Depression vulnerabilities in patients with different levels of depressive symptoms after acute coronary syndromes

Estimating the prevalence of depression in people with acute coronary syndromes: A systematic review and meta-analysis

BACKGROUND

The epidemic of acute coronary syndromes (ACS) poses a great challenge to depression. However, the prevalence of depression among ACS patients has not been fully determined. This meta-analysis aimed to provide an estimation of the global prevalence of depression among ACS patients (ACS depression).

METHODS

Online databases including PubMed, Cochrane Library, Web of Science, and Scopus were searched for all relevant studies that reported the prevalence of ACS depression through March 2023. Pooled prevalence of ACS depression with 95% confidence interval (CI) was estimated by the random-effect model. All statistical analyses were performed using comprehensive meta-analysis software. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (identifier CRD42023409338).

RESULTS

A total of 28 studies (17 cohort studies, 9 cross-sectional studies, and 2 case-control studies) were included. The overall pooled prevalence of depression in ACS, derived from 28 studies, was 28.5% (95% CI: 0.28-0.29, P = .000, I2 = 99%). 21 included studies showed a prevalence of 20.3% (95% CI: 0.20-0.21, P = .000, I2 = 96%) in men, and the prevalence in women was 13.6% (95% CI: 0.13-0.14, P = .000, I2 = 95%). Subgroup analysis showed the lowest prevalence in Europe (20.7%, 95% CI: 0.20-0.22, P = .000, I2 = 98%); On different diagnostic criteria, the diagnostic and statistical manual of mental disorders (DSM-IV) (36.8%, 95% CI: 0.35-0.38, P = .000, I2 = 96%) has the highest prevalence. In terms of end year of data collection, the prevalence of ACS depression was lower for studies that ended data collection after 2012 (25.7%, 95% CI: 0.25-0.27, P = .000, I2 = 99%) than in studies before 2012 (30%, 95% CI: 0.29-0.31, P = .000, I2 = 98%).

CONCLUSION SUBSECTIONS

This systematic review and meta-analysis suggest high global prevalence of depression among ACS patients, underlining the necessity of more preventive interventions among ACS patients especially in Asian and North American regions.

AMPAkines have site-specific analgesic effects in the cortex

Different brain areas have distinct roles in the processing and regulation of pain and thus may form specific pharmacological targets. Prior research has shown that AMPAkines, a class of drugs that increase glutamate signaling, can enhance descending inhibition from the prefrontal cortex (PFC) and nucleus accumbens. On the other hand, activation of neurons in the anterior cingulate cortex (ACC) is known to produce the aversive component of pain. The impact of AMPAkines on ACC, however, is not known. We found that direct delivery of CX516, a well-known AMPAkine, into the ACC had no effect on the aversive response to pain in rats. Furthermore, AMPAkines did not modulate the nociceptive response of ACC neurons. In contrast, AMPAkine delivery into the prelimbic region of the prefrontal cortex (PL) reduced pain aversion. These results indicate that the analgesic effects of AMPAkines in the cortex are likely mediated by the PFC but not the ACC.

Risk Factors for Post-Acute Coronary Syndrome Depression: A Meta-analysis of Observational Studies

BACKGROUND

The incidence of depression is very common among patients with post-acute coronary syndrome (ACS) and leads to adverse outcomes.

AIMS

The aim of this meta-analysis was to detect risk factors for depression among patients with ACS and to provide clinical evidence for its prevention.

METHODS

The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline to search the PubMed, Web of Science, EMBASE, and EBSCO databases from January 1996 to March 2018. Data that met the inclusion criteria were extracted to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the risk factors of post-ACS depression.

