Cardiac history, prior depression and personality predict course of depressive symptoms after myocardial infarction

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.

Global prevalence of depression, anxiety, and stress in cardiac patients: A systematic review and meta-analysis

BACKGROUND

Cardiovascular disease is one of the most common chronic and life-threatening diseases. Due to the changes made in the normal living conditions of people after suffering from cardiovascular diseases, the appearance of symptoms of depression, anxiety, and stress is common among these patients. The results of the studies show the different prevalence of these disorders, so this study aimed to standardize the global prevalence of depression, anxiety, and stress in Cardiac patients by a systematic review and meta-analysis approach.

METHODS

The present systematic review and meta-analysis were conducted from 2000 to 2022. National and international databases were considered to retrieve related studies, including SID, Magiran, Scopus, Embase, PubMed, and Web of Science (WoS). Joanna Briggs Institute (JBI) checklist was used to evaluate studies qualitatively. Heterogeneity between studies was assessed by I2 index, and data analysis was performed in Comprehensive Meta-Analysis software.

RESULTS

After reviewing the retrieved studies, finally 68 studies on the prevalence of depression with a sample size of 110,219, 36 studies on the prevalence of anxiety with a sample size of 72,374 and 5 studies on the prevalence of stress with a sample size of 533 considered for the meta-analysis. Based on the results of the Meta-Analysis, the overall estimation of the prevalence of depression was 31.3 % (95 % confidence interval: 25.4/0.38 %), anxiety prevalence; 32.9 % (95 % confidence interval: 21.9-46.6 %) and stress prevalence was 57.7 % (95 % confidence interval: 45.3-3.3 %).

CONCLUSION

The result of the present study shows the high prevalence rate of depression, anxiety, and stress in cardiac patients. Therefore, it is recommended that health professionals and policymakers pay more attention to preventing and controlling these disorders.

Prevalence of Symptoms of Anxiety Disorders and Depression in Cardiac Rehabilitation Patients in an Academic Hospital: a Case Study

The relationship between body and mind is increasingly recognized in the occurrence and prognosis of cardiac disease. Based on reports detailing the potential (and the influence of certain risk factors) of developing depression and anxiety following cardiovascular disease, or a cardiac event, most notably acute coronary syndrome (ACS), we investigated whether such symptoms also existed in patient cases found at the cardiac rehabilitation unit of an academic hospital of Eastern Ontario. We examined data from charts during a 6-year period (2012-2017). The Hospital Anxiety and Depression Scale cumulated data within a retrospective cross-sectional study, was used to estimate the prevalence of anxious and depressive symptoms that might reflect the presence of psychological distress. Overall, our sample included 1178 patient files, 81.3% of which were diagnosed with ACS and 69.6% were male. 63.1% of the patients were between 60 and 79 years old at the time of diagnosis. Most patients were Caucasian (81.1%), married (60.3%), and living with their family (74.3%), and 49.7% were recorded as overweight or obese. We found that 29.3% of patients reported symptoms of psychological distress. Regression analyses revealed strong negative correlations between the proportion of symptoms of psychological distress and factors like age and functional capacity as measured by metabolic equivalents. Significant associations were also established between symptoms of psychological distress and factors such as obesity, sedentary lifestyle, smoking, and sex (female). This study was undertaken as part of a business case to implement a new cardiac rehabilitation programme in an academic hospital of Eastern Ontario and illustrate to the managers and decision-makers, the important factors to consider and to target when developing a stepped-care program for patients in cardiac rehabilitation in order to prevent psychological distress and how such a program was relevant to their institution.

Recurrent versus new-onset depressive symptoms: Relationships with biomarkers of cardiovascular health following acute coronary syndrome

OBJECTIVE

New-onset depressive symptoms commonly arise among persons without a history of major depressive disorder (MDD) in the setting of acute medical illness. Although depressive symptoms in general are associated with alterations in prognostic biomarkers following acute coronary syndrome (ACS), the nature of specifically new-onset depressive symptoms is less well-characterized. It is unclear whether such symptoms neurobiologically resemble recurrent symptoms of MDD or instead represent a distinct condition. In this exploratory analysis, we aimed to examine the effects of prior MDD history on the relationships between post-ACS depressive symptoms and cardiovascular biomarkers.

METHODS

One-hundred sixty-four participants attended study visits 2 weeks and 6 months after ACS to complete self-report measures and provide biomarker samples. MDD history was identified by a psychiatrist through systematic electronic medical record review. Generalized estimating equations were performed to examine the moderating effects of MDD history on concurrent relationships between depressive symptoms and several biomarkers (endothelin-1, soluble intercellular adhesion molecule-1, high-sensitivity C-reactive protein, interleukin-6, and tumor necrosis factor-alpha).

RESULTS

Twenty percent (n = 33) of participants had a history of MDD. Depressive symptoms were more strongly associated with levels of endothelin-1 in patients with prior MDD compared to those without (B = 0.024, 95% CI [0.005, 0.043], p = .012), adjusting for age, sex, medical factors, and anxiety. MDD history did not moderate relationships between depressive symptoms and other biomarkers.

CONCLUSION

Recurrent post-ACS depressive symptoms are more strongly associated with elevated endothelin-1 levels than new-onset symptoms. Further work is needed to clarify the mechanism and clinical implications of this relationship.

Challenges in coronary heart disease prevention - experiences from a long-term follow-up study in Norway

Objective. To determine longitudinal changes in lifestyle behaviour and lipid management in a chronic coronary heart disease (CHD) population. Design. A multi-centre cohort study consecutively included 1127 patients at baseline in 2014-2015, on average 16 months after a CHD event. Data were collected from hospital records, a questionnaire and clinical examination. Seven hundred and seven of 1021 eligible patients participated in a questionnaire-based follow-up in 2019. Data were analysed with univariate statistics. Results. After a mean follow-up of 4.7 years (SD 0.4) from baseline, the percentage of current smokers (15% versus 16%), obesity (23% versus 25%) and clinically significant symptoms of anxiety (21% versus 17%) and depression (13% versus 14%) remained unchanged, whereas the proportion with low physical activity increased from 53% to 58% (p < .001). The proportions with reduced physical activity level were similar in patients over and under 70 years of age. Most patients were still taking statins (94% versus 92%) and more patients used high-intensity statin (49% versus 54%, p < .001) and ezetimibe (5% versus 15%, p < .001) at follow-up. 73% reported ≥1 primary-care consultation(s) for CHD during the last year while 27% reported no such follow-up. There were more smokers among participants not attending primary-care consultations compared to those attending (19% versus 14%, p = .026). No differences were found for other risk factors. Conclusions. We found persistent suboptimal risk factor control in coronary outpatients during long-term follow-up. Closer follow-up and intensified risk management including lifestyle and psychological health are needed to improved secondary prevention and outcome of CHD. Trial registration: Registered at ClinicalTrials.gov: NCT02309255.Registered at 5 December 2014, registered retrospectively.

The Heritability of Type D Personality by an Extended Twin-Pedigree Analysis in the Netherlands Twin Register

Type D (Distressed) personality combines negative affectivity (NA) and social inhibition (SI) and is associated with an increased risk of cardiovascular disease. We aimed to (1) validate a new proxy based on the Achenbach System of Empirically Based Assessment (ASEBA) for Type D personality and its NA and SI subcomponents and (2) estimate the heritability of the Type D proxy in an extended twin-pedigree design in the Netherlands Twin Register (NTR). Proxies for the dichotomous Type D classification, and continuous NA, SI, and NAxSI (the continuous measure of Type D) scales were created based on 12 ASEBA items for 30,433 NTR participants (16,449 twins and 13,984 relatives from 11,106 pedigrees) and sources of variation were analyzed in the ‘Mendel’ software package. We estimated additive and non-additive genetic variance components, shared household and unique environmental variance components and ran bivariate models to estimate the genetic and non-genetic covariance between NA and SI. The Type D proxy showed good reliability and construct validity. The best fitting genetic model included additive and non-additive genetic effects with broad-sense heritabilities for NA, SI and NAxSI estimated at 49%, 50% and 49%, respectively. Household effects showed small contributions (4–9%) to the total phenotypic variation. The genetic correlation between NA and SI was .66 (reflecting both additive and non-additive genetic components). Thus, Type D personality and its NA and SI subcomponents are heritable, with a shared genetic basis for the two subcomponents.

