Contribution of depression and anxiety to impaired health-related quality of life following first myocardial infarction

Hesperidin reduces serum levels of triglyceride after coronary artery bypass graft surgery

Hesperidin, as an antioxidant and anti-inflammatory agent, has beneficial effects on cardiovascular diseases. This study aimed to determine the effects of hesperidin supplementation on inflammation, oxidative stress, and lipid profile in depressed coronary artery bypass graft surgery (CABG) patients. Eighty patients after coronary artery bypass graft surgery participated in this clinical trial and were randomly divided into two groups. The intervention group received 200 mg/d pure hesperidin supplement and the second group received placebo for 12 weeks. Both groups continued their usual diet. Serum concentrations of inflammatory and stress oxidative markers (hs-CRP, P-selectin, and ox-LDL) were measured and compared at baseline and the end of the intervention. The changes in serum levels of triglyceride were significantly different between the two groups (p < .05). HDL-c significantly increased in groups but the differences between the two groups were not statistically significant (p > .05). Hesperidin did not affect FBS, other lipid parameters, hs-CRP, P-selectin, and OX-LDL (p > .05). SBP and DBP differences were not statistically significant (p > .05). After 12 weeks of intervention, hesperidin reduced serum levels of triglyceride in depressed post-CABG patients.

Longitudinal Associations of Work Stress with Changes in Quality of Life among Patients after Acute Coronary Syndrome: A Hospital-Based Study

(1) Background: Targeting a sample of Chinese employees in this study, the correlation of work stress with changes in quality of life (QoL) was explored subsequent to acute coronary syndrome (ACS). (2) Methods: Patients suffering from the first ACS episode, with regular paid work before ACS, were eligible for this one-year longitudinal study. Effort-reward imbalance (ERI), together with job strain (JS) models, were employed to evaluate work stress before discharge, and QoL prior to discharge (baseline), as well as at 1, 6, and 12 months following discharge, were measured using the 8-Items Short Form (SF-8), in addition to the Seattle Angina Questionnaire (SAQ). Moreover, generalized estimating equations were used to determine the relationship of work stress to longitudinal QoL variations. (3) Results: After adjusting for covariates, high work stress at the baseline measured by JS was associated with the slow recovery of both mental health (p < 0.01) and physical health (p < 0.05) in SF-8, while ERI-measured work stress was related to slower improvement in SF-8 physical health (p < 0.001), SAQ-angina stability (AS) (p < 0.05), SF-8 mental health (p < 0.001), and SAQ-angina frequency (AF) (p < 0.05). After mutual adjustment for JS and ERI, high work stress as assessed by JS displayed no correlation with any QoL alteration (all p > 0.05), whereas ERI-determined work stress at a high level still presented a relationship to slow improvement in SF-8 physical health, SAQ-AS, SF-8 mental health, and SAQ-AF (all p < 0.05). (4) Conclusion: Work stress was associated with slow recovery of QoL in patients with ACS across one year. For ACS patients, ERI was a stronger predictor of QoL variations than JS.

Lipid Biomarkers in Depression: Does Antidepressant Therapy Have an Impact?

Studies have revealed mixed results on how antidepressant drugs affect lipid profiles of patients with major depression disorder (MDD). Even less is known about how patients respond to a switch of antidepressant medication with respect to their metabolic profile. For this, effects of a switch in antidepressants medication on lipid markers were studied in MDD patients. 15 participants (females = 86.67%; males = 13.33%; age: 49.45 ± 7.45 years) with MDD and a prescribed switch in their antidepressant medication were recruited at a psychosomatic rehabilitation clinic. Participants were characterized (with questionnaires and blood samples) at admission to the rehabilitation clinic (baseline, T0) and followed up with a blood sample two weeks (T1) later. HDL, LDL, total cholesterol, and triglycerides were determined (T0), and their change analyzed (Wilcoxon test) at follow up (T1). Decrements in HDL (p = 0.041), LDL (p < 0.001), and total cholesterol (p < 0.001) were observed two weeks after a switch in antidepressant medication. Triglycerides showed no difference (p = 0.699). Overall, LDL, HDL, and total cholesterol are affected by a change in antidepressant drugs in patients with MDD. These observations are of clinical relevance for medical practitioners in the planning and management of treatment strategies for MDD patients.

Job burnout is associated with slow improvement of quality of life in the employees after a first episode of acute coronary syndrome: A hospital-based longitudinal study in China

OBJECTIVE

This study investigated the association between job burnout and quality of life (QoL) after acute coronary syndrome (ACS) in a Chinese sample.

METHODS

This was a one-year longitudinal study. Participants included patients with a first episode of ACS who were still employed. The Copenhagen Burnout Inventory (CBI) assessed job burnout before discharge, and QoL was assessed using the Medical Outcome Study 8-Items Short Form Health Survey (SF-8) and the Seattle Angina Questionnaire (SAQ) before discharge (baseline), at one month, six months and 12 months after discharge. Generalized estimating equations determined the association between job burnout and longitudinal changes of QoL.

RESULTS

All participants were assigned to either a "low job burnout" group (n = 70) or a "high job burnout" group (n = 50), based on the upper quartile of job burnout scores. Longitudinally over 1-year follow-up period, the scores of the SF-8 and SAQ among patients with a high level of burnout were lower than those in the low job burnout group. Job burnout was significantly associated with lower physical and mental health (SF-8), as well as greater physical limitation and lower treatment satisfaction (SAQ) over time.

CONCLUSION

Job burnout at baseline predicted slow improvement of QoL after ACS in a Chinese working sample.

Effects of Supervised Cardiac Rehabilitation Programmes on Quality of Life among Myocardial Infarction Patients: A Systematic Review and Meta-Analysis

Coronary heart disease is the leading cause of death and disability worldwide. Traditionally, cardiac rehabilitation programmes are offered after cardiac events to aid recovery, improve quality of life, and reduce adverse events. The objective of this review was to assess the health-related quality of life, after a supervised cardiac rehabilitation programme, of patients who suffered a myocardial infarction. A systematic review was carried out in the CINAHL, Cochrane, LILACS, Medline, Scopus, and SciELO databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Randomised controlled trials were selected. Meta-analyses were performed for the Short Form Health Survey SF-36, Myocardial Infarction Dimensional Assessment Scale (MIDAS), MacNew Heart Disease-Health-Related Quality of Life (HRQL) questionnaire, and European Quality of Life-Visual Analogue Scale (EuroQol-VAS) with the software Cochrane RevMan Web. Ten articles were found covering a total of 3577 patients. In the meta-analysis, the effect size of the cardiac rehabilitation programme was statistically significant in the intervention group for physical activity, emotional reaction, and dependency dimensions of the MIDAS questionnaire. For the control group, the score improved for SF-36 physical functioning, and body pain dimensions. The mean difference between the control and intervention group was not significant for the remaining dimensions, and neither for the MacNew Heart Disease-HRQL and EuroQol-VAS questionnaires. Supervised cardiac rehabilitation programmes were effective in improving health-related quality of life, however, there was a potential variability in the interventions; therefore, the results should be interpreted with caution. This study supports the importance of providing care and evaluating interventions via the supervision of trained health professionals, and further randomised clinical trials are needed to analyse the positive changes in mental and physical health outcomes.

