Depression after myocardial infarction

Enhanced Myocardial Adenylyl Cyclase Activity Alters Heart-Brain Communication

BACKGROUND

The central nervous system's influence on cardiac function is well described; however, direct evidence for signaling from heart to brain remains sparse. Mice with cardiac-selective overexpression of adenylyl cyclase type 8 (TGAC8) display elevated heart rate/contractility and altered neuroautonomic surveillance.

OBJECTIVES

In this study the authors tested whether elevated adenylyl cyclase type 8-dependent signaling at the cardiac cell level affects brain activity and behavior.

METHODS

A telemetry system was used to record electrocardiogram (ECG) and electroencephalogram (EEG) in TGAC8 and wild-type mice simultaneously. The Granger causality statistical approach evaluated variations in the ECG/EEG relationship. Mouse behavior was assessed via elevated plus maze, open field, light-dark box, and fear conditioning tests. Transcriptomic and proteomic analyses were performed on brain tissue lysates.

RESULTS

Behavioral testing revealed increased locomotor activity in TGAC8 that included a greater total distance traveled (+43%; P < 0.01), a higher average speed (+38%; P < 0.01), and a reduced freezing time (-45%; P < 0.01). Dual-lead telemetry recording confirmed a persistent heart rate elevation with a corresponding reduction in ECG-R-waves interval variability and revealed increased EEG-gamma activity in TGAC8 vs wild-type. Bioinformatic assessment of hippocampal tissue indicated upregulation of dopamine 5, gamma-aminobutyric acid A, and metabotropic glutamate 1/5 receptors, major players in gamma activity generation. Granger causality analyses of ECG and EEG recordings showed a marked increase in informational flow between the TGAC8 heart and brain.

CONCLUSIONS

Perturbed signals arising from the heart cause changes in brain activity, altering mouse behavior. More specifically, the brain interprets augmented myocardial humoral/functional output as a "sustained exercise-like" situation and responds by activating central nervous system output controlling locomotion.

Myeloperoxidase as a Potential Biomarker of Acute-Myocardial-Infarction-Induced Depression and Suppression of the Innate Immune System

While myeloperoxidase (MPO) serves as an indicator of both neutrophil and innate-immune-system function, the potential suppression of the innate immune system in patients with acute myocardial infarction (AMI)-induced depression might be evidenced by a decrease in MPO serum levels. The aim of this prospective study was to (1) determine whether serum concentrations of MPO vary immediately and 6 months after AMI and (2) to investigate whether MPO concentrations at the time of the AMI are significant predictors of AMI-induced depression and the depression-associated suppression of the innate immune system. A total of 109 AMI patients were assessed with the Hamilton Depression Scale (HAMD-17) immediately after admission to the hospital and 6 months later. The MPO status was assessed with serum samples, which were also collected immediately and 6 months after AMI. The depressive patients showed significantly lower MPO blood levels immediately and 6 months after the AMI compared to the patients without depression (ANCOVA: MPO (depression) F = 4.764, df = 1, p = 0.031). The baseline MPO was observed as a significant predictor (p = 0.027) of AMI-induced depression 6 months after AMI. MPO is a potential biomarker for AMI-induced depression, indicating a depression-associated suppression of the innate immune system.

Understanding the links between cardiovascular and psychiatric conditions

Individuals recently diagnosed with a cardiovascular disease are at higher risk of developing a mental illness, with mortality increasing when both conditions are present.

[Infarto agudo de miocardio: revisión sobre factores de riesgo, etiología, hallazgos angiográficos y desenlaces en pacientes jóvenes]

La enfermedad cardiovascular persiste como primera causa mundial de muerte en los adultos. La población de adultos jóvenes ha cursado con cambios en el estilo de vida con el paso de las décadas, favoreciendo la aparición de ateroesclerosis en etapas más tempranas y como consecuencia la aparición de eventos cardiovasculares de manera más prematura. Se ha identificado que dentro de los factores de riesgo más comunes, la mayoría de ellos son potencialmente modificables. En comparación con adultos mayores, se ha identificado con mayor prevalencia la presencia de etiologías no ateroescleróticas de infarto de miocardio, como la disección coronaria espontánea, alteraciones anatómicas, embolia y espasmo coronarios. Los hallazgos angiográficos y desenlaces son diferentes de acuerdo con el grupo de edad y el sexo. Por dicho motivo realizamos una búsqueda en PubMed de los estudios y registros publicados para el estudio del infarto agudo de miocardio en paciente jóvenes. Con dicha información realizamos la presente revisión con el objetivo de una mejor comprensión de los hallazgos comunes en este grupo y realizar su comparación con grupos de mayor edad.

