Association of physical versus affective depressive symptoms with cardiac event-free survival in patients with heart failure

Relationship Between Resilience and Perceived Control After Acute Coronary Syndrome: A Prospective Study

BACKGROUND

Patients with acute coronary syndrome report poor health-related quality of life and decreased levels of perceived control. Perceived control is a person's belief that they can cope with negative events. Resilience is an adaptation that gives people the capacity to recover from difficult situations, and higher levels of resilience may impact recovery after an acute event.

OBJECTIVE

The aim of this study was to analyze the relationship between resilience, perceived control, and health outcomes of patients hospitalized with acute coronary syndrome within 6 months of discharge.

METHODS

Data were collected prospectively from adult patients hospitalized with acute coronary syndrome in 3 university hospitals in the Tokyo Metropolitan area, Japan. All data were collected between December 2015 and December 2019. The Sukemune-Hiew Resilience Test (part 1) was used to measure resilience, which includes 3 domains of social support, self-efficacy, and sociality. The Control Attitudes Scale-Revised was used to measure perceived control. Linear regression and path analysis were used to statistically analyze the relationship among variables.

RESULTS

Higher resilience, especially self-efficacy, was associated with higher perceived control during admission. Higher resilience, especially social support, during admission was associated with perceived control at 6 months after adjusting for income and education. Higher resilience during admission was associated with better perceived control at 3 months, which was associated with better health outcomes at 6 months. Higher income and lower depression were related to higher resilience.

CONCLUSIONS

Nurses should make sure patients with depression, low income, and low social support are connected with appropriate treatment and social support resources.

Factors related to perceived control and health-related quality of life of patients after acute coronary syndrome during admission and after discharge

Aim

To explore the relationship between demographic factors, acute coronary syndrome‐related factors, perceived control and health‐related quality of life during admission, 3 months and 6 months after discharge, in patients with acute coronary syndrome.

Methods

Participants were recruited for this longitudinal study after admission for acute coronary syndrome in three university hospitals in the Tokyo metropolitan area, Japan. Self‐administered questionnaires included demographic data, perceived control, health‐related quality of life, acute coronary syndrome symptoms, fatigue, depression and anxiety.

Results

Participants (N = 137) had an average age of 62.8 (SD 11.6) years and 80.3% were male. As a result of Path analysis, higher perceived control (β = 0.258, p = .001), lower anxiety (β = −0.226, p = .009) and lower fatigue (β = −0.231, p = .010), were significantly related to better health‐related quality of life (General health). Only annual income was significantly related to perceived control (β = 0.187, p = .029). Eighty‐two (59.9%) participants at 3 months and 54 (39.4%) participants at 6 months completed the questionnaires. Perceived control (F = 7.074, p = .001) and General health (χ² = 10.22, p = .006) significantly increased over the 6 months. Perceived control during admission was significantly related with health‐related quality of life at 3 months. Perceived control at 3 months was significantly related with health‐related quality of life at 6 months.

Conclusion

Perceived control was an important factor for health‐related quality of life of the Japanese patients with acute coronary syndrome. It is necessary to investigate whether nursing interventions to enhance perceived control lead to improvement of health‐related quality of life.

The Association Between Depressive Symptoms and N-Terminal Pro-B-Type Natriuretic Peptide With Functional Status in Patients With Heart Failure

BACKGROUND

N-terminal pro-B-type natriuretic peptide (NT-proBNP) and depressive symptoms are each associated with functional status in patients with heart failure (HF), but their association together with functional status has not been examined.

OBJECTIVE

The aim of this study was to determine whether functional status scores differ as a function of depressive symptoms and NT-proBNP levels considered together.