Suicide prediction among men and women with depression: A population-based study

BACKGROUND

Accurate identification of persons at risk of suicide is challenging because suicide is a rare outcome with a multifactorial origin. The purpose of this study was to predict suicide among persons with depression using machine learning methods.

METHODS

A case-cohort study was conducted in Denmark between January 1, 1995 and December 31, 2015. Cases were all persons who died by suicide and had an incident depression diagnosis in Denmark (n = 2,774). The comparison subcohort was a 5% random sample of all individuals in Denmark at baseline, restricted to persons with an incident depression diagnosis during the study period (n = 11,963). Classification trees and random forests were used to predict suicide.

RESULTS

In men with depression, there was a high risk of suicide among those who were prescribed other analgesics and antipyretics (i.e., non-opioid analgesics such as acetaminophen), prescribed hypnotics and sedatives, and diagnosed with a poisoning (n = 96; risk = 81%). In women with depression, there was an elevated risk of suicide among those who were prescribed other analgesics and antipyretics, anxiolytics, and hypnotics and sedatives, but were not diagnosed with poisoning nor cerebrovascular diseases (n = 338; risk = 58%).

DISCUSSION

Psychiatric disorders and their associated medications were strongly indicative of suicide risk. Notably, anti-inflammatory medications (e.g., acetaminophen) prescriptions, which are used to treat chronic pain and illnesses, were associated with suicide risk in persons with depression. Machine learning may advance our ability to predict suicide deaths.

Health-related quality of life and exercise-based cardiac rehabilitation in contemporary acute coronary syndrome patients: a systematic review and meta-analysis

PURPOSE

To review the literature on health-related quality of life (HRQoL) outcomes for exercise-based cardiac rehabilitation (EBCR) in contemporary acute coronary syndrome (ACS) patients.

METHODS

Electronic databases (CENTRAL, MEDLINE, Embase, and CINAHL) were searched from January 2000 to March 2019 for randomised controlled trials (RCTs) comparing EBCR to a no-exercise control in ACS patients recruited after year 2000, follow-up of at least 6 months, and HRQoL as outcome. Potential papers were independently screened by two reviewers. Risks of bias were assessed using the Cochrane Tool. Data analyses were performed using RevMan v5.3, random effects model.

RESULTS

Fourteen RCTs (1739 participants) were included, with eight studies suitable for meta-analyses. EBCR resulted in statistically significant and clinically important improvements in physical performance (mean difference [MD] 7.09, 95% CI 0.08, 14.11) and general health (MD 5.08, 95% CI 1.03, 9.13) (SF-36) at 6 months, and in physical functioning (MD 9.82, 95% CI 1.46, 18.19) at 12 months. Statistically significant and sustained improvements were also found in social and physical functioning. Meta-analysis of two studies using the MacNew Heart Disease HRQoL instrument did not show any significant benefits. Of the six studies unsuitable for meta-analyses, five reported significant changes in overall HRQoL, general physical activity levels and functional capacity, or quality-adjusted life-years (QALYs).

CONCLUSIONS

In an era where adherence to clinical practice guidelines has improved survival, EBCR still achieves clinically meaningful improvements in physical performance, general health, and physical functioning in the short and long term in contemporary ACS patients.

Perseverative negative thinking predicts depression in people with acute coronary syndrome

OBJECTIVE

Depression is common in people who have experienced recent Acute Coronary Syndrome (ACS), and predicts worse medical outcomes. Mechanisms underpinning the development of depression and its association with poor medical outcomes are unclear however. The aim of this study was to investigate the role of perseverative negative thinking (e.g. worry and rumination) in predicting depression in people with recent ACS.

METHODS

Adults attending specialist inpatient and outpatient cardiology services who had recently experienced ACS were invited to participate in this observational prospective cohort study. Questionnaire assessments were completed within 6months of index ACS (baseline), then 2months and 6months later.

RESULTS

169 participants (131 male (78%), median age 68 (±16) years) completed baseline questionnaires, and 111 completed follow-ups. After controlling for the effects of key covariates, baseline rumination was a significant predictor of depression at 6months, accounting for 2% of the variance in depression. This association was partially mediated by poor problem-solving ability and lack of social support. Neither worry nor rumination at baseline were significant predictors of quality of life at 6months.

CONCLUSIONS

Rumination is a significant independent predictor of depression, and this association may be partially explained by deficits in problem-solving ability and reduced social support. Both rumination and problem solving may provide useful targets for the development of evidence-based interventions to reduce depression among people with coronary heart disease.

[Сhanges in quality of life in patients with congestive heart failure after cardiac resynchronization therapy]

PURPOSE

To assess the quality of life (QoL) changes in patients with congestive heart failure (CHF) one year after cardiac resynchronization therapy (CRT).

METHODS

The study included 82 patients (68 males and 14 females) aged from 30 to 74 (mean age 55.8±9.2 years) who underwent implantation of a biventricular cardiac pacemaker for CRT. Depending on the echocardiographic response to CPT, the patients were divided into two groups: 56 people with a positive response (responders) and 26 people with insufficient response (non-responders). The SF-36 questionnaire was used to measure QoL. The results of the questionnaire were represented as scores over the eight subscales: physical functioning (PF), role-physical functioning (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), and mental health perceptions (MH). The QoL assessment was performed before and one year after CRT.

RESULTS

Patients with CHF one year following CRT had significantly higher rates of improvement in PF QoL (before CRT 46.28±26.16; one year after CRT 53.05±27.65, p=0.023). The statistical tendency towards QoL improvement was revealed: VT QoL (before CRT 47.07±20.12, after CRT 51.83±20.07, p=0.081), SF (before СРТ 61.58±25.06, after CRT 67.07±24.57, p=0.088). Group of responders one year after CRT had significantly higher rates of improvement of QoL in PF (45.2±26.0 before CRT vs 57.1±26.4 after CRT, p=0.001); in VT (46.5±20.8 vs 54.4±19.7, p=0.010) and in SF (60.9±26.4 vs 70.8±20.8, p=0.012). The statistical tendency towards QoL improvement was revealed in BP (57.5±25.1 before CRT vs 64.8±23.8 after CRT, p=0.079), in GH (45.3±16.4 vs 49.1±18.0, p=0.079) and in MH (57.7±18.9 vs 62.5±17.7, p=0.081). In the group of nonresponders the statistical tendency towards decrease in QoL was detected during one year after CRT in RE (46.2±45.3 before CRT vs 26.9±41.1 after CRT, p=0.07). No significant differences were found in paired comparisons of other QoL indicators.