Effects of clinical depression on left ventricular dysfunction in patients with acute coronary syndrome

Depression is associated with heart failure independent of traditional cardiovascular disease risk factors. Enhanced platelet activation has been suggested as a potential mechanism and has been associated with negative inotropic effects that can affect left ventricular ejection fraction (LVEF). We examined 131 consecutive acute coronary syndrome (ACS) patients to assess whether depression increased the risk for developing LV dysfunction, and to determine the effects of platelet serotonin signaling in this relationship. Major depression was assessed using the Structured Clinical Interview and depressive symptoms were measured using the Beck Depression Inventory (BDI), with BDI ≥ 10 defined as abnormal. LV dysfunction was defined as LVEF ≤ 45%. Platelet serotonin response was measured by serotonin augmented platelet aggregation and platelet serotonin receptor density. Mean age of ACS participants was 59 years, 78.6% male and 74.0% Caucasian. 34.4% of patients had a reduced LVEF ≤ 45% on presentation. Almost half (47.0%) of patients had BDI ≥ 10 and 18.0% had major depressive disorder. Platelet serotonin response was found to be augmented in depressed patients with low LVEF compared to depressed patients with normal LVEF (p < 0.020). However, the presence of LV dysfunction was found to be similar in both depressed (32.3%) and non-depressed (36.2%) patients (p = 0.714). This suggests alternative factors contribute to poor cardiovascular outcomes in depressed patients that are independent of LV function in post ACS patients.

Assessing Prognosis of Acute Coronary Syndrome in Recent Clinical Trials: A Systematic Review

There is no recent comprehensive overview of contemporary clinical trials assessing short and long-term outcomes in patients with acute coronary syndrome (ACS). This paper reviews factors from recent clinical trials that influenced prognosis in patients with ACS. Cochrane and PubMed databases were screened systematically for clinical trials published in the English literature reporting on ACS prognosis. Two authors independently screened titles, abstracts, and full text. Studies meeting inclusion criteria evaluated the impact of modern practice on prognosis. In vitro and animal models studies, conference abstracts, imaging studies, and review articles were excluded. Disagreement in inclusion criteria was resolved by consensus. A large study of 8,859 patients showed no difference in all-cause mortality between 31 days and 2 years in patients with ST segment elevation myocardial infarction (STEMI) compared to those with non-ST segment elevation myocardial infarction (NSTEMI) or stable ischemic heart disease (SIHD). Other studies showed a significant increase in all-cause mortality in patients with STEMI within the first 30 days, with NSTEMI patients exhibiting a higher mortality rate compared to those with SIHD during the 2-year follow-up period. Our review found that women have a poorer short-term prognosis compared to men. Additionally, reports from patients receiving comprehensive and coordinated care showed longer survival rates. In view of the improved prognosis demonstrated for patients suffering from ACS, assessing prognosis in patients represents a formidable task in modern practice. Our review highlights the need for further evidence-based studies evaluating long-term outcomes on diagnostic and treatment strategies.

Particularities of Acute Myocardial Infarction in Young Adults

Coronary heart disease occurs more often in patients over the age of 45. However, recent data shows a growing incidence of coronary events in younger patients also. Young patients with acute myocardial infarction (AMI) represent a relatively small proportion of subjects suffering from an acute ischemic event. However, they represent a subset that is distinguished from elderly patients by a different profile of risk factors, often atypical clinical presentation, and different prognosis. The prevalence of risk factors such as smoking, dyslipidemia, and a family history of coronary events is higher in this group of patients compared to the general population with AMI. Because of an important negative impact on the patients’ psychology, impaired working abilities, and a high socioeconomical burden, myocardial infarction in young patients represents an important cardiovascular pathology. This manuscript aims to present the particularities of AMI occuring at a young age, in comparison with the rest of the population with AMI.

Correlates of memory loss and depression among myocardial infarction patients in Al-Qassim, Saudi Arabia

Background

After myocardial infarction (MI), patients have an elevated risk for depression, which has a negative impact on morbidity and mortality for patients. As depression and memory function are associated, we examined them in the context of one another. Our objectives were to determine the proportion of patients with either depression only, memory loss only, or both depression and memory loss and to examine the correlates with each outcome.

