Moser
- College of Nursing, University of Kentucky, Lexington, KY, USA
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