Prevalence, 12-Month Prognosis, and Clinical Management Need of Depression in Coronary Heart Disease Patients: A Prospective Cohort Study

BACKGROUND

Screening for depression in patients with coronary heart disease (CHD) remains controversial. There is limited data on the actual depression management need in routine care. The aim of this study was to examine the prevalence, treatment rates, prognosis, and management need of clinical and subclinical depression in CHD patients according to the American Heart Association recommendations and the National Institute for Health and Care Excellence (NICE) guideline "Depression in Adults with a Chronic Physical Health Problem".

METHODS

Patients were recruited at 2 German university clinics between 2012 and 2014. Depressive disorders were assessed according to the DSM-IV and depressive symptom severity at baseline and during follow-up was evaluated with the Patient Health Questionnaire (PHQ-9). Depression management need was determined by the severity and longitudinal course of depression symptoms.

RESULTS

Of 1,024 patients (19% women), 12% had clinical depression (depressive disorder) and 45% had subclinical depression (PHQ-9 score ≥5) at baseline. Among those with clinical depression, 46% were in treatment at least once during 12 months; 26% were continuously in treatment during follow-up. Depressive disorder and depressive symptoms were significant risk factor-adjusted predictors of the 12-months mortality (adjusted HR = 3.19; 95% CI 1.32-7.69, and adjusted HR = 1.09; 95% CI 1.02-1.16, respectively). Depressive symptoms persisted in 85% of the clinically depressed and in 47% of the subclinically depressed patients. According to current recommendations, 29% of all CHD patients would require depression management within 1 year.

CONCLUSIONS

There is a need for enhanced recognition, referral, and continuous and improved clinical management of depression in CHD patients.

Personality and widowhood increase the risk for incident depression in the two years following the first acute coronary syndrome

Objectives: Incident depression, occurring after an acute coronary syndrome (ACS) in never depressed patients, exerts a negative effect on the cardiac prognosis. Nonetheless only a few studies have evaluated the risk factor for incident depression and, particularly, no study have investigated the role of personality disorders. Therefore, the aim of this study is to verify if personality disorders represent a risk for incident depression in patients at their first ACS.Method: The study sample was selected among never depressed patients who were consecutively admitted to the Coronary Intensive Care Unit, from January 2009 to March 2012, for the first ACS. The study sample included 262 patients. The presence of depressive disorder was assessed with the Primary Care Evaluation of Mental Disorders (DSM-IV criteria), whereas its severity was evaluated with the Hospital Anxiety and Depression Scale. Evaluations were collected at baseline and at 1, 2, 4, 6, 9, 12 and 24 months of follow-up. Moreover, at baseline personality disorders were investigated with the Structured Clinical Interview for DSM-IV Axis II disorders.Results: Out of 262 subjects, a depressive disorder was diagnosed in 56 patients (21%). At baseline risk factors for incident depression were being widowed, having a distress reaction and narcissistic personality traits.Conclusion: Clinicians should keep in mind these characteristics when facing patients at their first ACS, given the detrimental effect of depression on cardiac prognosis. A psychological support should prevent the onset of incident depression in these patients.

Length Polymorphisms in the Angiotensin I-Converting Enzyme Gene and the Serotonin-Transporter-Linked Polymorphic Region Constitute a Risk Haplotype for Depression in Patients with Coronary Artery Disease

Genetic variations affecting the course of depressive symptoms in patients with coronary artery disease (CAD) have not yet been well studied. Therefore, we set out to investigate whether distinct haplotypes of the two insertion/deletion polymorphisms in the serotonin-transporter-linked polymorphic region (5-HTTLPR) and the angiotensin I-converting enzyme (ACE) gene located on chromosome 17 can be identified as risk factors for trajectories of depression. Clinical and genotyping data were derived from 507 depressed CAD patients participating in the randomized, controlled, multicenter Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease (SPIRR-CAD) trial, of whom the majority had an acute cardiac event before study inclusion. Depression scores on the Hospital Anxiety and Depression Scale (HADS) were assessed at baseline and at five follow-up time points up to 2 years after study entrance. At baseline, depression scores did not significantly differ between patients carrying the risk haplotype ACE D/D, 5-HTTLPR I/I (n = 46) and the non-risk haplotypes (n = 461, 10.9 ± 2.7 versus 10.4 ± 2.5, p = 0.254). HADS-depression scores declined from study inclusion during the first year irrespective of the genotype. At each follow-up time point, HADS-depression scores were significantly higher in ACE D/D, 5-HTTLPR I/I carriers than in their counterparts. Two years after study inclusion, the mean HADS depression score remained 1.8 points higher in patients with the risk haplotype as compared to subjects not carrying this haplotype (9.9 ± 4.2 versus 8.1 ± 4.0, p = 0.009). In summary, the presence of the ACE D/D, 5-HTTLPR I/I haplotype may be a vulnerability factor for comorbid depressive symptoms in CAD patients.

Anxiety and Depression After a Cardiac Event: Prevalence and Predictors

Introduction

Patients who are anxious or depressed after an acute cardiac event are at increased risk of a subsequent event and premature death. It is therefore important to identify these patients early in order to initiate supportive or even preventive measures. In the present study, we report on the prevalence of anxiety and depression during the first 12 months after an acute cardiac event, and the patient characteristics predictive of increased anxiety and depression risk in early and late convalescence.

Methods

We recruited a sample of 911 patients with acute myocardial infarction (AMI), acute coronary syndrome (ACS), and/or unstable angina (UA), and/or undergoing coronary artery bypass graft surgery (CABGS). Patients completed the Hospital Anxiety and Depression Scale (HADS) close to the time of their event, and again during early (2–4 months post-event) and late (6–12 months post-event) convalescence. Using HADS-A and HADS-D cut-offs of 8+, prevalence rates for anxiety, depression, and comorbid anxiety and depression were determined for each timepoint. Chi-square tests and odds ratios were used to identify baseline patient characteristics associated with increased anxiety and depression risk over 12 months.

Results

Anxiety rates were 43, 28, and 27% at the time of the event, early, and late convalescence. Depression rates were 22, 17, and 15%, respectively. Factors consistently associated with increased anxiety and depression risk were history of depression, financial strain, poor self-rated health, low socioeconomic status, younger age (<55 years), and smoking. Obesity, diabetes, and social isolation (living alone or being unpartnered) were identified as important albeit less significant risk factors. Neither sex nor event type were predictive of anxiety or depression.

Conclusion

This large patient sample provided the opportunity to identify rates of anxiety and depression during the 12 months after a cardiac event and key patient characteristics for increased risk. These risk factors are easily identifiable at the time of the event, and could be used to guide the targeting of support programs for patients at risk.

Persistent emotional distress after a first-time myocardial infarction and its association to late cardiovascular and non-cardiovascular mortality

BACKGROUND

Patients with symptoms of depression and/or anxiety - emotional distress - after a myocardial infarction (MI) have been shown to have worse prognosis and increased healthcare costs. However, whether specific subgroups of patients with emotional distress are more vulnerable is less well established. The purpose of this study was to identify the association between different patterns of emotional distress over time with late cardiovascular and non-cardiovascular mortality among first-MI patients aged <75 years in Sweden.

METHODS

We utilized data on 57,602 consecutive patients with a first-time MI from the national SWEDEHEART registers. Emotional distress was assessed using the anxiety/depression dimension of the European Quality of Life Five Dimensions questionnaire two and 12 months after the MI, combined into persistent (emotional distress at both time-points), remittent (emotional distress at the first follow-up only), new (emotional distress at the second-follow up only) or no distress. Data on cardiovascular and non-cardiovascular mortality were obtained until the study end-time. We used multiple imputation to create complete datasets and adjusted Cox proportional hazards models to estimate hazard ratios.

RESULTS

Patients with persistent emotional distress were more likely to die from cardiovascular (hazard ratio: 1.46, 95% confidence interval: 1.16, 1.84) and non-cardiovascular causes (hazard ratio: 1.54, 95% confidence interval: 1.30, 1.82) than those with no distress. Those with remittent emotional distress were not statistically significantly more likely to die from any cause than those without emotional distress.

DISCUSSION

Among patients who survive 12 months, persistent, but not remittent, emotional distress was associated with increased cardiovascular and non-cardiovascular mortality. This indicates a need to identify subgroups of individuals with emotional distress who may benefit from further assessment and specific treatment.

Methylation of the glucocorticoid receptor gene associated with depression in patients with acute coronary syndrome

OBJECTIVE

The present study investigated the longitudinal effects of NR3C1 1 F exon methylation on the risk of depression following ACS and treatment outcomes.