Methods

This study was a cohort of 264 patients who had myocardial infarction. Data sources included medical records and phone interviews.

Results

The participants’ mean age was 62 ± 12.2 years and mean body mass index was 28.4 ± 5.8 kg/m². Of the participants, 6.4% had memory loss alone, 23.17% had depression alone, and 6.1% had combined memory loss and depression. Activity level and poor health were significantly associated with depression only (p < 0.05). Poor health was significantly associated with combined memory loss and depression (p < 0.05).

Conclusion

Activity level and poor health were identified as correlates of depression as well as combined memory loss and depression. Future studies should aim to improve screening for depression among post-MI patients and develop appropriate interventions to raise the level of activity.

Myocardial Infarction in the "Young": Risk Factors, Presentation, Management and Prognosis

Myocardial infarction (MI) in the "young" is a significant problem, however there is scarcity of data on premature coronary heart disease (CHD) and MI in the "young". This may lead to under-appreciation of important differences that exist between "young" MI patients versus an older cohort. Traditional differences described in the risk factor profile of younger MI compared to older patients include a higher prevalence of smoking, family history of premature CHD and male gender. Recently, other potentially important differences have been described. Most "young" MI patients will present with non-ST elevation MI but the proportion presenting with ST-elevation MI is increasing. Coronary angiography usually reveals less extensive disease in "young" MI patients, which has implications for management. Short-term prognosis of "young" MI patients is better than for older patients, however contemporary data raises concerns regarding longer-term outcomes, particularly in those with reduced left ventricular systolic function. Here we review the differences in rate, risk factor profile, presentation, management and prognosis between "young" and older MI patients.

Proportion of antidepressants prescribed without a psychiatric diagnosis is growing

Over the past two decades, the use of antidepressant medications has grown to the point that they are now the third most commonly prescribed class of medications in the United States. Much of this growth has been driven by a substantial increase in antidepressant prescriptions by nonpsychiatrist providers without an accompanying psychiatric diagnosis. Our analysis found that between 1996 and 2007, the proportion of visits at which antidepressants were prescribed but no psychiatric diagnoses were noted increased from 59.5 percent to 72.7 percent. These results do not clearly indicate a rise in inappropriate antidepressant use, but they highlight the need to gain a deeper understanding of the factors driving this national trend and to develop effective policy responses. To the extent that antidepressants are being prescribed for uses not supported by clinical evidence, there may be a need to improve providers' prescribing practices, revamp drug formularies, or vigorously pursue implementation of broad reforms of the health care system that will increase communication between primary care providers and mental health specialists.

A national survey of GP and nurse attitudes and beliefs towards depression after myocardial infarction

AIM

To investigate primary care practitioner's attitudes to depression after myocardial infarction.

BACKGROUND

Depression after myocardial infarction affects almost half of all patients and has a considerable negative effect on recovery. Despite the increased prevalence of depression in this population, it is often not recognised or treated.

DESIGN

Survey.

METHOD

A total of 813 (106 general practitioners and 707 nurses) practitioners responded. Our questionnaire developed for this project by the authors in collaboration with a group of ten cardiovascular nurse specialists contained 27 items that were summated into five subscales.

RESULTS

Primary care practitioners underestimated the prevalence of depression in the post-myocardial infarction population. General acknowledgement of the negative impact that depression can have was reported by the majority of participants. Diagnosing depression was perceived as complex by both groups but significantly more so by nurses. General practitioners were significantly more positive about their understanding of the signs and symptoms of depression and in using depression-screening tools. We observed that training seems to have a significant effect on reported practice. Practitioners who reported that they had recent training in the management of depression were significantly more accurate in their estimate of how common depression was in this population.

CONCLUSION

Depression may be underdiagnosed in this population because primary care practitioners, especially nurses, are not aware of how common the disorder is and lack competence in diagnosis. There is merit in developing and testing a brief training intervention to ensure competence in depression screening and treatment in post-myocardial infarction patients.

RELEVANCE TO CLINICAL PRACTICE

Diagnosing depression in post-myocardial infarction patients is perceived by nurses as complex but training in the management of depression is seen as helping practice.