RESULTS

A total of 30 articles met the inclusion criteria, and 25 risk factors were found to be associated with depression. The top 5 risk factors are as follows: antidepression treatment (OR, 4.25; 95% CI, 3.41-5.31), housewife status (OR, 4.17; 95% CI, 1.83-9.53), history of depressive disorders (OR, 3.52; 95% CI, 2.69-4.61), widow status (OR, 2.34; 95% CI, 1.05-5.21), and history of congestive heart failure (OR, 2.03; 95% CI, 1.04-3.97). The authors also found that a married status, high education level, and employment are protective factors.

CONCLUSION

Clinical personnel should be alerted with regard to the high risk factors of depression, including female gender, low education level, unmarried status, living alone, unemployed status, unhealthy lifestyle, and complications such as cardiovascular, respiratory, and metabolic diseases. In particular, staff should pay attention to a history of previous depression, be concerned with the psychological condition of the patient, and monitor and perform early interventions to reduce the incidence of depression.

AMPAkines Target the Nucleus Accumbens to Relieve Postoperative Pain

BACKGROUND

AMPAkines augment the function of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors in the brain to increase excitatory outputs. These drugs are known to relieve persistent pain. However, their role in acute pain is unknown. Furthermore, a specific molecular and anatomic target for these novel analgesics remains elusive.

METHODS

The authors studied the analgesic role of an AMPAkine, CX546, in a rat paw incision (PI) model of acute postoperative pain. The authors measured the effect of AMPAkines on sensory and depressive symptoms of pain using mechanical hypersensitivity and forced swim tests. The authors asked whether AMPA receptors in the nucleus accumbens (NAc), a key node in the brain's reward and pain circuitry, can be a target for AMPAkine analgesia.

RESULTS

Systemic administration of CX546 (n = 13), compared with control (n = 13), reduced mechanical hypersensitivity (50% withdrawal threshold of 6.05 ± 1.30 g [mean ± SEM] vs. 0.62 ± 0.13 g), and it reduced depressive features of pain by decreasing immobility on the forced swim test in PI-treated rats (89.0 ± 15.5 vs. 156.7 ± 18.5 s). Meanwhile, CX546 delivered locally into the NAc provided pain-relieving effects in both PI (50% withdrawal threshold of 6.81 ± 1.91 vs. 0.50 ± 0.03 g; control, n = 6; CX546, n = 8) and persistent postoperative pain (spared nerve injury) models (50% withdrawal threshold of 3.85 ± 1.23 vs. 0.45 ± 0.00 g; control, n = 7; CX546, n = 11). Blocking AMPA receptors in the NAc with 2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo[f]quinoxaline-2,3-dione inhibited these pain-relieving effects (50% withdrawal threshold of 7.18 ± 1.52 vs. 1.59 ± 0.66 g; n = 8 for PI groups; 10.70 ± 3.45 vs. 1.39 ± 0.88 g; n = 4 for spared nerve injury groups).

CONCLUSIONS

AMPAkines relieve postoperative pain by acting through AMPA receptors in the NAc.

Depression following acute coronary syndrome: a Danish nationwide study of potential risk factors

PURPOSE

Depression is common following acute coronary syndrome, and thus, it is important to provide knowledge to improve prevention and detection of depression in this patient group. The objectives of this study were to examine: (1) whether indicators of stressors and coping resources were risk factors for developing depression early and later after an acute coronary syndrome and (2) whether prior depression modified these associations.

METHODS

The study was a register-based cohort study, which includes 87,118 patients with a first time diagnosis of acute coronary syndrome during the period 2001-2009 in Denmark. Cox regression models were used to analyse hazard ratios (HRs) for depression.

RESULTS

1.5 and 9.5 % develop early (≤30 days) and later (31 days-2 years) depression after the acute coronary syndrome. Among all patients with depression, 69.2 % had first onset depression, while 30.8 % developed a recurrent depression. Most patient characteristics (demographic factors, socioeconomic status, psychosocial factors, health-related behavioural factors, somatic comorbidities, and severity of acute coronary syndrome) were significantly associated with increased HRs for both early and later depressions. Prior depression modified most of these associations in such a way that the association was attenuated in patients with a prior depression.