CONCLUSION

We revealed significant increase in PF index in patients with CHF one year following CRT. The study showed that QoL was generally improving one year following CRT in responders while a tendency towards decrease in RE was detected in non-responders.

Enhanced psychological care in cardiac rehabilitation services for patients with new-onset depression: the CADENCE feasibility study and pilot RCT

BACKGROUND

Around 19% of people screened by UK cardiac rehabilitation programmes report having moderate or severe symptoms of depression. These individuals are at an increased risk of cardiac mortality and morbidity, reduced quality of life and increased use of health resources compared with their non-depressed counterparts. Maximising psychological health is a goal of cardiac rehabilitation, but psychological care is patchy.

OBJECTIVE(S)

To examine the feasibility and acceptability of embedding enhanced psychological care (EPC) within cardiac rehabilitation, we tested the feasibility of developing/implementing EPC and documented the key uncertainties associated with undertaking a definitive evaluation.

DESIGN

A two-stage multimethods study; a feasibility study and a qualitative evaluation, followed by an external pilot cluster randomised controlled trial (RCT) with a nested qualitative study.

SETTING

UK comprehensive cardiac rehabilitation teams.

PARTICIPANTS

Adults eligible for cardiac rehabilitation following an acute coronary syndrome with new-onset depressive symptoms on initial nurse assessment. Patients who had received treatment for depression in the preceding 6 months were excluded.

INTERVENTIONS

The EPC intervention comprised nurse-led mental health-care co-ordination and behavioural activation within cardiac rehabilitation. The comparator was usual cardiac rehabilitation care.

MAIN OUTCOME MEASURES

Measures at baseline, and at the 5- (feasibility and pilot) and 8-month follow-ups (pilot only). Process measures related to cardiac team and patient recruitment, and participant retention. Outcomes included depressive symptoms, cardiac mortality and morbidity, anxiety, health-related quality of life and service resource use. Interviews explored participant and nurses' views and experiences.

RESULTS

Between September 2014 and May 2015, five nurses from four teams recruited participants into the feasibility study. Of the 203 patients screened, 30 were eligible and nine took part (the target was 20 participants). At interview, participants and nurses gave valuable insights into the EPC intervention design and delivery. Although acceptable, the EPC delivery was challenging for nurses (e.g. the ability to allocate sufficient time within existing workloads) and the intervention was modified accordingly. Between December 2014 and February 2015, 8 out of 20 teams approached agreed to participate in the pilot RCT [five were randomised to the EPC arm and three were randomised to the usual-care (UC) arm]. Of the 614 patients screened, 55 were eligible and 29 took part (the target was 43 participants). At baseline, the trial arms were well matched for sex and ethnicity, although the EPC arm participants were younger, from more deprived areas and had higher depression scores than the UC participants. A total of 27 out of 29 participants were followed up at 5 months. Interviews with 18 participants (12 in the EPC arm and six in the UC arm) and seven nurses who delivered EPC identified that both groups acknowledged the importance of receiving psychological support embedded within routine cardiac rehabilitation. For those experiencing/delivering EPC, the intervention was broadly acceptable, albeit challenging to deliver within existing care.

LIMITATIONS

Both the feasibility and the pilot studies encountered significant challenges in recruiting patients, which limited the power of the pilot study analyses.

CONCLUSIONS

Cardiac rehabilitation nurses can be trained to deliver EPC. Although valued by both patients and nurses, organisational and workload constraints were significant barriers to implementation in participating teams, suggesting that future research may require a modified approach to intervention delivery within current service arrangements. We obtained important data informing definitive research regarding participant recruitment and retention, and optimal methods of data collection.

FUTURE RESEARCH

Consideration should be given to the delivery of EPC by dedicated mental health practitioners, working closely with cardiac rehabilitation services.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN34701576.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 30. See the NIHR Journals Library website for further project information.

Interventions to support return to work for people with coronary heart disease

BACKGROUND

People with coronary heart disease (CHD) often require prolonged absences from work to convalesce after acute disease events like myocardial infarctions (MI) or revascularisation procedures such as coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Reduced functional capacity and anxiety due to CHD may further delay or prevent return to work.

OBJECTIVES

To assess the effects of person- and work-directed interventions aimed at enhancing return to work in patients with coronary heart disease compared to usual care or no intervention.

SEARCH METHODS

We searched the databases CENTRAL, MEDLINE, Embase, PsycINFO, NIOSHTIC, NIOSHTIC-2, HSELINE, CISDOC, and LILACS through 11 October 2018. We also searched the US National Library of Medicine registry, clinicaltrials.gov, to identify ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) examining return to work among people with CHD who were provided either an intervention or usual care. Selected studies included only people treated for MI or who had undergone either a CABG or PCI. At least 80% of the study population should have been working prior to the CHD and not at the time of the trial, or study authors had to have considered a return-to-work subgroup. We included studies in all languages. Two review authors independently selected the studies and consulted a third review author to resolve disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and independently assessed the risk of bias. We conducted meta-analyses of rates of return to work and time until return to work. We considered the secondary outcomes, health-related quality of life and adverse events among studies where at least 80% of study participants were eligible to return to work.