Effort-reward imbalance at work and psychological distress: a validation study of post-myocardial infarction patients

OBJECTIVES

To examine whether the psychometric properties of the effort-reward imbalance (ERI) at work scales could be replicated with post-myocardial infarction (post-MI) patients and to measure the criterion validity through its association with psychological distress.

METHODS

A cross-sectional survey was conducted among 814 patients (739 men and 75 women) who had returned to work after their first MI and who were followed up by telephone at an average of 2.2 years after their baseline interview (1998-2000). The psychological demands scale of the Karasek Job Content Questionnaire was used to measure effort. Reward was measured with nine items from the original reward scale by Siegrist plus two proxy items. Exploratory and confirmatory factor analyses were used to test the theoretical structure of ERI. Using log-binomial regression models, we evaluated the association between ERI scales and psychological distress measured with the 14-item Psychiatric Symptom Index.

RESULTS

ERI scales and subscales demonstrated adequate internal consistencies. Exploratory factor analysis using oblique (promax) rotation yielded a three-factor solution with items representative of extrinsic effort (Factor 1) and reward subscales (Factors 2 and 3). Confirmatory factor analysis demonstrated a good fit with the data. The internal consistencies and discriminant validities of the ERI scales were satisfactory. Furthermore, effort, reward, and ERI ratio were significantly associated with psychological distress (adjusted prevalence ratio [PR] = 1.71, 95% confidence interval [CI] = 1.26-2.31; PR = 1.63, 95% CI = 1.16-2.29; and PR = 1.70, 95% CI = 1.17-2.47, respectively).

CONCLUSIONS

The psychometric properties of the ERI scales were generally reproduced among post-MI patients. The associations with psychological distress supported the criterion validity of the ERI scales in this population.

Effort-reward imbalance at work and recurrent coronary heart disease events: a 4-year prospective study of post-myocardial infarction patients

OBJECTIVE

Prospective studies have shown that effort-reward imbalance (ERI) at work is associated with the incidence of a first coronary heart disease (CHD) event. However, it is unknown whether ERI at work increases the risk of recurrent CHD events. The objective of this study was to determine whether ERI at work and its components (effort and reward) increase the risk of recurrent CHD in post-myocardial infarction (post-MI) workers.

METHODS

We carried out a prospective cohort study of 669 men and 69 women who returned to work after a first MI. ERI at work was assessed by telephone interview using validated scales of reward and psychological demands. The outcome was a composite of fatal CHD, nonfatal MI, and unstable angina. CHD risk factors were documented in medical files and by interview. The participants were followed up for a mean period of 4.0 years (1998-2005).

RESULTS

During the follow-up, 96 CHD events were documented. High ERI and low reward were associated with recurrent CHD (respective adjusted hazard ratios [HRs] = 1.75, 95% confidence interval [CI] = 0.99-3.08, and HR = 1.77, 95% CI = 1.16-2.71). There was a gender interaction showing stronger effects among women (respective adjusted HRs for high ERI and low reward: HR = 3.95, 95% CI = 0.93-16.79, and HR = 9.53, 95% CI = 1.15-78.68).

CONCLUSIONS

Post-MI workers holding jobs that involved ERI or low reward had increased risk of recurrent CHD.

Multiple pulmonary thromboembolism and severe depression

INTRODUCTION

Depression is known to have a bidirectional relationship with cardiovascular disease. Severe major depression associated with psychomotor retardation and immobility can be a risk factor for pulmonary embolism; the reverse pathway has not been reported.

CASE REPORT

We report a case of a 61-year-old man diagnosed with multiple pulmonary thromboembolism finally attributed to a right pulmonary artery intraluminal sarcoma. One month after the onset of presenting symptoms, the patient suddenly developed an episode of severe, melancholic depression, which remitted in six weeks under treatment with venlafaxine 225 mg/day.

DISCUSSION

Pathophysiological mechanisms implicated in the development of depression in our patient might resemble those postulated for post-myocardial infarction depression; in line with the "vascular depression" hypothesis, cerebral damage in the limbic circuitry caused by transient hypoxia, an inflammatory response or both may have contributed.

CONCLUSION

Multiple pulmonary thromboembolism seems to have a bidirectional relationship with major depression, in a similar way as myocardial infarction does.

