Relationship among depression scores, beta-endorphin, and angina pectoris during exercise in patients with coronary artery disease

Components of the Anger-Hostility Complex and Symptom Reporting in Patients with Coronary Artery Disease: A Multi-Measure Study

Multiple anger and hostility variables were investigated for associations with coronary artery disease (CAD) symptoms and to examine if those relationships were different for disease severity.Atwo year follow-up study of97 men with stenosed coronary arteries was undertaken. Questionnaires measured: nine forms of anger and hostility; Type A behaviour; anxiety; depression; social support; and ninesymptom measures. CAD severity was derived from clinicians’ ratings of coronary angiograms. Results are four fold: anger-hostility variables are relatively unimportant predictors of symptoms compared with anxiety and depression; psychosocial measures (except for expressed anger) are uncorrelated with CAD severity, though correlate numerously with CAD symptoms; symptoms are not distinguishable empirically in terms of frequency, intensity and duration with regard to type (‘angina pain’, ‘tiredness’ and ‘breathlessness and restricted mobility’); finally, CADsymptoms are unrelated to CAD severity. In conclusion, components of the angerhostility complex are of limited use for predicting CAD symptoms. However, anger expression is of utility for differentiating between CAD symptoms and disease severity.

Nontraditional Cardiac Rehabilitation in Korean Patients with Coronary Artery Disease

PURPOSE

This pilot investigation sought to compare outcomes including depression, anxiety, stress, mindful awareness, and exercise capacity between exercise-focused cardiac rehabilitation (ECR) and meditation-focused cardiac rehabilitation (MCR) programs for patients with coronary artery disease (CAD) who had percutaneous coronary intervention (PCI).

DESIGN

A nonrandomized pretest-posttest design was employed.

METHODS

Two different interventions (ECR vs. MCR) were implemented with participants of each group for 12 weeks. Questionnaires assessing depression, anxiety, stress, and mindful awareness and measures of peak VO2 were completed before and after the 12-week interventions.

FINDINGS

Thirteen patients completed the cardiac rehabilitation (CR) programs. Meditation-focused cardiac rehabilitation was associated with significantly greater reductions in depression as compared to ECR; there were no significant differences between the two groups on other outcomes.

CONCLUSIONS

The MCR program has similar effects to improve the physical and psychological outcomes, compared with the ECR program.

CLINICAL RELEVANCE

There is potential for patients with CAD to participate in and benefit from nontraditional CR programs, and such CR could play a role in secondary prevention of CAD.

Evening salivary alpha-amylase, major depressive disorder, and antidepressant use in the Netherlands Study of Depression and Anxiety (NESDA)

Salivary alpha-amylase (sAA) may be a suitable index for sympathetic activity and dysregulation of the autonomic nervous system. The relationship between antidepressants and depression with sAA levels was studied, since antidepressants were previously shown to have a profound impact on heart rate variability as an ANS indicator. Data are from 1692 participants of the Netherlands Study of Depression and Anxiety (NESDA) who were recruited from the community, general practice, and specialized mental health care. Differences in evening sAA levels were examined between patient groups (i.e., 752 current major depressive disorder [MDD], 611 remitted MDD, and 329 healthy controls) and between 46 tricyclic antidepressant (TCA) users, 307 selective serotonin reuptake inhibitor (SSRI) users, 97 users of another antidepressant, and 1242 non-users. Each participant sampled twice at 22.00h and 23.00h. In multivariable analysis, there was a trend over the three groups with increasing sAA levels from controls to remitted MDD to current MDD that approached significance. Furthermore, in comparison to non-users of antidepressants, TCA rather than SSRI users showed higher sAA levels, that persisted after multivariable adjustment. The present study shows that higher evening sAA levels in depressed patients, indicative of an increased sympathetic activity, may be induced by TCAs.

Treatment with double dose of omeprazole increases β-endorphin plasma level in patients with coronary artery disease

INTRODUCTION

The proton pump inhibitor empirical trial, besides the analysis of symptoms, is the main method in the diagnosis of gastro-oesophageal reflux disease-related chest pain. β-Endorphin acts as an endogenous analgesia system. The aim of the study was verify whether β-endorphin plasma level is affected by omeprazole administration and influences the severity of anginal symptoms and outcome of the "omeprazole test" in patients with coronary artery disease (CAD) and chest pain of suspected non-cardiac origin.

MATERIAL AND METHODS

Omeprazole was administered to 48 patients with CAD in a randomized, placebo-controlled, crossover study design. At the beginning of the study, and again after the 14-day omeprazole and placebo treatment, the β-endorphin plasma concentration was determined.