MAIN RESULTS

We found 39 RCTs (including one cluster- and four three-armed RCTs). We included the return-to-work results of 34 studies in the meta-analyses.Person-directed, psychological counselling versus usual careWe included 11 studies considering return to work following psychological interventions among a subgroup of 615 participants in the meta-analysis. Most interventions used some form of counselling to address participants' disease-related anxieties and provided information on the causes and course of CHD to dispel misconceptions. We do not know if these interventions increase return to work up to six months (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.84 to 1.40; six studies; very low-certainty evidence) or at six to 12 months (RR 1.24, 95% CI 0.95 to 1.63; seven studies; very low-certainty evidence). We also do not know if psychological interventions shorten the time until return to work. Psychological interventions may have little or no effect on the proportion of participants working between one and five years (RR 1.09, 95% CI 0.88 to 1.34; three studies; low-certainty evidence).Person-directed, work-directed counselling versus usual careFour studies examined work-directed counselling. These counselling interventions included advising patients when to return to work based on treadmill testing or extended counselling to include co-workers' fears and misconceptions regarding CHD. Work-directed counselling may result in little to no difference in the mean difference (MD) in days until return to work (MD -7.52 days, 95% CI -20.07 to 5.03 days; four studies; low-certainty evidence). Work-directed counselling probably results in little to no difference in cardiac deaths (RR 1.00, 95% CI 0.19 to 5.39; two studies; moderate-certainty evidence).Person-directed, physical conditioning interventions versus usual careNine studies examined the impact of exercise programmes. Compared to usual care, we do not know if physical interventions increase return to work up to six months (RR 1.17, 95% CI 0.97 to 1.41; four studies; very low-certainty evidence). Physical conditioning interventions may result in little to no difference in return-to-work rates at six to 12 months (RR 1.09, 95% CI 0.99 to 1.20; five studies; low-certainty evidence), and may also result in little to no difference on the rates of patients working after one year (RR 1.04, 95% CI 0.82 to 1.30; two studies; low-certainty evidence). Physical conditioning interventions may result in little to no difference in the time needed to return to work (MD -7.86 days, 95% CI -29.46 to 13.74 days; four studies; low-certainty evidence). Physical conditioning interventions probably do not increase cardiac death rates (RR 1.00, 95% CI 0.35 to 2.80; two studies; moderate-certainty evidence).Person-directed, combined interventions versus usual careWe included 13 studies considering return to work following combined interventions in the meta-analysis. Combined cardiac rehabilitation programmes may have increased return to work up to six months (RR 1.56, 95% CI 1.23 to 1.98; number needed to treat for an additional beneficial outcome (NNTB) 5; four studies; low-certainty evidence), and may have little to no difference on return-to-work rates at six to 12 months' follow-up (RR 1.06, 95% CI 1.00 to 1.13; 10 studies; low-certainty evidence). We do not know if combined interventions increased the proportions of participants working between one and five years (RR 1.14, 95% CI 0.96 to 1.37; six studies; very low-certainty evidence) or at five years (RR 1.09, 95% CI 0.86 to 1.38; four studies; very low-certainty evidence). Combined interventions probably shortened the time needed until return to work (MD -40.77, 95% CI -67.19 to -14.35; two studies; moderate-certainty evidence). Combining interventions probably results in little to no difference in reinfarctions (RR 0.56, 95% CI 0.23 to 1.40; three studies; moderate-certainty evidence).Work-directed, interventionsWe found no studies exclusively examining strictly work-directed interventions at the workplace.

AUTHORS' CONCLUSIONS

Combined interventions may increase return to work up to six months and probably reduce the time away from work. Otherwise, we found no evidence of either a beneficial or harmful effect of person-directed interventions. The certainty of the evidence for the various interventions and outcomes ranged from very low to moderate. Return to work was typically a secondary outcome of the studies, and as such, the results pertaining to return to work were often poorly reported. Adhering to RCT reporting guidelines could greatly improve the evidence of future research. A research gap exists regarding controlled trials of work-directed interventions, health-related quality of life within the return-to-work process, and adverse effects.

Suicidal Ideation Predicts Functioning and Quality of Life Over One Year after Acute Coronary Syndrome

OBJECTIVE

This study investigated the associations of suicidal ideation (SI) evaluated within 2 weeks after an acute coronary syndrome (ACS) episode with functioning, disability, and quality of life (QOL) at a 1-year follow-up assessment.

METHODS

This study recruited 1152 consecutive patients within 2 weeks of a confirmed ACS episode; 828 of these patients who were followed up 1 year later comprised the study sample. SI was determined at baseline using the "suicidal thoughts" item of the MontgomeryÅsberg Depression Rating Scale. At both examinations, social and occupational functioning were measured by the Social and Occupational Functioning Assessment Scale (SOFAS), disability was estimated by World Health Organization Disability Assessment Schedule-12 (WHODAS-12), and QOL was assessed using the World Health Organization Quality of Life-Abbreviated form (WHOQOL-BREF). Baseline covariates included sociodemographic data, depression characteristics, cardiovascular risk factors, and current cardiac status.

RESULTS

SI at baseline was independently associated with less improved or decreased scores on the SOFAS, WHODAS-12, and WHOQOL-BREF over 1 year after adjusting for relevant covariates.

CONCLUSION

SI within 2 weeks of an ACS episode predicted poorer functioning and QOL at a 1-year follow-up assessment. Thus, the simple evaluation of SI in patients with recently developed ACS could be helpful in screening for functioning and QOL during the chronic phase of this disease.

Depression Levels Following Discharge Predict Quality of Life in Heart Disease Patients

Abstract Depression and stress have been related with poor Health Related Quality of Life (HRQoL) prognosis. However, it is not clear when these depressive symptoms should be measured. A sample of 177 Coronary Heart Disease patients were followed for 15 months aimed to compare the effect of depression and stress measure at time of hospitalization and three months later on the physical HRQoL trajectory. Linear growth models’ results showed that depression and stress after discharge are negatively correlated with the physical HRQoL and depressive symptoms negatively affect the prognosis of these patients.

[Sense of Coherence Scale according to Antonovsky as a possible predictor for return to work for cardiac surgery intensive care patients]

BACKGROUND

For cardiac surgery patients who were employed prior to surgery, the return to their professional life is of special importance. In addition to medical reasons, such as pre-existing conditions, the success of the operation or postoperative course and patient-intrinsic reasons, which can be assessed with the Sense of Coherence (SOC) scale by Antonovsky, may also play a role in the question of a possible return into working life.

METHODS

In this study 278 patients (invasive coronary artery bypass graft surgery and/or surgery on heart valves, age < 60 years, employed) were questioned postoperatively via post with the SOC questionnaire. The SOC questionnaire was used in addition to questions about return to work. The cohort was stratified according to the time of return to work. Subsequently, the point of maximum sensitivity and specificity was determined for the total SOC score and the prediction power was considered.

RESULTS

Of the 278 patients, 61 questionnaires (22%) were considered as eligible and included in the analysis. Of these, 47 participants had returned to work after undergoing cardiac surgery and 14 participants had not. We observed significant differences in SOC values between both groups (146.07 ± 29.76 versus 124.29 ± 28.8, p = 0.020). Patients that returned to work within the first 6 months after surgery showed even higher SOC scores (148.56 ± 28.98, p = 0.034).

CONCLUSION

Patients with an SOC score < 130 are at greater risk not to return to their professional life after cardiac surgery. The SOC is an easily obtainable score that reliably predicts the probability of return to work after cardiac surgery.

Effect of an Education Programme on Cardiovascular Health Index among Patients with Myocardial Infarction: A Preliminary Study

Introduction

Health education is an essential part of controlling the risk of myocardial infarction (MI). This study evaluates the effects of one-on-one education programmes on the cardiovascular health index among patients with MI.