Cardiovascular Diseases among Suiciders: A Population-Based Study in Northern Finland Population

Objective. Depression has been found to be an independent risk factor with cardiovascular diseases (CVDs) and also associated with increased mortality among these patients. Method. We used a comprehensive database of all suicides (n = 2, 283) committed in Northern Finland with information on all hospital-treated cardiovascular diseases and psychiatric disorders. Results. Coronary artery disease (CAD) had been present in 7.7% and other cardiovascular diseases (CVDs) in 11.6% of the suiciders. The likelihood of suicide for patients with hospital-treated CAD was estimated to be two-fold compared to the general population while likelihood for suicide was not elevated among those with other CVDs. Males with CAD and females with CAD or any CVD had been hospitalized significantly more often with depression compared to reference group. Conclusions. Suicidality among patients with cardiovascular diseases has been suggested to associate with depression. Psychiatric consultation is highly recommended in clinical practice for cardiac patients with depression or alcohol-related disorders.

Anxiety and depression after acute myocardial infarction: an 18-month follow-up study with repeated measures and comparison with a reference population

BACKGROUND

Recently, there has been substantial improvement in coronary care and a corresponding reduction in mortality after acute myocardial infarction (AMI). Some studies suggest that improved prognosis has led to reduced levels of anxiety and depression after AMI, in both the short and long term. The aims of this study were to assess symptoms of anxiety and depression from the acute event to 18 months following AMI, and to compare results with levels in the Norwegian reference population.

DESIGN AND METHODS

The progress of 288 patients was monitored using self-reports 3, 6, 12 and 18 months after AMI. Anxiety and depression were measured by the Hospital Anxiety and Depression Scale. Reference population data were obtained from the Nord-Trøndelag Health Study 1995-1997 (the HUNT 2 Study).

RESULTS

At baseline, 19.7 and 13.6% of AMI patients reported high levels of anxiety and depressive symptoms, respectively. At baseline, AMI patients were more anxious, but not more depressed, when compared with the reference population (P<0.001 and P = 0.092, respectively). After 3-18 months, AMI patients' levels of anxiety and depression were not higher than levels in the reference population. Anxiety and depression at baseline and after 3 months were the best predictors of anxiety and depression after 18 months, although complications, bed days and lifestyle improvement also significantly predicted depression after 18 months.

CONCLUSION

Initially, AMI patients had higher levels of anxiety, but not depressive symptoms. After 3-18 months, these patients were not more anxious or depressed than the Norwegian reference population.

Health outcomes related to early adolescent depression

PURPOSE

The aim of the present study was to examine whether early adolescent major depressive disorder was associated with negative health outcomes in young adulthood after controlling for depression at the time of follow-up. In addition, indicators of medical and social costs associated with these health consequences were measured.

METHODS

A total of 705 adolescents participating in a longitudinal study of children varying in risk for depression due to maternal depression were assessed for a history of depression at age 15 years, depressive disorders at age 20, and a variety of health outcomes at age 20.

RESULTS

Results showed that even after controlling for the effects of concurrent depression at age 20, early adolescent depression continued to be associated with poorer interviewer-rated health, poorer self-perceived general health, higher health care utilization and increased work impairment due to physical health, although not with limitations to physical functioning or the presence of chronic medical conditions.

CONCLUSIONS

Depression during early adolescence has consequences for health and associated costs during young adulthood. The implications of these findings for screening and treatment of adolescent depression are discussed.

Living alone, patient sex and mortality after acute myocardial infarction

BACKGROUND

Psychosocial factors, including social support, affect outcomes of cardiovascular disease, but can be difficult to measure. Whether these factors have different effects on mortality post-acute myocardial infarction (AMI) in men and women is not clear.

OBJECTIVE

To examine the association between living alone, a proxy for social support, and mortality postdischarge AMI and to explore whether this association is modified by patient sex.

DESIGN

Historical cohort study.

PARTICIPANTS/SETTING

All patients discharged with a primary diagnosis of AMI in a major urban center during the 1998-1999 fiscal year.

MEASUREMENTS

Patients' sociodemographic and clinical characteristics were obtained by standardized chart review and linked to vital statistics data through December 2001.