CONCLUSION

Our results indicate that first time and recurrent depression following acute coronary syndrome have different risk profiles. This is important knowledge that may be used to focus future interventions for prevention and detection.

Relation between Major and Minor Depression and Heart Rate, Heart-Rate Variability, and Clinical Characteristics of Patients with Acute Coronary Syndrome

This study examined the prevalence of major and minor depression in patients with acute coronary syndrome and their relation with heart rate and heart-rate variability, and clinical characteristics. The study group included 297 patients, 200 men and 97 women, between ages of 21 and 70 years ( M age = 57.5 ± 9.6), who were admitted to a coronary care unit with acute coronary syndrome and survived to discharge from the hospital. Major and minor depression were diagnosed using DSM-IV. There were 44.1% patients with acute coronary syndrome without depression, 29.3% with minor depression, and 26.6% with major depression. The prevalence of minor and major depression was more elevated in patients with non-ST-segment elevation myocardial infarction and unstable angina than in patients with ST-segment elevation myocardial infarction. Ventricular fibrillation and atrial fibrillation were more common in patients with major and minor depression than in patients without depression. The 24-hr. duration of heart-beat intervals and heart-rate variability were significantly lower in patients with major and minor depression than in patients without depression. This study implies that clinical depression was significantly comorbid with the acute coronary syndrome and was related to hypertension, diabetes mellitus, age, sex, type of acute coronary syndrome, left ventricular failure, higher heart rate, and lower heart-rate variability.

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.

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.

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.

The psychosocial context impacts medication adherence after acute coronary syndrome

BACKGROUND

Depression is associated with poor adherence to medications and worse prognosis in patients with acute coronary syndrome (ACS).

PURPOSE

To determine whether cognitive, behavioral, and/or psychosocial vulnerabilities for depression explain the association between depression and medication adherence among ACS patients.

METHODS

One hundred sixty-nine ACS patients who agreed to have their aspirin adherence measured using an electronic pill bottle for 3 months were enrolled within 1 week of hospitalization. Linear regression was used to determine whether depression vulnerabilities predicted aspirin adherence after adjustment for depressive symptoms, demographics, and comorbidity.

RESULTS

Of the depression vulnerabilities, only role transitions (beta = -3.32; P = 0.02) and interpersonal conflict (beta -3.78; P = 0.03) predicted poor adherence. Depression vulnerabilities did not mediate the association between depressive symptoms and medication adherence.

CONCLUSIONS

Key elements of the psychosocial context preceding the ACS including major role transitions and conflict with close contacts place ACS patients at increased risk for poor medication adherence independent of depressive symptoms.

The cardiac anxiety questionnaire: cross-validation among cardiac inpatients

OBJECTIVE

General anxiety symptoms are common in patients with cardiac disease and considered to have an adverse effect on cardiac prognosis. The role of specific cardiac anxiety, however, is still unknown. The aim of this study is to examine the factor structure, reliability, and validity of the Dutch version of the Cardiac Anxiety Questionnaire (CAQ), which was specifically designed to assess heart focused anxiety.

METHODS

Two hundred thirty-seven patients admitted for an acute coronary syndrome (ACS) and a control group of 49 patients admitted for an exacerbation of rheumatoid arthritis (RA) completed the CAQ, the Agoraphobic Cognitions Questionnaire, Mobility Inventory, Beck Depression Inventory, Beck Anxiety Inventory, and the State-Trait Anxiety Inventory.

RESULTS

Although the original three-factor solution (fear, avoidance, and attention) was acceptable (model fit parameters: CFI = 0.89 and TLI = 0.87), our data were best explained by a four-factor model including safety seeking behaviors. Internal consistency and test-retest reliability were good. The CAQ had moderate correlations with the other anxiety and depression questionnaires. Recently admitted ACS patients had significantly higher scores than RA patients, even after controlling for general anxiety and depressive symptoms (p < 0.001).