Methods

A quasi-experimental study was conducted in Kuala Lumpur Hospital, Malaysia. Data were collected from November 2014 to January 2015 with a total of 58 respondents who met the inclusion criteria. The respondents received a 20-min one-on-one education programme regarding coronary heart disease, treatment and prevention, and healthy lifestyle. A questionnaire comprising demographic data was administered and the cardiovascular health index was measured before and after four weeks of the education programme. Data were analysed with descriptive and inferential statistics.

Results

There were statistically significant decreases in the score of anxiety, stress, depression, body mass index, and smoking status (P < 0.001) between pre-test and post-test.

Conclusion

The findings suggest that the one-on-one education programme could improve the cardiovascular health index of patients with MI. Furthermore, nurses need to develop and implement a standard education structure programme for patients with MI to improve health outcomes.

Assessing the effectiveness of Enhanced Psychological Care for patients with depressive symptoms attending cardiac rehabilitation compared with treatment as usual (CADENCE): a pilot cluster randomised controlled trial

BACKGROUND

Around 17% of people attending UK cardiac rehabilitation programmes have depression. Optimising psychological wellbeing is a rehabilitation goal, but provision of psychological care is limited. We developed and piloted an Enhanced Psychological Care (EPC) intervention embedded within cardiac rehabilitation, aiming to test key areas of uncertainty to inform the design of a definitive randomised controlled trial (RCT) and economic evaluation.

METHODS

An external pilot randomised controlled trial (RCT) randomised eight cardiac rehabilitation teams (clusters) to either usual care of cardiac rehabilitation provision (UC), or EPC in addition to UC. EPC comprised mental health care coordination and patient-led behavioural activation with nurse support. Adults eligible for cardiac rehabilitation following an acute coronary syndrome and identified with new-onset depressive symptoms during an initial nurse assessment were eligible. Measures were performed at baseline and 5- and 8-month follow-ups and compared between EPC and UC. Team and participant recruitment and retention rates, and participant outcomes (clinical events, depression, anxiety, health-related quality of life, patient experiences, and resource use) were assessed.

RESULTS

Eight out of twenty teams were recruited and randomised. Of 614 patients screened, 55 were eligible and 29 took part (5%, 95% CI 3 to 7% of those screened), with 15 patient participants cluster randomised to EPC and 14 to UC. Nurse records revealed that 8/15 participants received the maximum number of EPC sessions offered; and 4/15 received no sessions. Seven out of fifteen EPC participants were referred to another NHS psychological service compared to none in UC. We followed up 27/29 participants at 5 months and 17/21 at 8 months. The mean difference (EPC minus UC) in depressive symptoms (Beck Depression Inventory) at follow-up (adjusting for baseline score) was 1.7 (95% CI - 3.8 to 7.3; N = 26) at 5 months and 4.4 (95% CI - 1.4 to 10.2; N = 17) at 8 months.

DISCUSSION

While valued by patients and nurses, organisational and workload constraints are significant barriers to EPC implementation. There remains a need to develop and test new models of psychological care within cardiac rehabilitation. Our study offers important data to inform the design of future trials of similar interventions.

TRIAL REGISTRATION

ISRCTN34701576 . Registered on 29 May 2014. Funding details: UK NIHR HTA Programme (project 12/189/09).

Health related quality of life among myocardial infarction survivors in the United States: a propensity score matched analysis

Background

Little is known regarding the health-related quality of life among myocardial infarction (MI) survivors in the United States. The purpose of this population-based study was to identify differences in health-related quality of life domains between MI survivors and propensity score matched controls.

Methods

This retrospective, cross-sectional matched case-control study examined differences in health-related quality of life (HRQoL) among MI survivors of myocardial infarction compared to propensity score matched controls using data from the 2015 Behavioral Risk Factor Surveillance System (BRFSS) survey. Propensity scores were generated via logistic regression for MI survivors and controls based on gender, race/ethnicity, age, body mass index (BMI), smoking status, and comorbidities. Chi-square tests were used to compare differences between MI survivors to controls for demographic variables. A multivariate analysis of HRQoL domains estimated odds ratios. Life satisfaction, sleep quality, and activity limitations were estimated using binary logistic regression. Social support, perceived general health, perceived physical health, and perceived mental health were estimated using multinomial logistic regression. Significance was set at p < 0.05.

Results

The final sample consisted of 16,729 MI survivors matched to 50,187 controls (n = 66,916). Survivors were approximately 2.7 times more likely to report fair/poor general health compared to control (AOR = 2.72, 95% CI: 2.43–3.05) and 1.5 times more likely to report limitations to daily activities (AOR = 1.46, 95% CI: 1.34–1.59). Survivors were more likely to report poor physical health >15 days in the month (AOR = 1.63, 95% CI: 1.46–1.83) and poor mental health >15 days in the month (AOR = 1.25, 95% CI: 1.07–1.46) compared to matched controls. There was no difference in survivors compared to controls in level of emotional support (rarely/never: AOR = 0.75, 95% CI: 0.48–1.18; sometimes: AOR = 0.73, 95% CI: 0.41–1.28), hours of recommended sleep (AOR = 1.14, 95% CI: 0.94–1.38), or life satisfaction (AOR = 1.62, 95% CI: 0.99–2.63).

Conclusion

MI survivors experienced lower HRQoL on domains of general health, physical health, daily activity, and mental health compared to the general population.

CHOICE: Choosing Health Options In Chronic Care Emergencies

Background

Over 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.

Objectives

The aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).

Design

A three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.

Setting

Primary care. Manchester and London.

Participants

People aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.

Results

Evidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.

Limitations

The findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.

Conclusions

Prior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.

Future work

The potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Correlates of health-related quality of life in patients with myocardial infarction: A literature review

BACKGROUND

By the increasing emphasis on health-related quality of life (HRQoL) in patients with myocardial infarction (MI), it is necessary to explore factors that affect HRQoL in this population.

OBJECTIVES

This study aimed to identify correlates of HRQoL in patients with MI.

DESIGN

A literature review of the factors that affect HRQoL in patients with MI (1995-2016).

DATA SOURCES

Three main databases-CINAHL, MEDLINE and PsychINFO-were searched to retrieve relevant peer-reviewed articles published in English.

REVIEW METHODS

In consultation with a medical librarian, we identified relevant MeSH terms and used them for searching the literature: health-related quality of life/quality of life/HRQoL/QoL, myocardial infarction/heart attack/MI and predict*/factor. Data elements were extracted and narratively described variables synthesised into four categories.