RESULTS

Of 880 patients, 164 (18.6%) were living alone at admission and they were significantly more likely to be older and female than those living with others. Living alone was independently associated with mortality [adjusted hazard ratio (HR) 1.6, 95% confidence interval (CI) 1.0-2.5], but interacted with patient sex. Men living alone had the highest mortality risk (adjusted HR 2.0, 95% CI 1.1-3.7), followed by women living alone (adjusted HR 1.2, 95% CI 0.7-2.2), men living with others (reference, HR 1.0), and women living with others (adjusted HR 0.9, 95% CI 0.5-1.5).

CONCLUSIONS

Living alone, an easily measured psychosocial factor, is associated with significantly increased longer-term mortality for men following AMI. Further prospective studies are needed to confirm the usefulness of living alone as a prognostic factor and to identify the potentially modifiable mechanisms underlying this increased risk.

Depression, constructive thinking and patient satisfaction in cardiac treatment adherence

Many patients fail to adhere to prescribed treatment regimens, particularly patients who are depressed. This study examined the link between depression and adherence among 92 patients undergoing post-operative cardiac rehabilitation. Self-reported adherence was measured in terms of both general recommendations and specific health behaviours. Greater depression was associated with general - but not specific - adherence, and this relationship was mediated by lower satisfaction with their doctor - patient interactions. The link between depression and patient satisfaction was itself mediated by less constructive thinking among patients. These results suggest that adherence among cardiac rehabilitation patients may be enhanced by addressing patients' cognitive coping, and by improving the quality of their doctor - patient interactions.

Post-MI psychiatric syndromes: six unanswered questions

Depression, anxiety, and other psychological variables following acute myocardial infarction (MI) have been the subject of intense study over the last two decades. Through selective literature review and editorial commentary, we address six vital, unanswered questions concerning these psychological variables and their impact on coronary outcome. The picture that emerges is complex. Despite all that has been learned about the nature, consequences, and management of post-MI depression and related disorders, there remain many open issues. First, the prevalence, phenomenology, medical impact, and method of diagnosis of post-MI depression and other psychiatric syndromes remain unclear. In addition, at least four pathophysiologic mechanisms have been proposed to explain the link between depression and cardiac disease, but evidence of causation remains elusive. There have been increasingly well-designed treatment studies of post-MI depression, but the optimal agents and timing of treatment have yet to be defined. Finally, few recent studies of post-MI anxiety have been conducted. To make further progress, large, multicenter trials that use optimized screening tools, obtain data at several time points, consider multiple psychosocial variables, and correct carefully for medical/cardiac severity are required.

The Hospital Anxiety and Depression Scale depression subscale, but not the Beck Depression Inventory-Fast Scale, identifies patients with acute coronary syndrome at elevated risk of 1-year mortality

OBJECTIVE

The objective of this study was to investigate the use of short-form depression scales in assessing 1-year mortality risk in a national sample of patients with acute coronary syndrome (ACS).

METHODS

Patients with ACS (N=598) completed either the Hospital Anxiety and Depression Scale depression subscale (HADS-D) or the Beck Depression Inventory-Fast Scale (BDI-FS). Their mortality status was assessed at 1 year.

RESULTS

Cox proportional hazards modeling showed that patients depressed at baseline (combining HADS-D and BDI-FS depressed cases) were more likely to die within 1 year [hazard ratio (HR)=2.8, 95% CI=1.4-5.7, P=.005], even when controlling for major medical and demographic variables (HR=4.1, 95% CI=1.6-10.3, P=.003). Scoring above the threshold on the HADS-D predicted mortality (HR=4.2, 95% CI=1.8-10.0, P=.001), but scoring above the threshold on the BDI-FS did not (HR=1.8, 95% CI=0.6-5.6, P=.291).

CONCLUSION

The HADS-D predicted increased risk of 1-year mortality in patients with ACS.

Depressive symptoms and treatment after acute coronary syndrome

BACKGROUND

There is limited data regarding the effects of depression treatment adequacy on the mental component of health-related quality of life in a post-acute coronary syndrome population.

METHODS

All patients diagnosed with an acute coronary syndrome and discharged from a university-affiliated hospital during a 3-year period were mailed a survey that included the SF-8, EQ-5D and other self-reported measures of disease and treatment (e.g. physical functioning, comorbidity, medication compliance and perceived cardiac severity). Patients were categorized based on self-report of depressive symptoms and antidepressant medication. Adjusted mean mental health-related quality of life scores were determined by least square mean analysis controlling for independent variables.