METHODS

We studied 284 patients with HF who were divided into 4 groups based on the median split of NT-proBNP levels and cut point for depressive symptoms (Beck Depression Inventory ≥ 14): (1) low NT-proBNP of 562.5 pg/mL or less without depressive symptoms, (2) low NT-proBNP of 562.5 pg/mL or less with depressive symptoms, (3) high NT-proBNP of greater than 562.5 pg/mL without depressive symptoms, and (4) high NT-proBNP of greater than 562.5 pg/mL with depressive symptoms. The Duke Activity Status Index was used to assess functional status.

RESULTS

Nonlinear regression demonstrated that patients without depressive symptoms were more than twice as likely to have higher (better) functional status scores than patients with depressive symptoms regardless of NT-proBNP levels after controlling for age, gender, prescribed antidepressants, and body mass index. Functional status levels of patients with low NT-proBNP did not differ from those with high NT-proBNP in the presence of depressive symptoms.

CONCLUSION

When examined together, depressive symptoms rather than NT-proBNP levels predicted functional status.

CLINICAL IMPLICATIONS

Adequate treatment of depressive symptoms may lead to better functional status regardless of HF severity.

Neuroimmune Mechanisms of Depression in Adults with Heart Failure

Heart failure (HF) is a major and costly public health concern, and its prognosis is grim-with high hospitalization and mortality rates. HF affects millions of individuals across the world, and this condition is expected to become "the epidemic" of the twenty-first century (Jessup et al., 2016). It is well documented that individuals with HF experience disproportionately high rates of depression and that those who are depressed have worse clinical outcomes than their nondepressed counterparts. The purpose of this chapter is to introduce the reader to the study of depression in HF, and how psychoneuroimmunologic principles have been applied to further elucidate mechanisms (i.e., neurohormonal and cytokine activation) linking these comorbid disorders.

Two-Step Screening for Depressive Symptoms and Prediction of Mortality in Patients With Heart Failure

BACKGROUND

Comorbid depression in patients with heart failure is associated with increased risk for death. In order to effectively identify depressed patients with cardiac disease, the American Heart Association suggests a 2-step screening method: administering the 2-item Patient Health Questionnaire first and then the 9-item Patient Health Questionnaire. However, whether the 2-step method is better for predicting poor prognosis in heart failure than is either the 2-item or the 9-item tool alone is not known.

OBJECTIVE

To determine whether the 2-step method is better than either the 2-item or the 9-item questionnaire alone for predicting all-cause mortality in heart failure.

METHODS

During a 2-year period, 562 patients with heart failure were assessed for depression by using the 2-step method. With the 2-step method, results are considered positive if patients endorse either depressed mood or anhedonia on the 2-item screen and have scores of 10 or higher on the 9-item screen.

RESULTS

Screening results with the 2-step method were not associated with all-cause mortality. Patients with scores positive for depression on either the 2-item or 9-item screen alone had 53% and 60% greater risk, respectively, for all-cause death than did patients with scores negative for depression after adjustments for covariates (hazard ratio, 1.530; 95% CI, 1.029-2.274 for the 2-item screen; hazard ratio, 1.603; 95% CI, 1.079-2.383 for the 9-item screen).

CONCLUSIONS

The 2-step method has no clear advantages compared with the 2-item screen alone or the 9-item screen alone for predicting adverse prognostic effects of depressive symptoms in heart failure.

Differing Effects of Fatigue and Depression on Hospitalizations in Men and Women With Heart Failure

BACKGROUND

In patients with heart failure, worsening of signs and symptoms and depression can affect hospitalization and also each other, resulting in synergistic effects on hospitalizations. A patient's sex may play a role in these effects.

OBJECTIVES

To determine the effects of fatigue and depression on all-cause hospitalization rates in the total sample and in subgroups of men and women.

METHODS

A secondary analysis was done of data collected January 1, 2010, through December 31, 2012 (N = 582; mean age, 63.2 years [SD, 14.4]). Data were collected on fatigue, depression, sample characteristics, vital signs, results of laboratory tests, medications, and frequency of hospitalization. Patients were categorized into 4 groups on the basis of the International Classification of Diseases, Ninth Revision: no fatigue or depression, fatigue only, depression only, and both fatigue and depression. General linear regression was used to analyze the data.