RESULTS

The level of plasma β-endorphin after the administration of omeprazole was significantly greater than at the start of the study and following the placebo. Responders to omeprazole had an average lower β-endorphin plasma concentration than subjects who failed to respond to this therapy. Subjects with symptoms in class III (according to the Canadian Cardiovascular Society classification) after omeprazole administration had a greater β-endorphin plasma level than subjects in class II for anginal symptom severity.

CONCLUSIONS

Fourteen-day therapy with a double omeprazole dose significantly increases the β-endorphin plasma concentration in patients with CAD. Circulating β-endorphin does not seem to be involved in the mechanism for the "omeprazole test" outcome, although an individually different effect on pain threshold cannot be excluded.

Histories of major depression and premenstrual dysphoric disorder: Evidence for phenotypic differences

This study examined unique versus shared stress and pain-related phenotypes associated with premenstrual dysphoric disorder (PMDD) and prior major depressive disorder (MDD). Sympathetic nervous system (SNS) and hypothalamic-pituitary-adrenal (HPA)-axis measures were assessed at rest and during mental stress, as well as sensitivity to cold pressor and tourniquet ischemic pain tasks in four groups of women: (1) non-PMDD with no prior MDD (N=18); (2) non-PMDD with prior MDD (N=9); (3) PMDD with no prior MDD (N=17); (4) PMDD with prior MDD (N=10). PMDD women showed blunted SNS responses to stress compared to non-PMDD women, irrespective of prior MDD; while women with prior MDD showed exaggerated diastolic blood pressure responses to stress versus never depressed women, irrespective of PMDD. However, only in women with histories of MDD did PMDD women have lower cortisol concentrations than non-PMDD women, and only in non-PMDD women was MDD associated with reduced cold pressor pain sensitivity. These results suggest both unique phenotypic differences between women with PMDD and those with a history of MDD, but also indicate that histories of MDD may have special relevance for PMDD.

Psychosocial modulators of angina response to myocardial ischemia

BACKGROUND

Although angina is often caused by atherosclerotic obstruction of the coronary arteries, patients with similar amounts of myocardial ischemia may vary widely in their symptoms. We sought to compare clinical and psychosocial characteristics associated with more frequent angina after adjusting for the amount of inducible ischemia.

METHODS AND RESULTS

From 2004 to 2006, 788 consecutive patients undergoing single-photon emission computed tomography stress perfusion imaging at 2 Seattle hospitals were assessed for their frequency of angina over the previous 4 weeks with the Seattle Angina Questionnaire and for a broad range of psychosocial characteristics. Among patients with demonstrable ischemia on single-photon emission computed tomography (summed difference score >or=2; n=191), angina frequency was categorized as none (Seattle Angina Questionnaire score=100; n=68), monthly (score=61 to 99; n=66), and weekly or daily (score=0 to 60; n=57). Using multivariable ordinal logistic regression, increasing angina was significantly associated with a history of coronary revascularization (odds ratio 2.24, 95% confidence interval 1.19 to 4.19), anxiety (odds ratio 4.72, 95% confidence interval 1.91 to 11.66), and depression (odds ratio 3.12, 95% confidence interval 1.45 to 6.69) after adjustment for the amount of inducible ischemia.

CONCLUSIONS

Among patients with a similar burden of inducible ischemia, a history of coronary revascularization and current anxiety and depressive symptoms were associated with more frequent angina. These results support the study of angina treatment strategies that aim to reduce psychosocial distress in conjunction with efforts to lessen myocardial ischemia.

Review: Mechanisms of silent myocardial ischaemia: with particular reference to diabetes mellitus

Angina occurs relatively late following the onset of ischaemia: after the development of left ventricular dysfunction and electrocardiographic changes. Most ischaemic episodes are not severe enough or long enough to fully stimulate the anginal pain pathway. They are therefore clinically silent. More severe and prolonged episodes of ischaemia can also be silent. Pain thresholds vary between individuals and this is due to differences in gating mechanisms at the level of the thalamus. This gating appears to be modulated by levels of endogenous endorphins, among other mechanisms. This seems to have a relation to personality type. Silent ischemia is especially common in diabetic patients, and is often due to cardiac autonomic neuropathy.