METHODS

In total, 969 patients admitted for recent ACS were recruited within 2 weeks of ACS; 711 of these patients were followed up at 1 year. Depressive disorder was diagnosed according to DSM-IV criteria and included prevalent depressive disorder at baseline and incident or persistent depressive disorder at follow-up based on depression status at the two examinations. Of the 378 baseline participants who were diagnosed with depression, 255 participated in a randomized double-blind placebo-controlled trial of escitalopram, while the remaining 123 were managed with the usual medical treatment for ACS.NR3C1 1 F exon methylation was measured using peripheral blood samples, and various demographic and clinical characteristics were assessed as covariates.

RESULTS

Higher NR3C1 1 F exon methylation levels were independently associated with prevalent depressive disorder at baseline but not with incident or persistent depressive disorder at follow-up based on logistic regression analyses adjusted for covariates. The effects of escitalopram on the remission of depressive symptoms was not influenced by NR3C1 1 F exon methylation status in ACS patients, but a placebo effect on the remission of depressive symptoms was observed, particularly in patients with lower methylation levels.

CONCLUSIONS

ACS patients with higher NR3C1 1 F exon methylation levels were at higher risk of developing depressive disorder within 2 weeks of ACS. Additionally, adequate antidepressant treatment may be effective for the remission of depressive symptoms regardless of NR3C1 1 F exon methylation status.

Somatic and sociodemographic predictors of depression outcome among depressed patients with coronary artery disease - a secondary analysis of the SPIRR-CAD study

BACKGROUND

Depressive symptoms are common in patients with coronary artery disease (CAD) and are associated with an unfavourable outcome. Establishing prognostic patient profiles prior to the beginning of mental health care may facilitate higher efficacy of targeted interventions. The aim of the current study was to identify sociodemographic and somatic predictors of depression outcome among depressed patients with CAD.

METHODS

Based on the dataset of the multicentre SPIRR-CAD randomised controlled trial (n = 570 patients with CAD and ≥ 8 points on the Hospital Anxiety and Depression Scale (HADS)), 141 potential sociodemographic and somatic predictors of the change in the HADS-D depression score from baseline to 18-month-follow-up were derived in two different ways. We screened for univariable association with response, using either analysis of (co)variance or logistic regression, respectively, both adjusted for baseline HADS-D value and treatment group. To guard against overfitting, multivariable association was evaluated by a linear or binomial (generalised) linear model with lasso regularisation, a machine learning approach. Outcome measures were the change in continuous HADS-D depression scores, as well as three established binary criteria. The Charlson Comorbidity Index (CCI) was calculated to assess possible influences of comorbidities on our results and was also entered in our machine learning approach.

RESULTS

Higher age (p = 0.002), unknown previous myocardial infarction (p = 0.013), and a higher heart rate variability during numeracy tests (p = .020) were univariably associated with a favourable depression outcome, whereas hyperuricemia (p ≤ 0.003), higher triglycerides (p = 0.014), NYHA class III (p ≤ 0.028), state after resuscitation (p ≤ 0.042), intake of thyroid hormones (p = 0.007), antidiabetic drugs (p = 0.015), analgesic drugs (p = 0.027), beta blockers (p = 0.035), uric acid drugs (p ≤ 0.039), and anticholinergic drugs (p = 0.045) were associated with an adverse effect on the HADS-D depression score. In all analyses, no significant differences between study arms could be found and physical comorbidities also had no significant influence on our results.

CONCLUSION

Our findings may contribute to identification of somatic and sociodemographic predictors of depression outcome in patients with CAD. The unexpected effects of specific medication require further clarification and further research is needed to establish a causal association between depression outcome and our predictors.

TRIAL REGISTRATION

www.clinicaltrials.gov   NCT00705965 (registered 27th of June, 2008). www.isrctn.com   ISRCTN76240576 (registered 27th of March, 2008).

Clinically significant ventricular arrhythmias and progression of depression and anxiety following an acute coronary syndrome

BACKGROUND

Depression and anxiety are common and associated with worse clinical outcomes in patients who experience an acute coronary syndrome (ACS). We investigated the association between major ventricular arrhythmias (VAs) with the progression of depression and anxiety among hospital survivors of an ACS.

METHODS

Patients were interviewed in hospital and by telephone up to 12 months after hospital discharge. The primary outcome was the presence of moderate/severe symptoms of depression and anxiety defined as a Patient Health Questionnaire (PHQ)-9 score ≥ 10 and a Generalized Anxiety Disorder (GAD)-7 score ≥ 10 at baseline and 1 month and PHQ-2 ≥ 3 and GAD-2 ≥ 3 at 3, 6, and 12 months. We used marginal models to examine the association between major VAs and the symptoms of depression or anxiety over time.

RESULTS

The average age of the study population (n = 2074) was 61.1 years, 33.5% were women, and 78.3% were white. VAs developed in 105 patients (5.1%). Symptoms of depression and anxiety were present in 22.2% and 23.5% of patients at baseline, respectively, and declined to 14.1% and 12.6%, respectively, at 1-month post-discharge. VAs were not significantly associated with the progression of symptoms of depression (adjusted relative risk [aRR] = 1.29, 95% confidence interval [CI] = 0.94-1.77) and anxiety (aRR = 1.22, 95% CI = 0.86-1.72), or with change in average scores of PHQ-2 and GAD-2 over time, both before and after risk adjustment.

CONCLUSION

The prevalence of symptoms of depression and anxiety was high after an ACS but declined thereafter and may not be associated with the occurrence of major in-hospital VAs.

Factors associated with emotional distress in patients with myocardial infarction: Results from the SWEDEHEART registry

Background

Emotional distress, symptoms of depression and anxiety, is common among patients after a myocardial infarction (MI), and is associated with an increased risk of cardiovascular morbidity. Real world population data on factors associated with emotional distress in MI patients are scarce. The aim was to determine factors associated with incident emotional distress two and 12 months post MI respectively, and with persistent emotional distress, versus remittent, in patients <75 years old.

Design

This was a registry-based observational study.

Methods

Data from the national SWEDEHEART registry on 27,267 consecutive patients with a first-time MI, followed up at two and 12 months post MI (n = 22,911), were included in the analyses. Emotional distress was assessed with the EuroQol-5D questionnaire. Several candidate sociodemographic and clinical factors were analysed for their association with emotional distress in multivariate models.

Results

Symptoms of emotional distress were prevalent in 38% and 33% at two and 12 months post MI respectively. At both time-points, previous depression and/or anxiety, readmission for new cardiovascular event, female gender, younger age, born outside the neighbouring Nordic countries, smoking and being neither employed nor retired showed the strongest associations with emotional distress. Other factors related to medical history, the MI and its care or were only modestly associated with emotional distress. Persistent emotional distress was associated with younger age, female gender, smoking and being born outside of the Nordic countries.

Conclusion

Previous depression/anxiety, female gender, younger age, smoking, born outside of the Nordic countries, neither employed nor retired and readmission due to cardiovascular events were strongly associated with emotional distress post MI. These factors may be of relevance in tailoring rehabilitation programmes.

Patient healthcare trajectory. An essential monitoring tool: a systematic review

BACKGROUND

Patient healthcare trajectory is a recent emergent topic in the literature, encompassing broad concepts. However, the rationale for studying patients' trajectories, and how this trajectory concept is defined remains a public health challenge. Our research was focused on patients' trajectories based on disease management and care, while also considering medico-economic aspects of the associated management. We illustrated this concept with an example: a myocardial infarction (MI) occurring in a patient's hospital trajectory of care. The patient follow-up was traced via the prospective payment system. We applied a semi-automatic text mining process to conduct a comprehensive review of patient healthcare trajectory studies. This review investigated how the concept of trajectory is defined, studied and what it achieves.

METHODS

We performed a PubMed search to identify reports that had been published in peer-reviewed journals between January 1, 2000 and October 31, 2015. Fourteen search questions were formulated to guide our review. A semi-automatic text mining process based on a semantic approach was performed to conduct a comprehensive review of patient healthcare trajectory studies. Text mining techniques were used to explore the corpus in a semantic perspective in order to answer non-a priori questions. Complementary review methods on a selected subset were used to answer a priori questions.

RESULTS

Among the 33,514 publications initially selected for analysis, only 70 relevant articles were semi-automatically extracted and thoroughly analysed. Oncology is particularly prevalent due to its already well-established processes of care. For the trajectory thema, 80% of articles were distributed in 11 clusters. These clusters contain distinct semantic information, for example health outcomes (29%), care process (26%) and administrative and financial aspects (16%).