RESULTS

In both the total sample and the subgroups, the number of hospitalizations in patients with both fatigue and depression was greater than the number in patients without either symptom. Among women, the number of hospitalizations in the fatigue-only group and in the depression-only group was greater than that in the group with neither symptom. In men, the number of hospitalizations in the fatigue-only group was greater than that in the group without either symptom.

CONCLUSION

Fatigue and depression do not have synergistic effects on hospitalization, but men and women differ in the effects of these symptoms on hospitalization.

Cognitive Function in Heart Failure Is Associated With Nonsomatic Symptoms of Depression But Not Somatic Symptoms

BACKGROUND

Patients with heart failure (HF) have high rates of cognitive impairment and depressive symptoms. Depressive symptoms have been associated with greater cognitive impairments in HF; however, it is not known whether particular clusters of depressive symptoms are more detrimental to cognition than others.

OBJECTIVE

The aim of this study was to identify whether somatic and/or nonsomatic depressive symptom clusters were associated with cognitive function in persons with HF.

METHODS

Participants were 326 HF patients (40.5% women, 26.7% non-white race-ethnicity, aged 68.6 ± 9.7 years). Depressive symptoms were measured using a depression questionnaire commonly used in medical populations: the Patient Health Questionnaire-9. Somatic and nonsomatic subscale scores were created using previous factor analytic results. A neuropsychological battery tested attention, executive function, and memory. Composites were created using averages of age-adjusted scaled scores. Regressions adjusting for demographic and clinical factors were conducted.

RESULTS

Regressions revealed that Patient Health Questionnaire-9 total was associated with attention (β = -.14, P = .008) and executive function (β = -.17, P = .001). When analyzed separately, the nonsomatic subscale, but not the somatic symptoms subscale (P values ≥ .092), was associated with attention scores (β = -.15, P = .004) and memory (β = -.11, P = .044). Both nonsomatic (β = -.18, P < .001) and somatic (β = -.11, P = .048) symptoms were related to executive function. When included together, only the nonsomatic symptom cluster was associated with attention (β = -.15, P = .020) and executive function (β = -.19, P = .003).

CONCLUSIONS

Greater overall depressive symptom severity was associated with poorer performance on multiple cognitive domains, an effect driven primarily by the nonsomatic symptoms of depression.

CLINICAL IMPLICATIONS

These findings suggest that screening explicitly for nonsomatic depressive symptoms may be warranted and that the mechanisms underlying the depression-cognitive function relationship in HF are not solely related to sleep or appetite disturbance. Thus, interventions that target patients' somatic symptoms only (eg, poor appetite or fatigue) may not yield maximum cognitive benefit compared with a comprehensive treatment that targets depressed mood, anhedonia, and other nonsomatic symptoms.

Acute coronary syndrome-associated depression: the salience of a sickness response analogy?

Depression emerging in conjunction with acute coronary syndrome (ACS) is thought to constitute a distinct high-risk phenotype with inflammatory determinants. This review critically examines the notion put forward in the literature that ACS-associated depression constitutes a meaningful subtype that is qualitatively different from depressive syndromes observed in psychiatric patients; and evaluates the salience of an analogy to the acute sickness response to infection or injury as an explanatory model. Specific features differentiating ACS-associated depression from other phenotypes are discussed, including differences in depression symptom profiles, timing of the depressive episode in relation to ACS, severity of the cardiac event, and associated immune activation. While an acute sickness response analogy offers a plausible conceptual framework, concrete evidence is lacking for inflammatory activity as the triggering mechanism. It is likely that ACS-associated depression encompasses several causative scenarios.