Experimentally induced mood changes preferentially affect pain unpleasantness

Our group previously demonstrated that changes in mood induced by pleasant or unpleasant odors affect the perceived unpleasantness of painful heat stimuli, without significantly altering perceived pain intensity. In the present study, we examined whether changing mood by viewing emotionally laden visual stimuli also preferentially alters pain unpleasantness. Twelve female subjects immersed their right hand in hot water while observing a video showing a person experiencing the same type of pain (ie, model condition), unpleasant scenes not involving people (ie, disasters condition), or a cityscape video (ie, cityscape condition). Subjects were asked to rate pain intensity, pain unpleasantness, mood, anxiety/calmness, and video unpleasantness, and their skin conductance was measured throughout the experiment. Pain unpleasantness (but not intensity) ratings were higher during the disasters condition, which was associated with the worst mood, than during the cityscape condition; neither mood nor pain unpleasantness was altered in the model video compared with the cityscape video. Moreover, mood was significantly correlated with pain unpleasantness but not with pain intensity. Because these results are similar to those observed when odors were used to alter mood, we conclude that the effects of mood on the affective components of pain are independent of mood induction technique used.

PERSPECTIVE

This article provides new evidence that changes in mood affect the pain experience by preferentially modulating pain unpleasantness. This finding could potentially help health professionals to treat pain symptoms in patients with altered mood, suggesting methods of pain management aimed at easing the affective, along with the sensory, components of pain.

An interactive model of pain and myocardial ischemia

The biopsychosocial model has been used to describe the intertwined factors that may act as mechanisms in cardiovascular disease, as well as those found in pain conditions. This model may also prove useful in understanding a diagnosis that overlaps these two areas, angina. This article reviews the literature related to biological, psychological, and social mechanisms of painful ischemic episodes and discusses the interactions of those variables. We propose an integrated model that incorporates the biopsychosocial mechanisms that may be responsible for the variability in pain reporting with ischemic episodes. We show how sex differences manifested in various biopsychosocial factors may interact to influence the presence of painful versus silent myocardial ischemia. We present a plan for future research to elucidate this interaction.

Psychological distress and exertional angina in men and women undergoing thallium scintigraphy

The relation between psychological factors and angina has mostly been studied in male patients with confirmed CAD and few have evaluated this relation during actual provocation of ischemia. This study evaluated gender differences in the association between psychological distress and angina pain experience in 907 Caucasian patients (479 women, mean age = 60 years) undergoing exercise stress testing with thallium scintigraphy. Data were analyzed separately for patients with and without exercise related ischemia using a series of 2 (low/high distress) x 2 (gender) ANOVAs as well as binary logistic regressions. Among all patients, distress and gender were associated with greater risk and intensity of angina pain during testing (p < 0.05) and more angina following exertion (p < 0.05) or stress (p < 0.05) at home.

CONCLUSION

angina pain was more severe in women and individuals with high levels of distress, regardless of their ischemic status. A generalized hypersensitivity to pain/symptoms may be indicated in these patients.

Effects of recreational physical activity and back exercises on low back pain and psychological distress: findings from the UCLA Low Back Pain Study

OBJECTIVES

We sought to estimate the effects of recreational physical activity and back exercises on low back pain, related disability, and psychological distress among patients randomized to chiropractic or medical care in a managed care setting.

METHODS

Low back pain patients (n=681) were randomized and followed for 18 months. Participation in recreational physical activities, use of back exercises, and low back pain, related disability, and psychological distress were measured at baseline, at 6 weeks, and at 6, 12, and 18 months. Multivariate logistic regression modeling was used to estimate adjusted associations of physical activity and back exercises with concurrent and subsequent pain, disability, and psychological distress.

RESULTS

Participation in recreational physical activities was inversely associated--both cross-sectionally and longitudinally--with low back pain, related disability, and psychological distress. By contrast, back exercise was positively associated--both cross-sectionally and longitudinally--with low back pain and related disability.

CONCLUSIONS

These results suggest that individuals with low back pain should refrain from specific back exercises and instead focus on nonspecific physical activities to reduce pain and improve psychological health.

Chest pain in patients with cardiac and noncardiac disease

OBJECTIVE

To describe factors influencing chest pain expression in patients with cardiac or noncardiac disease.

METHODS

The authors conducted a case presentation and review of literature.

RESULTS

Causes of chest pain are diverse. Psychologic factors influence chest pain expression commonly in patients with or without cardiac disease.

CONCLUSIONS

Physicians and other therapists must be aware of psychologic influences on chest pain expression to provide optimal treatment to their patients.

Are exercise stress tests appropriate for assessing myocardial ischemia in patients with major depressive disorder?

BACKGROUND

Major depressive disorder (MDD) disproportionately affects patients with coronary artery disease (CAD). Evidence of myocardial ischemia with electrocardiography (ECG) or single-photon-emission-computed-tomography (SPECT) assessments during exercise testing is an important determinant of CAD prognosis. However, many key symptoms of MDD, such as reduced interest in daily activities, lack of energy, and fatigue, may affect exercise performance and the detection of ischemia in patients with MDD. This study evaluated the extent to which MDD and depressive symptomatology moderate exercise test performance and compared the ability of ECG versus SPECT for detecting ischemia in 1367 consecutive patients who underwent exercise testing.