CONCLUSION

This literature review highlights the recent interest in the trajectory concept. The approach is also gradually being used to monitor trajectories of care for chronic diseases such as diabetes, organ failure or coronary artery and MI trajectory of care, to improve care and reduce costs. Patient trajectory is undoubtedly an essential approach to be further explored in order to improve healthcare monitoring.

Influences of the Big Five personality traits on the treatment response and longitudinal course of depression in patients with acute coronary syndrome: A randomised controlled trial

BACKGROUND

Influences of the Big Five personality traits on the treatment response and longitudinal course of depression in patients with acute coronary syndrome: A randomised controlled trial.

METHODS

This naturalistic observational study initially recruited 1152 ACS patients; 685 patients completed personality assessments at baseline, of whom 630 were followed-up one year later. Of the 294 patients with depression, 207 participated in a 24-week double blind trial of escitalopram or placebo. The remaining 87 patients who received medical treatment only and the 391 who had not depression were also followed in a one year naturalistic observational study. The Big five personality traits were assessed using the Big Five Inventory. The influences of personality on the Hamilton Depression Rating Scale score changes were analysed using a mixed-model repeated-measures analysis of covariance.

RESULTS

A Cluster analysis identified two personality types: resilient and vulnerable. The vulnerable personality type was characterized by lower extraversion, agreeableness, and conscientiousness - but higher neuroticism - than the resilient type. This personality type was independently associated with a poorer outcome of depression in ACS patients during the 24-week treatment period and the one year longitudinal follow-up period compared to the resilient personality type, irrespective of treatment allocation.

LIMITATIONS

Recruitment from a single institution may limit generalisability. Personality traits were investigated 12-weeks after ACS; thus, the responses may have been influenced by the prior receipt of escitalopram.

CONCLUSIONS

Personality types influences the treatment outcome and longitudinal course of depression in ACS patients independent of antidepressant treatment.

Improving health professionals' self-efficacy to support cardiac patients' emotional recovery: the 'Cardiac Blues Project'

BACKGROUND

Many patients experience the 'cardiac blues' at the time of an acute cardiac event, and one in five go on to develop severe depression. These emotional responses often go undetected and unacknowledged. We initiated the 'Cardiac Blues Project' in order to help support patients' emotional recovery. As part of the project, we developed online training in order to support health professionals in the identification and management of the cardiac blues and depression. The aim of this study was to assess the acceptability of the training and its impacts on health professionals' self-efficacy.

METHOD

In July 2014, a 'cardiac blues' pack of patient resources, including access to health professional online training, was mailed to 606 centres across Australia. In the first 3 months after distribution, 140 health professionals registered to undertake the online training and participated in the present study. Participants provided information via a six-item pre- and post-training self-efficacy scale and on 10 post-training acceptability items.

RESULTS

Health professionals' self-efficacy improved significantly after undertaking the online training across the six domains assessed and for the total score. Acceptability of the training was high across all 10 items assessed. Ratings of usefulness of the training in clinical practice were particularly favourable amongst those who worked directly with cardiac patients.

CONCLUSIONS

The health professional training significantly improves health professionals' confidence in identifying and managing the 'cardiac blues' and depression. Monitoring of uptake is ongoing and future studies will investigate patient outcomes.

Symptom Trajectories After an Emergency Department Visit for Potential Acute Coronary Syndrome

BACKGROUND

Many patients evaluated for acute coronary syndrome (ACS) in emergency departments (EDs) continue to experience troubling symptoms after discharge-regardless of their ultimate medical diagnosis. However, comprehensive understanding of common post-ED symptom trajectories is lacking.

OBJECTIVES

The aim of this study was to identify common trajectories of symptom severity in the 6 months after an ED visit for potential ACS.

METHODS

This was a secondary analysis of data from a larger observational, prospective study conducted in five U.S. EDs. Patients (N = 1005) who had electrocardiogram and biomarker testing ordered, and were identified by the triage nurse as potentially having ACS, were enrolled. Symptom severity was assessed in the hospital after initial stabilization and by telephone at 30 days and 6 months using the validated 13-item ACS Symptom Checklist. Growth mixture modeling was used for the secondary analysis. The eight most commonly reported symptoms (chest discomfort, chest pain, chest pressure, light-headedness, shortness of breath, shoulder pain, unusual fatigue, and upper back pain) were modeled across the three study time points. Models with increasing numbers of classes were compared, and final model selection was based on a combination of interpretability, theoretical justification, and statistical fit indices.

RESULTS

The sample was 62.6% male with a mean age of 60.2 years (SD = 14.17 years), and 57.1% ruled out for ACS. Between two and four distinct trajectory classes were identified for each symptom. The seven different types of trajectories identified across the eight symptoms were labeled "tapering off," "mild/persistent," "moderate/persistent," "moderate/worsening," "moderate/improving," "late onset, "and "severe/improving." Trajectories differed on age, gender, and diagnosis.

DISCUSSION

Research on the individual nature of symptom trajectories can contribute to patient-centered, rather than disease-centered, care. Further research is needed to verify the existence of multiple symptoms trajectories in diverse populations and to assess the antecedents and consequences of individual symptom trajectories.

BDNF val66met polymorphism and depressive disorders in patients with acute coronary syndrome

INTRODUCTION

Brain-derived neurotrophic factor (BDNF) may be the key to understanding the development of depression in patients with acute coronary syndrome (ACS), as it is associated with both conditions. Because the expression of BDNF is influenced by genetic polymorphisms, in this study we investigated the association between the BDNF polymorphism val66met and both the risk of depression in ACS and the treatment response.

METHODS

Among the 969 patients with recent ACS at baseline, 711 were re-evaluated after 1 year of follow-up. Depressive disorder status was assessed according to the DSM-IV criteria both at baseline and at follow-up. Baseline prevalence, follow-up incidence, and the persistence of depression were also determined. Of the 378 patients diagnosed with depression at baseline, 255 were randomized to a 24-week double-blind placebo-controlled trial of escitalopram; the remaining 123 received the usual care. Associations between the BDNF val66met polymorphism and both depression status and treatment response were investigated using logistic regression models.

RESULTS

The prevalence and persistence, but not the incidence of depressive disorders were significantly associated with BDNF met alleles. Patients in the escitalopram group who carried the met allele had a significantly higher rate of remission than those who did not. Depressive disorders tended to persist at 1 year in patients managed with placebo or medical treatment only, and particularly those patients positive for BDNF met alleles, although the difference was not statistically significant.

LIMITATIONS

The generalizability should be considered since this study conducted in a single center.

CONCLUSIONS

ACS patients positive for BDNF met alleles are vulnerable to depressive disorders at baseline and to its persistence. Antidepressant treatment may be effective in this subgroup of patients and may prevent the persistence of depression.

Longitudinal modelling of theory-based depressive vulnerabilities, depression trajectories and poor outcomes post-ACS

BACKGROUND

Depression is associated with increased mortality in patients with acute coronary syndrome (ACS). However, little is known about the theoretical causes of depression trajectories post-ACS, and whether these trajectories predict subsequent morbidity/mortality. We tested a longitudinal model of depressive vulnerabilities, trajectories and mortality.

METHODS

A prospective observational study of 374 ACS patients was conducted. Participants completed questionnaires on theoretical vulnerabilities (interpersonal life events, reinforcing events, cognitive distortions, and Type D personality) during hospitalisation and depression at baseline and 3, 6 and 12 months post-hospitalisation. Latent class analysis determined trajectories of depression. Path analysis was used to test relationships among vulnerabilities, depression trajectories and outcomes (combination of 1-year morbidity and 7-year mortality).

RESULTS

Vulnerabilities independently predicted persistent and subthreshold depression trajectory categories, with effect sizes significantly highest for persistent depression. Both subthreshold and persistent depression trajectories were significant predictors of morbidity/mortality (e.g. persistent depression OR=2.4, 95% CI=1.8-3.1, relative to never depressed).

LIMITATIONS

Causality cannot be inferred from these associations. We had no measures of history of depression or treatments, which may affect associations.

CONCLUSIONS

Theoretical vulnerabilities predicted depression trajectories, which in turn predicted increased morbidity/mortality, demonstrating for the first time a potential longitudinal chain of events post-ACS. This longitudinal model has important practical implications as clinicians can use vulnerability measures to identify those at most risk of poor outcomes.