Changes in Depressive Symptoms and Mortality in Patients With Heart Failure: Effects of Cognitive-Affective and Somatic Symptoms

OBJECTIVES

Depression is an independent predictor of adverse outcomes in patients with heart failure (HF). However, the effect of changes in cognitive-affective and somatic symptoms on mortality of HF patients is not known. The purpose of this study was to examine whether changes in cognitive-affective and somatic depressive symptoms over time were associated with mortality in HF.

METHODS

In this secondary analysis of data from the Rural Education to Improve Outcomes in Heart Failure clinical trial, we analyzed data from 457 HF patients (39% female, mean [standard deviation] age = 65.6 [12.8] years) who survived at least 1 year and repeated the Patient Health Questionnaire at 1 year. Cognitive-affective and somatic depression scores were calculated, respectively, based on published Patient Health Questionnaire factor models. Using Cox proportional hazards regression analyses, we evaluated the effect of changes in cognitive-affective and somatic symptoms from baseline to 1 year on cardiac and all-cause deaths.

RESULTS

Controlling for baseline depression scores and other patient characteristics, the change in somatic symptoms was associated with increased risk of cardiac death during the subsequent 1-year period (hazard ratio = 1.24, 95% confidence interval = 1.07-1.44, p = .005), but the change in cognitive-affective symptoms was not (hazard ratio = 0.94, 95% confidence interval = 0.81-1.08, p = .38). Similar results were found for all-cause mortality.

CONCLUSIONS

Worsening somatic depressive symptoms, not cognitive-affective symptoms, are independently associated with increased mortality of HF patients. The findings suggest that routine and ongoing assessment of somatic depressive symptoms in HF patients may help clinicians identify patients at increased risk for adverse outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00415545.

Depressive symptoms, health-related quality of life, and cardiac event-free survival in patients with heart failure: a mediation analysis

PURPOSE

Health-related quality of life (HRQOL) and depressive symptoms both are associated with an adverse prognosis in heart failure (HF), although their associations with outcomes have been examined only in isolation. Therefore, it is unknown how HRQOL and depressive symptoms might interact in their associations with outcomes. The present study was conducted to determine whether the association between HRQOL and cardiac event-free survival is mediated by depressive symptoms in HF patients given that depressive symptoms are associated strongly with HRQOL.

METHODS

A total of 209 HF patients (61 ± 11 years, 24 % female, 49 % NYHA III/IV) participated. The Minnesota Living with HF Questionnaire and the Patient Health Questionnaire-9 were used to measure HRQOL and depressive symptoms, respectively. Patients were followed for a median of 357 days to determine cardiac event-free survival.

RESULTS

In Cox regression analysis, HRQOL [hazard ratio (HR) 1.013; 95 % confidence interval (CI) 1.001-1.026] and depressive symptoms (HR 1.075; 95 % CI 1.025-1.127) predicted cardiac event-free survival separately, controlling for demographic and clinical variables. HRQOL independently explained 38.7 % of the variance in depressive symptoms (p < 0.05; standardized β = 0.695) in a multiple regression. When HRQOL and depressive symptoms were entered in the model simultaneously, only depressive symptoms independently predicted cardiac event-free survival (HR 1.068; 95 % CI 1.001-1.139), demonstrating a mediation effect of depressive symptoms.

CONCLUSIONS

Depressive symptoms mediated the relationship between HRQOL and cardiac event-free survival. Interventions targeting HRQOL to enhance patient outcomes must also address patient depressive symptoms to be fully efficacious.

Associations between depression and anxiety symptoms and retinal vessel caliber in adolescents and young adults

OBJECTIVE

Previous longitudinal studies suggest that depression and anxiety are associated with risk for cardiovascular disease. The aim of the present study was to test whether an association between depression and anxiety symptoms and retinal vessel caliber, an indicator of subclinical cardiovascular risk, is apparent as early as adolescence and young adulthood.