CONCLUSION

The CAQ is a reliable and valid instrument to assess cardiac anxiety in patients hospitalized with ACS. These results enable longitudinal studies to examine the relationship of heart-focused anxiety with cardiac prognosis and to evaluate interventions specifically targeted at anxiety in cardiac patients.

Psychosocial vulnerabilities to depression after acute coronary syndrome: the pivotal role of rumination in predicting and maintaining depression

Psychosocial vulnerabilities may predispose individuals to develop depression after a significant life stressor, such as an acute coronary syndrome (ACS). The aims are (1) to examine the interrelations among vulnerabilities, and their relation with changes in depressive symptoms 3 months after ACS, (2) to prospectively assess whether rumination interacts with other vulnerabilities as a predictor of later depressive symptoms, and (3) to examine how these relations differ between post-ACS patients who meet diagnostic criteria for depression at baseline versus patients who do not. Within 1 week after hospitalization for ACS, and again after 3 months, 387 patients (41% female, 79.6% white, mean age 61) completed the Beck Depression Inventory (BDI) and measures of vulnerabilities (lack of pleasant events, dysfunctional attitudes, role transitions, poor dyadic adjustment). Exclusion criteria were a BDI score of 5-9, terminal illness, active substance abuse, cognitive impairment, and unavailability for follow-up visits. We used hierarchical regression modeling cross-sectionally and longitudinally. Controlling for baseline (in-hospital) depression and cardiovascular disease severity, vulnerabilities significantly predicted 3 month depression severity. Rumination independently predicted increased depression severity, above other vulnerabilities (β = 0.75, p < 0.001), and also interacted with poor dyadic adjustment (β = 0.32, p < 0.001) to amplify depression severity. Among initially non-depressed patients, the effects of vulnerabilities were amplified by rumination. In contrast, in patients who were already depressed at baseline, there was a direct effect of rumination above vulnerabilities on depression severity. Although all vulnerabilities predict depression 3 months after an ACS event has occurred rumination plays a key role to amplify the impact of vulnerabilities on depression among the initially non-depressed, and maintains depression among those who are already depressed.

Depression in coronary artery disease

INTRODUCTION

Depression is one of the Common psychological disorders. From the cognitive point of view, the unhealthy attitudes increase the severity of the depression. The aim of this study was to investigate depression and unhealthy attitudes in coronary patients hospitalized at Tabriz Shahid Madani Heart Center.

METHODS

One hundred twenty eight hospitalized patients having myocardial Infarctions were studied regarding unhealthy attitudes, severity of depression and demographic data.

RESULTS

The study showed a significant relation between unhealthy attitudes, BDI (Beck Depression Inventory) and severe depression. Moreover, a significant relation existed between gender and depression (P=0.0001). In addition, the level of education increased the intensity of unhealthy attitudes (P=0.0001). Several researches in both outside and inside Iran support the idea.

CONCLUSION

Based on present study and more other investigations, it can be suggested to provide the necessary elements and parameters such as antidepressant medication, psychologists, complementary treatment for coping with negative mood and its unwanted consequences.

Unipolar depression and the progression of coronary artery disease: toward an integrative model

BACKGROUND

Despite extensive research on the relationship between depression and coronary artery disease (CAD) after an acute coronary syndrome (ACS), causal interpretations are still difficult. This uncertainty has led to much confusion regarding screening and treatment for depression in CAD patients.

METHOD

A critical and conceptual analysis of the pertinent literature, which elaborates the implications of the heterogeneity in symptom pattern, etiology, and course of depression in CAD patients.