BDNF methylation and depressive disorder in acute coronary syndrome: The K-DEPACS and EsDEPACS studies

OBJECTIVE

Epigenetic regulation investigated by methylation tests has been associated with pathogenesis and treatment response in depressive disorders. However, these hypotheses have rarely been tested in patients with acute coronary syndrome (ACS) vulnerable to depression. This study aimed to investigate whether brain derived neurotrophic factor (BDNF) methylation status is associated with occurrence and treatment response of depressive disorder in ACS.

METHODS

Of 969 patients with recently developed ACS were recruited at baseline, 711 were followed 1 year thereafter. Depressive disorder was diagnosed according to DSM-IV criteria, and classified as baseline prevalent, and follow-up incident or persistent depressive disorder according to status at the two examinations. In addition, of 378 baseline participants with depressive disorder, 255 were randomized to a 24-week double blind trial of escitalopram (N=127) or placebo (N=128), while the remaining 123 received conventional medical treatment for ACS. BDNF methylation percentages were estimated using leukocyte DNA, and a range of demographic and clinical characteristics were evaluated as covariates.

RESULTS

In logistic regression models, higher BDNF methylation status was independently associated with prevalent depressive disorder at baseline and with its persistence at follow-up. Escitalopram was more effective than placebo for treating depressive disorder in those with a higher methylation, and this effects lead to prevent persistent depressive disorder.

CONCLUSIONS

ACS patients with higher BDNF methylation were susceptible to early depressive disorder, and to its persistence one year later. Adequate antidepressants treatment may effective particularly in those with higher BDNF methylation and then can overcome epigenetic vulnerability for depression persistence in ACS patients. ClinicalTrial.gov identifier for the 24 week drug trial, NCT00419471.

The role of alexithymia in predicting incident depression in patients at first acute coronary syndrome

OBJECTIVE

Alexithymia has been considered both to predispose to depression and to worsen cardiac prognosis after an acute coronary syndrome. Nonetheless, no studies have evaluated its role as a risk factor for incident depression, in patients with acute coronary syndrome.

METHODS

In 251 consecutive patients, the presence of a first-ever depressive episode was evaluated with the Primary Care Evaluation of Mental Disorders at baseline and 1, 2, 4, 6, 9, 12 and 24 months after their first acute coronary syndrome. At baseline, patients completed the Toronto Alexithymia Scale (TAS-20) and the Hospital Anxiety and Depression Scale.

RESULTS

Out of 251 subjects (80.9% males), a first-ever depressive episode was diagnosed in 66 patients. Depressed and never-depressed patients differed in female gender, living status, alexithymic scores at TAS-20 and depressive symptoms. Nonetheless, nor the TAS-20 factors nor its total score were predictive of developing a depressive episode in a Cox regression. Moreover, baseline differences in TAS-20 scores between the two groups, disappeared after controlling for anhedonic symptoms.

CONCLUSION

Our results do not support the hypothesis that alexithymia at TAS-20 is a risk factor for incident depression after acute coronary syndrome.

Depressive symptom trajectories over a 6-year period following myocardial infarction: predictive function of cognitive appraisal and coping

The association between distinct patterns of depression and coping variables in myocardial infarction (MI) survivors over the long-term is unclear. The study aims to evaluate depressive trajectories and their covariates, including coping and cognitive appraisal, following MI over a period of 6 years. Depressive symptoms were assessed in 200 patients a few days after the first MI, and 1 month, 6 months and 6 years later. Cognitive appraisal and coping were assessed during the first three time points. Three latent depressive trajectories were identified: chronic (high; increasing then decreasing; n = 49), rising (moderate; decreasing then increasing; n = 121) and low (low; decreasing then stabilizing; n = 30). The chronic trajectory was associated with higher negative appraisal and emotion-focused coping. The findings clarify the long-term longitudinal trajectories of post-MI depressive symptoms and their association with coping variables, revealing the unfavorable impact of negative cognition and palliative coping.

Risk factors for incident depression in patients at first acute coronary syndrome

The association between depression and acute coronary syndrome (ACS) is well-established and the first seems to impact meaningfully on cardiac prognosis. Nonetheless only a few studies have evaluated the relationship between incident depression, defined as new cases in patients with no history of depression, and ACS. Therefore the aim of this study is to analyse the risk factors of incident depression in a sample of patients who were presenting their first ACS. 304 consecutive patients were recruited. The presence of major (MD) and minor (md) depression was assessed with the Primary Care Evaluation of Mental Disorders (PRIME-MD), whereas its severity was evaluated with the Hospital Anxiety and Depression Scale (HADS). Evaluations were collected both at baseline and at 1, 2, 4, 6, 9 and 12 month follow ups. Out of 304 subjects (80.6% males), MD was diagnosed in 15 (4.9%) and md in 25 patients (8.2%). At baseline risk factors for a post-ACS depressive disorder were being women (MD only), widowed (md only) and having mild anhedonic depressive symptoms few days after the ACS. Clinicians should keep in mind these variables when facing a patient at his/her first ACS, given the detrimental effect of depression on cardiac prognosis.

Predictors of depressive disorder following acute coronary syndrome: Results from K-DEPACS and EsDEPACS

INTRODUCTION

Depression is common and associated with poor prognosis in acute coronary syndrome (ACS). There are few reports on the predictors of incident and persistent post-discharge depressive disorders in ACS. This study aimed to investigate the incidence and persistence of depressive disorder over a one year follow-up, and predictors of these outcomes.

METHODS

1152 patients with recently developed ACS were recruited at baseline, and 828 were followed one year thereafter. Depressive disorder (major and minor) was diagnosed according to DSM-IV criteria, and analyzed according to baseline prevalence, and follow up incidence and persistence. Of 446 baseline participants with depressive disorders, 300 were randomized to a 24-week double blind trial of escitalopram or placebo, while the remaining 146 received medical treatment as usual. Associations of baseline socio-demographic and clinical characteristics with depressive disorder were investigated using logistic regression models.

RESULTS

Two-week prevalence, and one-year incidence and persistence of depressive disorder were 38.7%, 13.1%, and 46.3%, respectively. Baseline depressive disorder was independently associated with female, lower educational level, previous ACS and higher heart rate. Incident depressive disorder was independently predicted by current unemployment, family history of depression, higher baseline Hamilton Depression Rating Scale(HAMD) score and lower left ventricular ejection fraction, and persistent depressive disorder by higher baseline HAMD score and the placebo or medical treatment as usual group in the 24-week trial.

LIMITATIONS

The generalizability should be considered since this study conducted in a single center.

CONCLUSIONS

Depressive disorder in ACS patients is common and often persistent, and is associated with baseline characteristics and insufficient treatment. Appropriate detection and treatment of depressive disorder are clearly important in ACS patients.

What does the beck depression inventory measure in myocardial infarction patients? a psychometric approach using item response theory and person-fit

Observed associations between depression following myocardial infarction (MI) and adverse cardiac outcomes could be overestimated due to patients' tendency to over report somatic depressive symptoms. This study was aimed to investigate this issue with modern psychometrics, using item response theory (IRT) and person-fit statistics to investigate if the Beck Depression Inventory (BDI) measures depression or something else among MI-patients. An IRT-model was fit to BDI-data of 1135 MI patients. Patients' adherence to this IRT-model was investigated with person-fit statistics. Subgroups of "atypical" (low person-fit) and "prototypical" (high person-fit) responders were identified and compared in terms of item-response patterns, psychiatric diagnoses, socio-demographics and somatic factors. In the IRT model, somatic items had lower thresholds compared to depressive mood/cognition items. Empirically identified "atypical" responders (n = 113) had more depressive mood/cognitions, scored lower on somatic items and more often had a Comprehensive International Diagnostic Interview (CIDI) depressive diagnosis than "prototypical" responders (n = 147). Additionally, "atypical" responders were younger and more likely to smoke. In conclusion, the BDI measures somatic symptoms in most MI patients, but measures depression in a subgroup of patients with atypical response patterns. The presented approach to account for interpersonal differences in item responding could help improve the validity of depression assessments in somatic patients.

Systematic Review and Individual Patient Data Meta-Analysis of Sex Differences in Depression and Prognosis in Persons With Myocardial Infarction: A MINDMAPS Study

OBJECTIVE

Using combined individual patient data from prospective studies, we explored sex differences in depression and prognosis post-myocardial infarction (MI) and determined whether disease indices could account for found differences.