RESULTS

A total of 48 studies met the inclusion criteria and were included in the review. Correlates of HRQoL in patients with MI were identified in the following categories: demographic, behavioural, disease-related, and psychosocial factors. Specific correlates included age and gender-identity for demographic factors; physical activity and smoking for behavioural factors; severity of MI, symptoms, and comorbidities for disease-related factors; anxiety and depression for psychosocial factors.

CONCLUSIONS

Identifying correlates of HRQoL can help identify patients who are at risk for poor HRQoL in the recovery or rehabilitation stage of post-MI. Future intervention should focus on adjustable correlates such as behavioural and psychosocial factors to promote HRQoL among patients after experiencing MI.

Assessing the effectiveness of enhanced psychological care for patients with depressive symptoms attending cardiac rehabilitation compared with treatment as usual (CADENCE): study protocol for a pilot cluster randomised controlled trial

BACKGROUND

Around 17% of people eligible for UK cardiac rehabilitation programmes following an acute coronary syndrome report moderate or severe depressive symptoms. While maximising psychological health is a core goal of cardiac rehabilitation, psychological care can be fragmented and patchy. This study tests the feasibility and acceptability of embedding enhanced psychological care, composed of two management strategies of proven effectiveness in other settings (nurse-led mental health care coordination and behavioural activation), within the cardiac rehabilitation care pathway.

METHODS/DESIGN

This study tests the uncertainties associated with a large-scale evaluation by conducting an external pilot trial with a nested qualitative study. We aim to recruit and randomise eight comprehensive cardiac rehabilitation teams (clusters) to intervention (embedding enhanced psychological care into routine cardiac rehabilitation programmes) or control (routine cardiac rehabilitation programmes alone) arms. Up to 64 patients (eight per team) identified with depressive symptoms upon initial assessment by the cardiac rehabilitation team will be recruited, and study measures will be administered at baseline (before starting rehabilitation) and at 5 months and 8 months post baseline. Outcomes include depressive symptoms, cardiac mortality and morbidity, anxiety, health-related quality of life and service resource use. Trial data on cardiac team and patient recruitment, and the retention and flow of patients through treatment will be used to assess intervention feasibility and acceptability. Qualitative interviews will be undertaken to explore trial participants' and cardiac rehabilitation nurses' views and experiences of the trial methods and intervention, and to identify reasons why patients declined to take part in the trial. Outcome data will inform a sample size calculation for a definitive trial.

DISCUSSION

The pilot trial and qualitative study will inform the design of a fully powered cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of the provision of enhanced psychological care within cardiac rehabilitation programmes.

TRIAL REGISTRATION

ISRCTN34701576 (Registered 29 May 2014).

Tumour necrosis factor-α inhibitor therapy in chronic physical illness: A systematic review and meta-analysis of the effect on depression and anxiety

OBJECTIVE

Depression is more common among individuals with chronic physical illness than in the general population. New treatments for severe and chronic inflammatory conditions which inhibit tumour necrosis factor alpha (TNF-α), a pro-inflammatory cytokine, may be able to shed some light on the role of inflammatory mediators in depression. This systematic review and meta-analysis of randomised controlled trials determined the effects of TNF-α inhibitor therapy on depression and anxiety in people with chronic physical illness.

METHODS

Seven databases were searched from inception to January 2014: AMED, Central, Cochrane Database of Systematic Reviews, CINAHL, Embase, MEDLINE, and PsycINFO. Articles were screened for inclusion independently by two reviewers. Data extraction and appraisal were conducted by one reviewer and checked by a second. Random-effects meta-analyses were performed.

RESULTS

Six randomised controlled trials (reported in seven articles) met eligibility criteria and were included in the final review. In total 2540 participants were enrolled across the trials, with participants presenting with rheumatoid arthritis (n=3 trials), psoriasis (n=2) or ankylosing spondylitis (n=1). Meta-analyses, using standardised mean differences, showed evidence of small reductions in depression (-0.24; 95% CI -0.33 to -0.14; p<0.001), and anxiety (-0.17; 95% CI -0.31 to -0.02; p=0.02).

CONCLUSION

TNF-α inhibitor therapy reduces depression in people with chronic disease though the effects are small. Whilst this is consistent with inflammation contributing to the development of depression, further studies investigating a more detailed timeline of changes in depression, inflammatory biomarkers and disease activity status are required.

Effects of depression co-morbidity and treatment on quality of life in patients with acute coronary syndrome: the Korean depression in ACS (K-DEPACS) and the escitalopram for depression in ACS (EsDEPACS) study

BACKGROUND

Depression is common after acute coronary syndrome (ACS) with adverse effects on prognosis. There is little evidence on whether depression treatment improves quality of life (QoL) in ACS patients. The aim of this study was to investigate the effects of co-morbid depression and its treatment on QoL in ACS.

METHOD

In total, 1152 patients were recruited at baseline, 2-14 weeks after a confirmed ACS episode, and 828 were followed 1 year thereafter. Of 446 baseline participants with co-morbid depressive disorders, 300 were randomized to a 24-week double blind trial of escitalopram or placebo, while the remaining 146 received medical treatment only (MTO). QoL was measured by the World Health Organization Quality of Life -Abbreviated form (WHOQOL-BREF).

RESULTS

At baseline, QoL was significantly lower in patients with co-morbid depressive disorder than those without. QoL improvement was significantly greater in those receiving escitalopram than those receiving placebo over the 24-week treatment period. In the 1-year follow-up, the better outcomes associated with escitalopram remained evident against both placebo and MTO.

CONCLUSIONS

Depression was significantly associated with worse QoL even in patients with recently developed ACS. Depression treatment was associated with QoL improvement in ACS patients in the 24-week treatment period, the effects of which extended to 1 year.

The bidirectional relation between psychiatric disorders with selected cardiovascular and endocrinal diseases: an Egyptian perspective

Cardiovascular and endocrine diseases may act as burdens for individuals suffering from one of these medical illnesses, and whether through the ensuing psychological distress, or some biological mechanisms, these medical diseases can eventually lead to the development of psychiatric morbidities. Moreover, psychiatric morbidities negatively affect the prognosis of both cardiovascular and endocrine diseases. Despite transcultural differences, Egyptian patients with ischemic heart diseases (ISHD), heart failure (HF), diabetes mellitus (DM), or thyroid diseases (TD) endure the same psychological distress as their Western counterparts. Psychiatric assessment and evaluation should be regularly repeated among patients with cardiovascular and endocrinal diseases, and patients who are at risk should be closely followed up.

Early exercise-based rehabilitation improves health-related quality of life and functional capacity after acute myocardial infarction: a randomized controlled trial

BACKGROUND

The purpose of this study was to evaluate the influence of an early cardiac rehabilitation (CR) program on health-related quality of life (HRQL) and functional capacity in patients who recently experienced an acute myocardial infarction (AMI). This program was initiated in the inpatient setting and was followed by an unsupervised outpatient intervention.