RESULTS

Of 1217 eligible patients, 490 (40.3%) responded. Respondents averaged 65.2 (+/-11.3) years of age, 71% male, 92% Caucasian, 64% with MI history, 17% had their most recent cardiac event within 6 months. No depressive symptoms and no depression treatment (without depression) were reported by 59.8%, 27.6% reported untreated depressive symptoms (untreated), 8.6% reported depressive symptoms and antidepressant medication (undertreated), and 4.1% reported no symptoms and antidepressant medication (adequately treated). Adjusted mean SF-8 Mental Component Summary scores were 52.8, 52.5, 42.8 and 40.2 for patients without depression, adequately treated, untreated and undertreated, respectively (p<0.0001 for all pairwise comparisons except for patients without depression vs. adequately treated and untreated vs. undertreated).

CONCLUSIONS

Depressive symptoms are common in patients diagnosed with acute coronary syndrome and appear to be related to lower mental health-related quality of life. These observations stress the importance of diagnosis and treatment of depression in this population.

Work-related outcomes after a myocardial infarction

STUDY OBJECTIVE

To evaluate work-related outcomes of patients at 7 months after a myocardial infarction and to identify patient, disease, and intervention characteristics associated with these outcomes.

DESIGN

Cross-sectional survey analysis.

SETTING

Large Midwestern academic health system.

PATIENTS

Eighty-nine patients with the discharge diagnosis of acute myocardial infarction during a 1-year index period.

INTERVENTION

Work performance questionnaire administered by telephone, and medical record review.

MEASUREMENTS AND MAIN RESULTS

Seven months after discharge, 232 patients were interviewed by telephone to determine work status before and after myocardial infarction, work-related outcomes (absenteeism and perceived work performance, assessed by the Work Performance Scale [WPS] of the Functional Status Questionnaire), and health-related quality of life. Univariate analyses were used to determine the association between individual characteristics and work-related outcomes. Of the 89 patients who had worked before the index myocardial infarction, 21 (23.6%) did not return to work. Variables associated with the outcome of not returning to work were past myocardial infarction (before the index myocardial infarction), coronary artery bypass graft surgery, heart failure, positive stress test, and low score on the Physical Component Summary (PCS-12) scale of the Short Form-12. Patients who did not return to work also tended to have more comorbidities and take more prescribed drugs than those who returned to work. Median WPS scores were higher for patients who had higher ejection fractions at discharge, had not experienced a myocardial infarction before the index event, underwent a percutaneous revascularization intervention at the time of hospitalization, and had not recently been absent from work. Workers reporting absences had lower PCS-12 scores than their counterparts or reported a rehospitalization before the survey.

CONCLUSION

Preexisting cardiac disease and poorer physical functioning were consistently related to worse work-related outcomes. This small study demonstrates the need for a larger, broader study that includes health beliefs, treatment, and other job and patient factors that may influence work-related outcomes.

Depression in the elderly. Tailoring medical therapy to their special needs

Depression is often overlooked as a clinical diagnosis in older patients because it is assumed to be a normal response to aging, physical losses, or other life events. However, medical intervention for depression is appropriate in this population, especially those patients with severe chronic disease. In this article, Dr Raj discusses the prevalence of depression in the elderly, the role of cognitive impairment, the risk factors for first onset in old age, typical presentations in this age-group, and the response to treatment.

Maternal depressive symptoms and adherence to therapy in inner-city children with asthma

CONTEXT

Little is known about how depressive symptoms in mothers affects illness management in inner-city children with asthma.

OBJECTIVE

Our goal was to determine how maternal depressive symptoms influence child medication adherence, impact of the child's asthma on the mother, and maternal attitudes and beliefs.

METHODS

Baseline and 6-month surveys were administered to 177 mothers of young minority children with asthma in inner-city Baltimore, MD and Washington, DC. Medication adherence, disruptiveness of asthma, and select attitudes toward illness and asthma therapy were measured. Six-month data (N = 158) were used to prospectively evaluate long-term symptom control and emergency department use. Independent variables included asthma morbidity, age, depressive symptoms, and other psychosocial data.