METHODS

Individual patient data analysis of 10,175 MI patients who completed diagnostic interviews or depression questionnaires from 16 prospective studies from the MINDMAPS study was conducted. Multilevel logistic and Cox regression models were used to determine sex differences in prevalence of depression and sex-specific effects of depression on subsequent outcomes.

RESULTS

Combined interview and questionnaire data from observational studies showed that 36% (635/1760) of women and 29% (1575/5526) of men reported elevated levels of depression (age-adjusted odds ratio = 0.68, 95% confidence interval [CI] = 0.60-0.77). The risk for all-cause mortality associated with depression was higher in men (hazard ratio = 1.38, 95% CI = 1.30-1.47) than in women (hazard ratio = 1.22, 95% CI = 1.14-1.31; sex by depression interaction: p < .001). Low left ventricular ejection fraction (LVEF) was associated with higher depression scores in men only (sex by LVEF interaction: B = 0.294, 95% CI = 0.090-0.498), which attenuated the sex difference in the association between depression and prognosis.

CONCLUSIONS

The prevalence of depression post-MI was higher in women than in men, but the association between depression and cardiac prognosis was worse for men. LVEF was associated with depression in men only and accounted for the increased risk of all-cause mortality in depressed men versus women, suggesting that depression in men post-MI may, in part, reflect cardiovascular disease severity.

Optimism and recovery after acute coronary syndrome: a clinical cohort study

OBJECTIVE

Optimism is associated with reduced cardiovascular mortality, but its impact on recovery after acute coronary syndrome (ACS) is poorly understood. We hypothesized that greater optimism would lead to more effective physical and emotional adaptation after ACS and would buffer the impact of persistent depressive symptoms on clinical outcomes.

METHODS

This prospective observational clinical study took place in an urban general hospital and involved 369 patients admitted with a documented ACS. Optimism was assessed with a standardized questionnaire. The main outcomes were physical health status, depressive symptoms, smoking, physical activity, and fruit and vegetable consumption measured 12 months after ACS, and composite major adverse cardiac events (cardiovascular death, readmission with reinfarction or unstable angina, and coronary artery bypass graft surgery) assessed over an average of 45.7 months.

RESULTS

We found that optimism predicted better physical health status 12 months after ACS independently of baseline physical health, age, sex, ethnicity, social deprivation, and clinical risk factors (B = 0.65, 95% confidence interval [CI] = 0.10-1.20). Greater optimism also predicted reduced risk of depressive symptoms (odds ratio = 0.82, 95% CI = 0.74-0.90), more smoking cessation, and more fruit and vegetable consumption at 12 months. Persistent depressive symptoms 12 months after ACS predicted major adverse cardiac events over subsequent years (odds ratio = 2.56, 95% CI = 1.16-5.67), but only among individuals low in optimism (optimism × depression interaction; p = .014).

CONCLUSIONS

Optimism predicts better physical and emotional health after ACS. Measuring optimism may help identify individuals at risk. Pessimistic outlooks can be modified, potentially leading to improved recovery after major cardiac events.

Association of psychiatric history and type D personality with symptoms of anxiety, depression, and health status prior to ICD implantation

BACKGROUND

Personality factors and psychiatric history may help explain individual differences in risk of psychological morbidity and poor health outcomes in patients with an implantable cardioverter defibrillator (ICD).

PURPOSE

We examined associations between previous anxiety and depressive disorder, type D personality, anxiety or depressive symptoms, and health status in ICD patients prior to ICD implantation.

METHOD

Patients (N = 278; 83 % men; mean age = 62.2 years ±11) receiving a first ICD from September 2007 through April 2010 at the Medisch Spectrum Twente, The Netherlands completed validated questionnaires before implantation assessing type D personality (14-item Type D Scale), anxiety and depressive symptoms (Hospital Anxiety and Depression Scale), and health status (36-item Short Form Health Survey). History of anxiety or depressive disorder was assessed with the Mini International Neuropsychiatric Interview structural interview.

RESULTS

Previous anxiety or depressive disorder was prevalent in 8 and 19 % of patients, respectively. Type D personality was present in 21 %, depressive symptoms in 15 %, and anxiety in 24 %. In adjusted analyses, type D personality was a dominant correlate of previous depressive disorder (odds ratio (OR) 6.2, p < 0.001) and previous anxiety disorder (OR 3.9, p = 0.004). Type D personality (OR 4.0, p < 0.001), age (OR 1.03, p = 0.043), and gender (OR 2.5, p = 0.013) were associated with anxiety symptoms at baseline. Type D personality (OR 5.9. p < 0.001) was also associated with increased depressive symptoms at baseline. Heart failure and type D personality were related to poorer health status.

CONCLUSION

In ICD patients, prior to ICD implantation, a previous anxiety or depressive disorder, type D personality, and anxiety and depressive symptoms were associated with poorer health status. Type D personality was also independently associated with increased anxiety and depression symptoms.

Type D personality in never-depressed patients and the development of major and minor depression after acute coronary syndrome

BACKGROUND

Type D personality (TDP) has been proposed as a risk factor for the development of depressive symptoms after an acute coronary syndrome (ACS). However, contrasting findings emerged about its predicting power on the onset of depression, since an overlap between TDP and depressive symptoms has been proposed. The present study was aimed to verify whether TDP predicts the development of a depressive disorder in the 6 months after the discharge from hospital.

METHODS

Two hundred fifty consecutive patients were recruited, at the Coronary Intensive Care Unit at the University Hospital of Parma, who were both presenting their first ACS and had no history of depression. The presence and the severity of major (MD) and minor (md) depression were evaluated with the Primary Care Evaluation of Mental Disorders (PRIME-MD) and the Hospital Anxiety and Depression Scale (HADS) respectively. Type D Personality was assessed with the DS14, both at baseline and at 1, 2, 4 and 6 month follow ups.

RESULTS

Out of 250 subjects (81.2% males), MD was diagnosed in 12 patients (4.8%) and md in 18 patients (7.2%). At baseline risk factors for a post-ACS depressive disorder were HADS depression scores, whereas TDP, or its subscales, did not showed any effect.

LIMITATION

The small amount of patients with incidence of depression, due to highly selective inclusion criteria, tempers the reliability of our results.

CONCLUSION

Our data suggests that TDP does not predict the development of depressive disorders in never-depressed patients at their first ACS, when the baseline depression severity was controlled.

Initiation of statin therapy after acute myocardial infarction is not associated with worsening depressive symptoms: insights from the Prospective Registry Evaluating Outcomes After Myocardial Infarctions: Events and Recovery (PREMIER) and Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) registries

BACKGROUND

Whereas statins are considered the cornerstone of prevention after acute myocardial infarction (AMI), concerns about worsening depression in association with their use have been raised.

METHODS

Using data from 2 prospective AMI registries (PREMIER and TRIUMPH), we examined the change in depressive symptoms from baseline and at 1, 6 and 12 months among statin-naïve patients who were and were not discharged on a statin. Depressive symptoms were assessed with the 8-item Patient Health Questionnaire (PHQ-8). Within-group change in PHQ-8 scores from baseline to each follow-up period was assessed using paired t tests. A repeated-measures propensity-matched analysis examined whether changes in PHQ-8 scores from baseline were different between statin-treated and statin-untreated patients.

RESULTS

Of 3,675 patients not previously treated with statins, 3,050 (83%) were discharged on a statin and 625 (17%) were not. Scores of PHQ-8 in the statin group decreased from baseline by a mean (± SD) of 0.9 (± 5.1), 1.2 (± 5), and 1.1 (± 5.1) at 1, 6, and 12 months, respectively. Corresponding changes in the nonstatin group were 0.9 (± 5.2), 1.3 (± 5.1), and 1.5 (± 5.8), respectively (P < .0001 for all comparisons). After propensity matching, 451 patients not discharged on statins with 1,240 patients discharged on statins, the mean change in PHQ-8 scores between baseline and the 3 follow-up time points was not significantly different between groups (mean between-group difference at 1 month: -0.13, 95% CI [-0.69 to 0.43], P = .65; at 6 months: -0.07, 95% CI [-0.66 to 0.52], P = .82; and at 12 months: -0.05, 95% CI [-0.67 to 0.58], P = .88).

CONCLUSIONS

Initiation of statins after AMI was not associated with worsening depression.