METHODS

All patients underwent a brief, structured psychiatric interview (PRIME-MD) and completed the Beck Depression Inventory (BDI) on the day of their exercise (treadmill) test.

RESULTS

A total of 183 patients (13%) met diagnostic criteria for MDD. Patients with MDD achieved a significantly lower percent of maximal predicted heart rate (%MPHR), exhibited lower peak exercise mets, and spent less time exercising compared with patients without MDD (all P values <.05). BDI scores were also negatively correlated with all 3 indices of exercise performance (all P values <.01). There were no differences in rates of SPECT ischemia in patients with MDD (40%) versus patients without MDD (45%; P =.23); however, rates of ECG ischemia were significantly lower (30%) in patients with MDD than in patients without MDD (48%; P <.0001).

CONCLUSIONS

Results suggest that patients with CAD who have MDD, depressive symptomatology, or both exhibit poor exercise tolerance and performance and that ECG, as compared with SPECT, may not be as reliable in detecting ischemia in patients who are depressed.

Do asthma and physical inactivity influence the associations of personal and job stressors with perceived stress and depression? Findings from the 1998-1999 California Work and Health Survey

PURPOSE

The purpose of the study is to estimate the associations of personal and job stressors with perceived stress and depression, and to determine if these associations are modified by asthma and physical inactivity.

METHODS

Data from 2,902 adult respondents of the 1998-1999 California Work and Health Survey (CWHS) were used. The CWHS included items on asthma, exercise, personal stressors, psychological and physical job demands, and perceived stress and depression. Multivariable logistic regression modeling was used to estimate cross-sectional and longitudinal associations.

RESULTS

The estimated joint effects of high stressor scores and asthma on stress are compatible with greater than multiplicative effects in both cross-sectional and longitudinal analyses. Asthma did not appear to modify stressor-depression associations, and physical inactivity modified neither stressor-stress nor stressor-depression associations. Among the employed, the cross-sectional joint effects of personal stressors and physical inactivity on stress and depression are compatible with greater than multiplicative effects, as are the effects of low decision latitude and asthma on perceived stress.

CONCLUSIONS

Asthma and physical inactivity may augment the effects of stressors, suggesting that the increasing prevalence of asthma may contribute to greater stress perception and depression, and that exercise may ameliorate these conditions by dampening stressor effects.

Exercise and the treatment of clinical depression in adults: recent findings and future directions

This article critically reviews the evidence that exercise is effective in treating depression in adults. Depression is recognised as a mood state, clinical syndrome and psychiatric condition, and traditional methods for assessing depression (e.g. standard interviews, questionnaires) are described. In order to place exercise therapy into context, more established methods for treating clinical depression are discussed. Observational (e.g. cross-sectional and correlational) and interventional studies of exercise are reviewed in healthy adults, those with comorbid medical conditions, and patients with major depression. Potential mechanisms by which exercise may reduce depression are described, and directions for future research in the area are suggested. The available evidence provides considerable support for the value of exercise in reducing depressive symptoms in both healthy and clinical populations. However, many studies have significant methodological limitations. Thus, more data from carefully conducted clinical trials are needed before exercise can be recommended as an alternative to more traditional, empirically validated pharmacological and behavioural therapies.

Depression as a predictor for coronary heart disease. a review and meta-analysis

OBJECTIVE

To review and quantify the impact of depression on the development of coronary heart disease (CHD) in initially healthy subjects.

DATA SOURCES

Cohort studies on depression and CHD were searched in MEDLINE (1966-2000) and PSYCHINFO (1887-2000), bibliographies, expert consultation, and personal reference files.

DATA SELECTION

Cohort studies with clinical depression or depressive mood as the exposure, and myocardial infarction or coronary death as the outcome.

DATA EXTRACTION

Information on study design, sample size and characteristics, assessment of depression, outcome, number of cases, crude and most-adjusted relative risks, and variables used in multivariate adjustments were abstracted.

DATA SYNTHESIS

Eleven studies met the inclusion criteria. The overall relative risk [RR] for the development of CHD in depressed subjects was 1.64 (95% confidence interval [CI]=1.29-2.08, p<0.001). A sensitivity analysis showed that clinical depression (RR=2.69, 95% CI=1.63-4.43, p<0.001) was a stronger predictor than depressive mood (RR=1.49, 95% CI=1.16-1.92, p=0.02).