RESULTS

No difference in child asthma morbidity was observed between mothers high and low in depressive symptoms. However, mothers with high depressive symptoms reported significantly more problems with their child using inhalers properly (odds ratio [OR]: 5.0; 95% confidence interval [CI]: 1.3-18.9) and forgetting doses (OR: 4.2; 95% CI: 1.4-12.4). Depressive symptoms were also associated with greater emotional distress and interference with daily activities caused by the child's asthma, along with less confidence in asthma medications, ability to control asthma symptoms, and self-efficacy to cope with acute asthma episodes. In addition, depressed mothers reported less understanding about their child's medications and use (OR: 7.7; 95% CI: 1.7-35.9). Baseline asthma morbidity, maternal depression scores, and family income were independently associated with asthma symptoms 6 months later, whereas medication adherence was not predictive of subsequent asthma morbidity or emergency department use.

CONCLUSIONS

Maternal depressive symptoms were not associated with child asthma morbidity but were associated with a constellation of beliefs and attitudes that may significantly influence adherence to asthma medications and illness management. Identifying and addressing poor psychological adjustment in mothers is important when developing a child's asthma treatment and may facilitate parent-provider communication, medication adherence, and asthma management among inner-city children.

Screening for depression in medical care: pitfalls, alternatives, and revised priorities

Depression is a disorder seen commonly in general and specialty medical settings. Screening has been advocated as a means of ensuring that depressed patients are identified and receive appropriate treatment. Yet, recommendations for routine screening are frequently made without reference to empirical data demonstrating that it will have its intended effect. We examine the literature regarding screening in medical settings and suggest that screening in itself is unlikely to improve patient outcomes. Further, we identify costs to screening that are not readily apparent and that may negatively affect both patient outcomes and health-care delivery systems. We offer suggestions for how screening instruments might be used to improve the outcomes of depressed persons while minimizing negative effects on health care.

The significance of depression in older patients after myocardial infarction

OBJECTIVES

Depression is common in patients recovering from a myocardial infarction (MI) and is an independent risk factor for early mortality. Although most patients with MI are aged 65 and older, there is little information about post-MI depression in this age group. This study was performed to determine the significance of post-MI depression in individuals aged 65 and older.

DESIGN

A cohort study of hospitalized patients and a telephone interview 4 months later.

SETTING

A university-affiliated teaching hospital in Baltimore, Maryland.

PARTICIPANTS

Patients admitted with an acute MI (N = 284), 153 (53.9%) of whom were aged 65 and older; 101 of these (66.0%) completed the 4-month follow-up interview.

MEASUREMENTS

Patients were interviewed 3 to 5 days post-MI to evaluate for the presence of symptoms of depression (a score of > or =10 on the Beck Depression Inventory and for the presence of mood disorder using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised, Third Edition. Survivors were then interviewed by telephone 4 months after discharge to assess adherence to recommendations to reduce cardiac risk by using the Medical Outcomes Study Specific Adherence Scale. Comorbidities and prescribed medications were determined by review of hospital charts and computerized medical records.

RESULTS

Older patients with depression were more likely to die in the first 4 months than older patients without depression (26.5% vs 7.3%, P =.002). Older patients with depression were also more likely than older patients without depression to have had a prior MI (54.3% vs 31.0%, P =.012) and were somewhat more likely to have chronic lung disease (28.6% vs 14.4%, P =.054), a non-Q wave MI (88.6% vs 72.8%, P =.054), diabetes mellitus (48.6% vs 32.5%, P =.082), and a left ventricular ejection fraction below 35% (50.0% vs 33.3%, P =.084). Compared with older patients without depression, depressed older patients were also marginally less likely at discharge to be prescribed a beta-blocker (74.3% vs 86.3%, P =.092) or a lipid-lowering agent (31.4% vs 49.6%, P =.059). Depressed patients aged 65 and older were less likely to adhere to a low-fat/low-cholesterol diet (P <.01) or a diabetic diet (P <.01), or to be taking prescribed medications (P <.05), exercising regularly (P <.01), reducing stress (P <.01), and increasing social support (P <.01).

CONCLUSION

Depression is prevalent after an acute MI in patients aged 65 and older. Older post-MI patients with depression have more comorbidities than older patients without depression and have almost four times the risk of dying within the first 4 months after discharge. Although this increased risk is likely to be related to many factors, our data suggest that sicker patients who are older and depressed may less often be prescribed medications known to reduce post-MI mortality and may also have greater difficulty following recommendations to reduce cardiac risk than their counterparts without depression. Efforts to improve adherence to post-MI treatment guidelines and to enhance patient compliance may improve prognosis in this high-risk group.