RESULTS

We propose an integrative dynamic model of the depression-CAD relationship. The model rests on three core hypotheses: (1) Depression in CAD patients consists of mixtures of two types of depression, denoted as 'cognitive/affective' and 'somatic' depression, each having a somewhat characteristic symptom expression and etiology. (2) Effects of depression on CAD depend on the type and duration of depression. The dynamic aspect of the model indicates that post-ACS depression shifts, when it persists, from a marker of the severity (somatic type) and meaning (cognitive/affective type) of the ACS to a largely indirect causal factor in the progression of CAD. (3) The most plausible pathways mediating the effects of persistent/recurrent depression, irrespective of type, on cardiac prognosis are behavioral and act by making depressed CAD patients more susceptible to other CAD risks. The model offers testable predictions and explanations for a variety of apparently unrelated or inconsistent findings.

CONCLUSION

The proposed model may have potential for integrating findings regarding the depression-CAD relationship, contributing to the clarification of discords on screening and treatment of depression, and guiding future research.

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.

Persistent depressive symptoms after acute coronary syndrome are associated with compromised white matter integrity in the anterior cingulate: a pilot study

BACKGROUND

Persistent depressive symptoms after acute coronary syndrome (ACS) are common and increase the risk of recurrent cardiac events and mortality. However, the neurobiological correlates of post-ACS depressive symptoms have not yet been studied.

METHODS

Three months after ACS, 22 patients were scanned for the presence of cerebral deep white matter changes and microstructural abnormalities in the anterior cingulate cortex (ACC) and dorsolateral prefrontal cortex. We used the Coffey Rating Scale of deep white matter changes and measures of fractional anisotropy derived from diffusion tensor imaging. Patients also completed the Beck Depression Inventory, and the number of cardiovascular comorbidities as well as modifiable cardiovascular risk factors were assessed.

RESULTS

Controlling for cardiovascular comorbidity, depressive symptom severity at 3 months was negatively related to fractional anisotropy in the ACC (r = -0.72, p < 0.001), but this association disappeared when controlling for cardiovascular risk factors (p = 0.21). In comparison to patients who were non-depressed at 3 months after hospitalization (n = 14), patients with persistent depressive symptoms (n = 8) exhibited more advanced deep white matter changes overall (p < 0.02), but not when controlling for cardiovascular comorbidity. Persistently depressed patients also had lower fractional anisotropy in the ACC (p < 0.05), but this effect disappeared when controlling for modifiable cardiovascular risk factors.

CONCLUSIONS

This study provides the first evidence that persistent depressive symptoms after ACS are associated with vascular brain changes. Longitudinal studies are needed to determine whether depressive symptoms precede these changes or vice versa.

Short-term psychotherapeutic interventions for somatizing patients in the general hospital: a randomized controlled study

BACKGROUND

Treatment acceptance and motivation for psychotherapy of somatizing patients in the general hospital is low.

METHODS

Patients (n = 91) fulfilling the criteria for somatization were randomized into an intervention group (n = 49) and a control group (n = 42). The patients in the intervention group attended 5 psychotherapeutic sessions based on the modified reattribution model. The patients in the control group received psychoeducational reading material. The primary outcomes were motivation for psychotherapy and contacting a psychotherapist after discharge. The secondary outcomes consisted of changes regarding somatoform symptoms, emotional distress and quality of life.

RESULTS

Patients from the intervention group were significantly more motivated for psychotherapy (p = 0.001) than patients from the control group. At the 3-month follow-up, 42% of the patients from the intervention group had contacted a psychotherapist, compared to 20% of the patients from the control group (p = 0.045). At the 6-month follow-up, however, the ratio of patients having contacted a psychotherapist had changed to 44 and 29%, respectively, and was no longer significant. The intensity of somatoform symptoms and the anxiety symptoms decreased and mental functioning improved significantly over time for patients from both groups.

CONCLUSIONS

Short-term psychotherapeutic interventions for somatizing patients in general hospitals have a moderately better effect on motivation for psychotherapy and contacting a psychotherapist than psychoeducational reading material alone. Future studies should attempt to prove the effectiveness of short-term psychoeducational interventions for somatizing patients in the general hospital.