CONCLUSION

It is concluded that depression predicts the development of CHD in initially healthy people. The stronger effect size for clinical depression compared to depressive mood points out that there might be a dose-response relationship between depression and CHD. Implications of the findings for a broader bio-psycho-social framework are discussed.

Sex differences in chest pain in patients with documented coronary artery disease and exercise-induced ischemia: Results from the PIMI study

BACKGROUND

Sex differences in the pathophysiologic course of coronary artery disease (CAD) are widely recognized, yet accurate diagnosis of coronary artery disease in women remains challenging.

METHODS

To determine sex differences in the clinical manifestation of CAD, we studied chest pain reported during daily activities, exercise, and mental stress in 170 men and 26 women. All patients had documented CAD (>50% narrowing in at least 1 major coronary artery or prior myocardial infarction) and all had 1-mm ST-segment depression on treadmill exercise. We collected psychologic test results, serum samples (potassium, epinephrine, norepinephrine, cortisol, b-endorphin, and glucose), and cardiac function, sensory threshold, and autonomic function data at specified times before, during, or after exercise and mental stress tests to assess measures of depression, anxiety, and neurohormonal and thermal pain perception.

RESULTS

Women reported chest pain more often than men during daily activities (P =.04) and during laboratory mental stressors (P =.01) but not during exercise. Men had lower scores than women on measures of depression, trait anxiety, harm avoidance, and reward dependence (P <.05 for all). Women had significantly lower plasma b-endorphin levels at rest (4.2 +/- 3.9 vs 5.0 +/- 2.5 pmol/L for men, P =.005) and at maximal mental stress (6.4 +/- 5.1 vs 7.4 +/- 3.5 pmol/L for men, P <.01). A higher proportion of women than men had marked pain sensitivity to graded heat stimuli applied to skin (hot pain threshold <41 degrees C, 33% vs 10%, P =.001).

CONCLUSIONS

Our results reflect sex differences in the affective and discriminative aspects of pain perception and may help explain sex-related differences in clinical presentations.

Gender and psychosomatic aspects of ischemic heart disease

While women and their doctors have traditionally worried about mortality from breast and gynecological malignancies, over the past 5 years they have come to realize that ischemic cardiac disease (IHD) is the number one killer of women in most Western countries. This has led to public and professional education campaigns and a new emphasis on gender and gender-specific research in IHD. Unfortunately, this literature remains poorly developed and much work remains to be done. Even in samples in which there may be sufficient numbers to allow for the evaluation of gender and gender differences, these important analyses have often been overlooked. This article provides a review of what is known about gender and gender differences in psychosocial and behavioral issues in IHD.

Heart rate variability at rest and during mental stress in patients with coronary artery disease: differences in patients with high and low depression scores

This study tested the hypothesis that coronary artery disease (CAD) patients with high depressed mood scores differ in sympatho-vagal balance during mental stress compared to patients with low depressed mood scores. Using electrocardiographic monitoring, heart variability data from spectral analysis and hemodynamic parameters were obtained prior to and during mental stress from 34 men and 7 women. A public speaking task was used as the mental stressor. Patients were grouped by a median split of their Minnesota Multiphasic Personality Inventory-Depression score. During mental stress, patients with higher depression scores had greater changes in peak heart rate (p < .05) and low frequency to high frequency power ratio (p < 0.05) than patients with lower scores suggesting a shift toward more sympathetic activity during mental stress. These findings may be related to the reported relation between depression and survival risk in patients with CAD.

Chronic pain-associated depression: antecedent or consequence of chronic pain? A review

OBJECTIVE

To determine the current status for the association of chronic pain and depression and to review the evidence for whether depression is an antecedent or consequence of chronic pain (CP).

DESIGN

A computer and manual literature review yielded 191 studies that related to the pain-depression association. These reports were reviewed and sorted into seven categories relating to the topic of this paper. Eighty-three studies were then selected according to inclusion criteria and subjected to a structured review.

SETTING

Any medical treatment setting including pain treatment as inclusion criteria for selection of studies.

PATIENTS

Any patients with any type of chronic pain.

RESULTS

The reviewed studies were consistent in indicating that there is a statistical relationship between chronic pain and depression. For the relationship between pain and depression, there was greater support for the consequence and scar hypotheses than the antecedent hypothesis.

CONCLUSIONS

Depression is more common in chronic pain patients (CPPs) than in healthy controls as a consequence of the presence of CP. At pain onset, predisposition to depression (the scar hypothesis) may increase the likelihood for the development of depression in some CPPS. Because of difficulties in measuring depression in the presence of CP, the reviewed studies should be interpreted with caution.