METHODS

After the same inpatient care plan, low-risk patients who experienced an AMI were randomized into 2 groups: (1) a control group (CG) (n = 43) entailing usual care and (2) an intervention group (IG) (n = 45) entailing outpatient (unsupervised) CR primarily centered on a progressive walking program. Initially, all patients underwent a supervised exercise program with early mobilization beginning 12 hours after an AMI. On hospital discharge, all patients were classified according to cardiovascular risk. Quality of life was evaluated by the MacNew Heart Disease HRQL questionnaire 30 days after discharge. Functional capacity was determined by a 6-minute walk test (6MWT) distance on the day of inpatient discharge as well as 30 days afterward.

RESULTS

The HRQL global score was higher in the IG compared with the CG 30 days after discharge (P < 0.001); physical and emotional domain scores were both significantly higher in the IG (P < 0.001). Furthermore, the IG showed a greater 6MWT distance compared with the CG (P < 0.001).

CONCLUSIONS

A CR program based on early progressive exercises, initiated by supervised inpatient training and followed by an unsupervised outpatient program, improved HRQL and functional capacity in patients at low cardiovascular risk who recently experienced an AMI.

Randomised controlled trial of a 12 week yoga intervention on negative affective states, cardiovascular and cognitive function in post-cardiac rehabilitation patients

BACKGROUND

Negative affective states such as anxiety, depression and stress are significant risk factors for cardiovascular disease, particularly in cardiac and post-cardiac rehabilitation populations.Yoga is a balanced practice of physical exercise, breathing control and meditation that can reduce psychosocial symptoms as well as improve cardiovascular and cognitive function. It has the potential to positively affect multiple disease pathways and may prove to be a practical adjunct to cardiac rehabilitation in further reducing cardiac risk factors as well as improving self-efficacy and post-cardiac rehabilitation adherence to healthy lifestyle behaviours.

METHOD AND DESIGN

This is a parallel arm, multi-centre, randomised controlled trial that will assess the outcomes of post- phase 2 cardiac rehabilitation patients assigned to a yoga intervention in comparison to a no-treatment wait-list control group. Participants randomised to the yoga group will engage in a 12 week yoga program comprising of two group based sessions and one self-administered home session each week. Group based sessions will be led by an experienced yoga instructor. This will involve teaching beginner students a hatha yoga sequence that incorporates asana (poses and postures), pranayama (breathing control) and meditation. The primary outcomes of this study are negative affective states of anxiety, depression and stress assessed using the Depression Anxiety Stress Scale. Secondary outcomes include measures of quality of life, and cardiovascular and cognitive function. The cardiovascular outcomes will include blood pressure, heart rate, heart rate variability, pulse wave velocity, carotid intima media thickness measurements, lipid/glucose profiles and C-reactive protein assays. Assessments will be conducted prior to (week 0), mid-way through (week 6) and following the intervention period (week 12) as well as at a four week follow-up (week 16).

DISCUSSION

This study will determine the effect of yoga practice on negative affective states, cardiovascular and cognitive function in post-phase 2 cardiac rehabilitation patients. The findings may provide evidence to incorporate yoga into standardised cardiac rehabilitation programs as a practical adjunct to improve the management of psychosocial symptoms associated with cardiovascular events in addition to improving patients' cognitive and cardiovascular functions.

TRIAL REGISTRATION

ACTRN12612000358842.

Contribution of depression and anxiety to impaired quality of life in survivors of myocardial infarction

OBJECTIVE

To quantify the adverse influence of depression and anxiety assessed at the time of myocardial infarction, on the quality of life 5 years after the infarction.

METHODS

The Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI) were completed in a group of 196 patients admitted in the hospital following non-fatal myocardial infarction, and the SF-12 quality of life questionnaire was administered during the 5- year follow-up.

RESULTS

Regression analysis showed a strong association between baseline depression and QoL in both the physical and mental domains; the higher the depression scores, the poorer the QoL. However, anxiety present at the time of myocardial infarction did not predict later QoL.

CONCLUSIONS

Depression but not anxiety following MI predicts longer-term quality of life in myocardial infarction survivors.

Depression and anxiety following myocardial infarction and their inverse associations with future health behaviors and quality of life

BACKGROUND

Post-myocardial infarction (MI) depression and anxiety were found to predict prognosis and quality of life.

PURPOSE

The purpose of this study was to test a behavioral pathway from post-MI depression/anxiety to future quality of life.

METHODS

This is a longitudinal cohort study. Five hundred forty patients (≤65 years old) filled out questionnaires after a first MI, including socio-demographics, pre-MI health status and behaviors, MI severity, social support, sense of coherence, depression, and anxiety. Reports of health behaviors were obtained 5 years and of quality of life 10 years later.

RESULTS

A structural equations model confirmed that depression and anxiety were directly related to poorer quality of life 10 years later. These relationships were partly mediated by a positive association between anxiety and health behaviors at 5 years and a negative one between depression and health behaviors.

CONCLUSIONS

The opposite effects of anxiety and depression underscore the need to attend to both emotional reactions to MI while encouraging preventive health behaviors.

Evaluating the impact of depression, anxiety & autonomic function on health related quality of life, vocational functioning and health care utilisation in acute coronary syndrome patients: the ADVENT study protocol

BACKGROUND

Depression and anxiety are highly prevalent and co-morbid in acute coronary syndrome patients. Somatic and cognitive subtypes of depression and anxiety in acute coronary syndrome have been shown to be associated with mortality although their association with patient outcomes is unknown, as are the mechanisms that underpin these associations. We are conducting a prospective cohort study which aims to examine in acute coronary syndrome patients: (1) the role of somatic subtypes of depression and anxiety as predictors of health related quality of life outcomes; (2) how somatic subtypes of depression and anxiety relate to long term vocational functioning and healthcare utilisation; and (3) the role of the autonomic nervous system assessed by heart rate variability as a moderator of these associations.

METHODS

Patients are being screened after index admission for acute coronary syndrome at a single, high volume centre, MonashHeart, Monash Health, Victoria, Australia. The inclusion criterion is all patients aged > 21 years old and fluent in English admitted to MonashHeart, Monash Health with a diagnosis of acute coronary syndrome. The primary outcome is mean health related quality of life (Short Form-36) Physical and Mental Health Summary scores at 12 and 24 months in subtypes with somatic symptoms of depression and anxiety. Depressive domains are assessed by the Beck Depression Inventory II and the Cardiac Depression Scale. Anxiety is measured using the Speilberger State-Trait Anxiety Inventory and the Crown Crisp Phobic Anxiety questionnaire. Secondary outcomes include clinical variables, healthcare service utilisation and vocational functioning.