METHODS

Participants were 865 adolescents and young adults who participated in the Brisbane Longitudinal Twin Study and the Twin Eye Study in Tasmania. Participants completed an assessment of depression/anxiety symptoms (the Somatic and Psychological Health Report) when they were 16.5 years old (mean age), and they underwent retinal imaging, on average, 2.5 years later (range, 2 years before to 7 years after the depression/anxiety assessment). Retinal vessel caliber was assessed using computer software.

RESULTS

Depression and anxiety symptoms were associated with wider retinal arteriolar caliber in this sample of adolescents and young adults (β = 0.09, p = .016), even after adjusting for other cardiovascular risk factors (β = 0.08, p = .025). Multiple regression analyses revealed that affective symptoms of depression/anxiety were associated with retinal vessel caliber independently of somatic symptoms.

CONCLUSIONS

Depression and anxiety symptoms are associated with measurable signs in the retinal microvasculature in early life, suggesting that pathological microvascular mechanisms linking depression/anxiety and cardiovascular disease may be operative from a young age.

Antidepressants do not improve event-free survival in patients with heart failure when depressive symptoms remain

OBJECTIVE

The purpose of this secondary data analysis was to compare event-free survival among four groups of patients with heart failure (HF) that were stratified by presence of depressive symptoms and antidepressants.

METHODS

We analyzed data from 209 outpatients (30.6% female, 62 ± 12 years, 54% NYHA Class III/IV) enrolled in a multicenter HF registry who had data on depressive symptoms, antidepressant use, and cardiac rehospitalization and death outcomes during 1 year follow up. Depressive symptoms were assessed using the Patient Health Questionnaire-9.

RESULTS

Depressive symptoms, not antidepressant therapy, predicted event-free survival (HR = 2.4, 95% CI = 1.2-4.6, p = .009). Depressed patients without antidepressants had 4.1 times higher risk of death and hospitalization than non-depressed patients on antidepressant (95% CI = 1.2-13.9, p = .022) after controlling for age, gender, NYHA class, body mass index, diabetes, medication of ACEI and beta-blockers.

CONCLUSION

Antidepressant use was not a predictor of event-free survival outcomes when patients still reported depressive symptoms. Ongoing assessment of patients on antidepressants is needed to assure adequate treatment.

Differential predictive value of depressive versus anxiety symptoms in the prediction of 8-year mortality after acute coronary syndrome

OBJECTIVE

Both depression and anxiety have been associated with poor prognosis in patients with acute coronary syndrome (ACS). However, certain symptoms and how they are measured may be more important than others. We investigated three different scales to determine their predictive validity.

METHODS

Patients with ACS (N = 598) completed either the Hospital Anxiety and Depression Scales (HADS-A, HADS-D; n = 316) or the Beck Depression Inventory-Fast Screen (n = 282). Their all-cause mortality status was assessed at 8 years.

RESULTS

During follow-up, 20% (121/598) of participants died. Cox proportional hazards modeling showed that the HADS-D was predictive of mortality (hazard ratio [HR] = 1.11, 95% confidence interval [CI] = 1.04-1.19), and this association remained significant after adjustment for major clinical/demographic factors, whereas the HADS-A (HR = 0.96, 95% CI = 0.85-1.09) and the Beck Depression Inventory-Fast Screen (HR = 0.99, 95% CI = 0.91-1.08) were not. The following depression items from the HADS-D predicted mortality: "I still enjoy the things I used to enjoy" (HR = 1.38, 95% CI = 1.05-1.82), "I can laugh and see the funny side of things" (HR = 1.48, 95% CI = 1.11-1.96), "I feel as if I am slowed down" (HR = 1.66, 95% CI = 1.24-2.22), and "I look forward with enjoyment to things" (HR = 1.36, 95% CI = 1.08-1.72).

CONCLUSIONS

Depressive symptoms related to lack of enjoyment or pleasure and physical or cognitive slowing, as measured by the HADS-D, predicted all-cause mortality at 8 years ACS patients, whereas other depressive and anxiety symptoms did not. Whether symptoms of distress predict prognosis in ACS seems to be dependent on the measures and items used.