Depression and cardiac disease: epidemiology, mechanisms, and diagnosis

In patients with cardiovascular disease (CVD), depression is common, persistent, and associated with worse health-related quality of life, recurrent cardiac events, and mortality. Both physiological and behavioral factors—including endothelial dysfunction, platelet abnormalities, inflammation, autonomic nervous system dysfunction, and reduced engagement in health-promoting activities—may link depression with adverse cardiac outcomes. Because of the potential impact of depression on quality of life and cardiac outcomes, the American Heart Association has recommended routine depression screening of all cardiac patients with the 2- and 9-item Patient Health Questionnaires. However, despite the availability of these easy-to-use screening tools and effective treatments, depression is underrecognized and undertreated in patients with CVD. In this paper, we review the literature on epidemiology, phenomenology, comorbid conditions, and risk factors for depression in cardiac disease. We outline the associations between depression and cardiac outcomes, as well as the mechanisms that may mediate these links. Finally, we discuss the evidence for and against routine depression screening in patients with CVD and make specific recommendations for when and how to assess for depression in this high-risk population.

One-year follow up of cardiac anxiety after a myocardial infarction: a latent class analysis

INTRODUCTION

Longitudinal elevated depressive symptom scores are associated with a less favorable cardiac outcome. Although anxiety has received less attention, meta-analysis suggests that high baseline levels of general anxiety might worsen cardiac outcome. The objective of this study was to explore the longitudinal course of cardiac anxiety after a myocardial infarction (MI).

METHODS

The Cardiac Anxiety Questionnaire (CAQ) was administered to 194 patients hospitalized for MI after admission, and one, three, six and twelve months after discharge. Latent class growth analysis (LCGA) was performed to identify groups based on cardiac anxiety course. Between group differences were checked on relevant socio-demographic, cardiac and psychiatric variables.

RESULTS

LCGA identified three groups with stable CAQ levels over time, indicative of high (7.7%), intermediate (45.4%) and low (30.4%) levels of cardiac anxiety, respectively. A fourth group (16.5%) reported high levels of cardiac anxiety that decreased over time. Between group differences were of particular interest for the two subgroups that started high in cardiac anxiety, since these may differentiate patients with spontaneous remission from those who might be in need of treatment. Patients in whom cardiac anxiety persisted were less often employed, had more diabetes mellitus, a history of acute coronary syndrome, depressive symptoms, anxiety and avoidance at baseline and a lower quality of life at follow-up.

CONCLUSION

This first study addressing cardiac anxiety after an MI identified four trajectories. Future studies should focus on cardiac outcome and treatment strategies for cardiac anxiety in the subgroup with persistent high anxiety levels.

Cortisol levels and history of depression in acute coronary syndrome patients

BACKGROUND

Depressed mood following an acute coronary syndrome (ACS) is a risk factor for future cardiac morbidity. Hypothalamic-pituitary-adrenal (HPA) axis dysregulation is associated with depression, and may be a process through which depressive symptoms influence later cardiac health. Additionally, a history of depression predicts depressive symptoms in the weeks following ACS. The purpose of this study was to determine whether a history of depression and/or current depression are associated with the HPA axis dysregulation following ACS.

METHOD

A total of 152 cardiac patients completed a structured diagnostic interview, a standardized depression questionnaire and a cortisol profile over the day, 3 weeks after an ACS. Cortisol was analysed using: the cortisol awakening response (CAR), total cortisol output estimated using the area under the curve method, and the slope of cortisol decline over the day.

RESULTS

Total cortisol output was positively associated with history of depression, after adjustment for age, gender, marital status, ethnicity, smoking status, body mass index (BMI), Global Registry of Acute Cardiac Events (GRACE) risk score, days in hospital, medication with statins and antiplatelet compounds, and current depression score. Men with clinically diagnosed depression after ACS showed a blunted CAR, but the CAR was not related to a history of depression.

CONCLUSIONS

Patients with a history of depression showed increased total cortisol output, but this is unlikely to be responsible for associations between depression after ACS and later cardiac morbidity. However, the blunted CAR in patients with severe depression following ACS indicates that HPA dysregulation is present.

Type D personality is associated with increased comorbidity burden and health care utilization among 3080 cancer survivors

OBJECTIVE

Cancer survivors often report comorbid diseases, but there are individual differences in risk. Type D personality is a general propensity to psychological distress that is related to poor cardiovascular outcomes. In this study, we examined whether type D was also related to comorbidity burden and health care utilization among cancer survivors.

METHODS

Individuals diagnosed with endometrial cancer or colorectal cancer between 1998 and 2007, or with lymphoma or multiple myeloma between 1999 and 2008 as registered in the Eindhoven Cancer Registry, received the Self-Administered Comorbidity Questionnaire, questions on health care utilization and the Type D personality scale; 69% (n=3080) responded.

RESULTS

Nineteen percent of survivors had a type D personality. Over a 12-month period, type D survivors significantly more often reported osteoarthritis, back pain, and depression than non-type D survivors. Also, type D survivors more often reported to feel bothered by high blood pressure, osteoarthritis, heart disease, depression, diabetes and lung disease during daily activities. Type D survivors more often visited their general practitioner than non-type D survivors (P<.001), also in relation to cancer (0 visits: 54% vs. 60%; 1-5: 28% vs. 22%; >5: 9% vs. 5%; P<.001), as well as their specialist (0 visits: 6% vs. 7%; 1-5 visits: 59% vs. 64%; >5 visits: 30% vs. 23%; P<.01).

CONCLUSION

Type D personality is a vulnerability factor that may help to identify subgroups of cancer survivors who are at an increased risk for comorbidity burden and increased health care utilization.

Type D personality as a cardiovascular risk marker in the general population: results from the Gutenberg health study

BACKGROUND

Type D personality is considered as an independent risk factor for morbidity and mortality in cardiovascular patients and a vulnerability factor for distress in the general population. Because representative community studies are rare, we sought to determine the prevalence of type D personality and its relationship with demographic characteristics, different features of mental disorders, cardiovascular risk factors, health behavior, endothelial function and cardiovascular biomarkers in the general population.

METHODS

The prevalence of type D personality and its correlates were analyzed cross-sectionally in a population-based sample of 5,000 Mid-Europeans aged 35-74 years from the Gutenberg Health Study.

RESULTS

The prevalence of type D personality was 22.2% without remarkable differences in sex distribution. Type D subjects were characterized by lower socioeconomic status, lack of a partnership, increased depression, anxiety, depersonalization and health care utilization. Despite its strong association with mental disorders, type D personality emerged as psychometrically distinct. Although type D personality was independently associated with coronary heart disease (OR = 1.54, p = 0.044), no associations with traditional cardiovascular risk factors were found independently from depression or anxiety.

CONCLUSIONS

Although type D personality is strongly associated with depression, anxiety, impaired mental and somatic health status, and increased health care utilization, the type D construct seems to comprise dysfunctional personality patterns not covered by depression and anxiety scales. Beyond these associations, the pathways of the cardiotoxic impact of type D personality remain to be elucidated. There is a need for prospective population studies on potential links between type D personality and cardiac disease.

Type D personality and persistence of depressive symptoms in a German cohort of cardiac patients

BACKGROUND

Depression is associated with a negative prognosis in coronary heart disease and heart failure patients. Type D personality has been shown to predict the persistence of depressive symptoms over 12 months. Data on longer follow-up periods and on the effectiveness of Type D as a screening tool compared to established measures of depressive symptoms are missing.

METHODS

Type D personality and depressive mood were assessed with the DS14 and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) in 679 consecutive cardiac patients (22.2% female, mean age 62.4±10.2 years) over a period of 6 years. Latent class and growth mixture models with Type D, comorbidity, age, and sex as covariates were used to model individual depression trajectory classes and to predict trajectories and class membership. Estimates of specificity and sensitivity were calculated for Type D and the HADS-D baseline cut-off point.

RESULTS

In a model with four latent classes (mild symptoms, moderate and increasing symptoms, significant but decreasing symptoms, and significant and increasing symptoms), Type D predicted the membership in the class with significant and increasing symptoms (OR=10.94, 4.93, and 3.15). Sensitivity and specificity were 59% and 78% for Type D and 47% and 80% for the HADS-D.

LIMITATIONS

Some possible confounders might be missing. With just two measurement points only linear trajectories could be modeled.

CONCLUSIONS

Type D personality is a stronger predictor for persistent depressive symptoms than the baseline HADS-D score, but the predictive power seems low for clinical practice.

Distinct psychological distress trajectories in rheumatoid arthritis: findings from an inception cohort

OBJECTIVE

As with other chronic physical illness, rates of depressive disorder are high in rheumatoid arthritis (RA). The aim of the current study was to identify distinct trajectories of psychological distress over 10 years in a cohort of RA patients recruited very early in the course of the disease.

METHODS

Psychological distress as measured by the Hospital Anxiety and Depression Scale total score was assessed annually in a subgroup of 784 patients enrolled in a multi-centre RA inception cohort (Early RA Study). A latent growth mixture modelling (GMM) approach was used to identify distinct psychological distress patterns.

RESULTS

Four distinct psychological distress trajectories were observed: low-stable (68%), high-stable (12%), high-decreasing (9%) and low-increasing (11%). Symptoms of pain, stiffness and functional impairment were significantly associated with levels of psychological distress at the time of diagnosis and after 3 years; serological markers of disease activity (ESR and CRP) were not.

CONCLUSIONS

Although the majority of individuals developing RA experience little or no impact of the effects of the disease on their psychological well-being, a significant proportion experience high levels of distress at some point which may be related to their subjective appraisal of their condition. Assessment and treatment of psychological distress should occur synchronously with somatic symptoms.

Emotional triggering and low socio-economic status as determinants of depression following acute coronary syndrome

BACKGROUND

The determinants of depression following acute coronary syndrome (ACS) are poorly understood. Triggering of ACS by emotional stress and low socio-economic status (SES) are predictors of adverse outcomes. We therefore investigated whether emotional triggering and low SES predict depression and anxiety following ACS.

METHOD

This prospective observational clinical cohort study involved 298 patients with clinically verified ACS. Emotional stress was assessed for the 2 h before symptom onset and compared with the equivalent period 24 h earlier using case-crossover methods. SES was defined by household income and education. Depression was measured with the Beck Depression Inventory and the Hamilton Rating Scale for Depression and anxiety with the Hospital Anxiety and Depression Scale 3 weeks after ACS and again at 6 and 12 months. Age, gender, ethnicity, marital status, the Global Registry of Acute Coronary Events risk score, duration of hospital stay and history of depression were included as covariates.

RESULTS

Emotional stress during the 2-h hazard period was associated with increased risk of ACS (odds ratio 1.88, 95% confidence interval 1.01-3.61). Both low income and emotional triggering predicted depression and anxiety at 3 weeks and 6/12 months independently of covariates. The two factors interacted, with the greatest depression and anxiety in lower income patients who experienced acute emotional stress. Education was not related to depression.

CONCLUSIONS

Patients who experience acute emotional stress during their ACS and are lower SES as defined by current affluence and access to resources are particularly vulnerable to subsequent depression and anxiety.

Depression and cardiac disease: a review

Depression is highly prevalent in cardiac patients, with 20% to 40% of patients meeting criteria for major depressive disorder or experiencing an elevation in depressive symptoms. These depressive symptoms are often chronic and persistent, and they have been associated with the development and progression of coronary artery disease, worse health-related quality of life, poor physical functioning, recurrent cardiac events, and a 2- to 2.5-fold increased risk of mortality. Impaired adherence to health behaviors and adverse physiological effects of depression, including inflammation, endothelial dysfunction, platelet hyperactivity, and autonomic nervous system abnormalities, may link depression with adverse cardiac outcomes. Pharmacologic and psychotherapeutic interventions appear to be safe and effective at reducing depressive symptoms in patients with cardiovascular disease and may impact cardiac outcomes. Unfortunately, depression often is unrecognized and untreated in this population, despite the availability of brief screening tools that can be used for this purpose. We recommend the routine screening of cardiac patients for depression when there are adequate mechanisms for management and referral, such as available consulting psychiatrists or care management programs that facilitate the delivery of pharmacologic and psychotherapeutic treatments in this vulnerable population.

Depression screening in patients with coronary heart disease: a critical evaluation of the AHA guidelines

OBJECTIVE

We lack evidence that routine screening for depression in patients with coronary heart disease (CHD) improves patient outcome. This lack has challenged the advisory issued by the American Heart Association (AHA) to routinely screen for depression in CHD patients. We assess the AHA advisory in the context of well-established criteria of screening for diseases.

METHODS

Using principles and criteria for screening developed by the World Health Organization and the United Kingdom National Screening Committee, we generated criteria pertinent to screening for depression in CHD patients. To find publications relevant to these criteria and clinical setting, we performed a broadly based literature search on "depression and CHD," supplemented by more focused literature searches.

RESULTS

Evidence for an association between depression and CHD is strong. Despite this, the AHA advisory has several limitations. It did not account for the complexity of the association between depression and CHD. It acknowledged there was no evidence that screening for depression leads to improved outcomes in cardiovascular populations but still recommended routine screening without providing an alternative evidence-based explanation. It ignored the paucity of literature about the safety and cost-effectiveness of routine screening for depression in CHD and failed to define the nature and extent of resources needed to implement such a program effectively.

CONCLUSION

We conclude that the AHA advisory is premature. We must first demonstrate the efficacy, safety, and cost-effectiveness of screening and define the resources necessary for its implementation and monitoring. Meanwhile, organizations representing cardiologists, psychiatrists, and general practitioners must coordinate efforts to manage depression and CHD through collaborative care, and work with the policy makers to develop the necessary infrastructure and services delivery system needed to optimize the outcome of depressed and at-risk-for-depression patients suffering from CHD.

Depressive vulnerabilities predict depression status and trajectories of depression over 1 year in persons with acute coronary syndrome

OBJECTIVE

Depression is prevalent in patients hospitalized with acute coronary syndrome (ACS). We determined whether theoretical vulnerabilities for depression (interpersonal life events, reinforcing events, cognitive distortions, Type D personality) predicted depression, or depression trajectories, post-hospitalization.

METHODS

We followed 375 ACS patients who completed depression scales during hospital admission and at least once during three follow-up intervals over 1 year (949 observations). Questionnaires assessing vulnerabilities were completed at baseline. Logistic regression for panel/longitudinal data predicted depression status during follow-up. Latent class analysis determined depression trajectories. Multinomial logistic regression modeled the relationship between vulnerabilities and trajectories.

RESULTS

Vulnerabilities predicted depression status over time in univariate and multivariate analysis, even when controlling for baseline depression. Proportions in each depression trajectory category were as follows: persistent (15%), subthreshold (37%), never depressed (48%). Vulnerabilities independently predicted each of these trajectories, with effect sizes significantly highest for the persistent depression group.

CONCLUSIONS

Self-reported vulnerabilities - stressful life events, reduced reinforcing events, cognitive distortions, personality - measured during hospitalization can identify those at risk for depression post-ACS and especially those with persistent depressive episodes. Interventions should focus on these vulnerabilities.

Vital exhaustion and cardiovascular prognosis in myocardial infarction and heart failure: predictive power of different trajectories

BACKGROUND

We examined the different trajectories of vital exhaustion (VE) over a 12-month period and their impact on prognosis in a sample of myocardial infarction (MI) and chronic heart failure (CHF) patients.

METHOD

Consecutive MI (n=407) and CHF patients (n=297) were assessed at baseline, and at 3- and 12-month follow-up for symptoms of VE. Latent growth mixture modelling was used to examine the course of VE over time. The combined clinical endpoint was defined as cardiac hospital readmission or death.

RESULTS

Four distinct trajectories for VE were found: low VE, decreasing VE, increasing VE, and severe VE. Sex, marital status, left ventricular ejection fraction, psychotropic medication, sample group (CHF v. MI) and depressive symptoms were associated with VE, varying according to classes. The mean follow-up period was 25.3 months in which 34.7% of the patients experienced an event. Multivariate Cox regression showed that, compared with patients in the low VE class, patients in the increasing VE class [hazard ratio (HR)=1.16, 95% confidence interval (CI) 1.58-3.61, p=0.01], and the severe VE class (HR=1.69, 95% CI 1.31-2.64, p=0.02) had an increased risk for adverse cardiovascular events (i.e. cardiovascular hospital readmission or cardiovascular death). Decreasing VE was not related to adverse cardiovascular events (HR=0.97, 95% CI 0.66-1.69, p=0.81).

CONCLUSIONS

VE trajectories varied across cardiac patients, and had a differential effect on cardiovascular outcome. Increasing VE and severe VE classes were predictors of poor cardiovascular prognosis. These results suggest that identification of cardiac patients with an increased risk of adverse health outcomes should be based on multiple assessments of VE.