DISCUSSION

This manuscript presents the protocol for a prospective cohort study which will investigate the role of somatic subtypes of depression and anxiety as predictors of health related quality of life, long-term vocational functioning and health service use, and the role of the autonomic nervous system in moderating these associations. Findings from the study have the potential to inform more effective pharmacological, psychological and behavioural interventions and better guide health policy on the use of health care resources.

Patients' perceptions of depression and coronary heart disease: a qualitative UPBEAT-UK study

BACKGROUND

The prevalence of depression in people with coronary heart disease (CHD) is high but little is known about patients' own perceptions and experiences of this. This study aimed to explore (i) primary care (PC) patients' perceptions of links between their physical condition and mental health, (ii) their experiences of living with depression and CHD and (iii) their own self-help strategies and attitudes to current PC interventions for depression.

METHOD

Qualitative study using consecutive sampling, in-depth interviews and thematic analysis using a process of constant comparison. 30 participants from the UPBEAT-UK cohort study, with CHD and symptoms of depression. All participants were registered on the General Practitioner (GP) primary care, coronary register.

RESULTS

A personal and social story of loss underpinned participants' accounts of their lives, both before and after their experience of having CHD. This theme included two interrelated domains: interpersonal loss and loss centred upon health/control issues. Strong links were made between CHD and depression by men who felt emasculated by CHD. Weaker links were made by participants who had experienced distressing life events such as divorce and bereavement or were living with additional chronic health conditions (i.e. multimorbidity). Participants also felt 'depressed' by the 'medicalisation' of their lives, loneliness and the experience of ageing and ill health. Just under half the sample had consulted their GP about their low mood and participants were somewhat ambivalent about accessing primary care interventions for depression believing the GP would not be able to help them with complex health and social issues. Talking therapies and interventions providing the opportunity for social interaction, support and exercise, such as Cardiac Rehabilitation, were thought to be helpful whereas anti-depressants were not favoured.

CONCLUSIONS

The experiences and needs of patients with CHD and depression are diverse and include psycho-social issues involving interpersonal and health/control losses. In view of the varying social and health needs of patients with CHD and depression the adoption of a holistic, case management approach to care is recommended together with personalised support providing the opportunity for patients to develop and achieve life and health goals, where appropriate.

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.

Depression and health-related quality of life in people with coronary heart disease: a systematic review

BACKGROUND

Depression affects 20% of people with coronary heart disease (CHD) and predicts worse health-related quality of life (HRQoL), but in primary studies the strength of this reported relationship has been inconsistent.

AIMS AND METHODS

We conducted a systematic review to investigate the extent to which depression independently predicts subsequent physical HRQoL. We searched electronic databases (MEDLINE, PsycINFO, CINAHL and EMBASE) to identify prospective cohort studies that included CHD patients, focused on depression and subsequent physical HRQoL using standardised measures. Included studies were assessed for methodological quality.

RESULTS

We identified 11 independent studies, of which nine showed a significant association between depression and subsequent physical HRQoL. There was no systematic methodological difference between those studies that did and did not show a significant association; in particular the results did not appear to be affected by the way depression or physical HRQoL was measured. Five of the 11 studies were of moderate to high methodological quality and controlled for both HRQoL and the severity of CHD at baseline. Four studies showed a significant association between depression and HRQoL.

CONCLUSIONS

Depression predicts subsequent physical HRQoL and this association was not attributable to confounding effects of baseline HRQoL or the severity of the CHD. Identification of depressed CHD patients may improve targeting of resources at people at increased risk of worse physical HRQoL. Treating depression may improve subsequent physical HRQoL, though this needs to be established in future randomised controlled trials.

Cardiac rehabilitation and quality of life: a systematic review

OBJECTIVE

The objective of this systematic review was to explore the effects of cardiac rehabilitation interventions on the quality of life of patients with coronary heart disease with a specific focus on interventions that could be delivered within the context of a publicly funded health service.

DESIGN

Systematic review of trials reporting quality of life data as an outcome measure. Electronic databases (CINAHL, MEDLINE and PsycINFO) were searched from 1 January 1999 to 25 November 2010 in the English language. Inclusion criteria were: randomised controlled trials of cardiac rehabilitation as configured for a publicly funded health service. Data were extracted by one reviewer and checked by a second reviewer.

RESULTS

The 16 papers reported RCTs conducted in nine countries. Fifteen measurement instruments were utilised to measure quality of life across the different studies precluding a meta-analysis. Four themes emerged from the thematic analysis of the selected papers: physical well-being (including fitness and symptoms); psychological well-being (including anxiety and depression); social well-being (including family life and relationships); and functional status (including return to work and previous life style). Physical domain outcomes suggest that cardiac rehabilitation may improve physical well-being and levels of physical activity and thereby improved levels of physical fitness. Both physical and psychological domain outcomes suggest that home-based interventions are at least as effective as centre-based interventions. Relatively few trials reported on quality of life within the social domain and any difference between centre-based and home-based interventions appeared to favour the home-based intervention.

CONCLUSIONS

This review indicates that cardiac rehabilitation improves the quality of life for coronary heart disease patients and that quality of life improvements have a bi-directional relationship with increased physical activity and vocational status. Further research is needed to explore the relationship of quality of life outcomes to cardiac mortality, the relationship between improved physical well-being and anxiety, and the quality of life and mortality effects of cardiac rehabilitation in older people.

Rehabilitation status three months after first-time myocardial infarction

OBJECTIVE

To describe the rehabilitation status three months after first-time myocardial infarction (MI) to identify focus areas for long-term cardiac rehabilitation (CR) in general practice. Design. Population-based cross-sectional study.

SETTING AND SUBJECTS

Patients with first-time MI in 2009 from the Central Denmark Region. Data were obtained from patient questionnaires and from registers.

RESULTS

Of the 1288 eligible patients, 908 (70.5%) responded. The mean (SD) age was 67.1 (11.7) years and 626 (68.9%) were men. Overall, 287 (31.6%) of the patients lived alone and 398 (45.4%) had less than 10 years of education. Upwards of half (58.5%) of the patients stated that they had participated in hospital-based rehabilitation shortly after admission. A total of 262 (29.2%) were identified with anxiety or depressive disorder or both, according to the Hospital Anxiety and Depression Scale. Of these, 78 (29.8%) reported that they had participated in psychosocial support, and 55 (21.0%) used antidepressants. One in five patients smoked three months after MI although nearly half of the smokers had stopped after the MI. Regarding cardioprotective drugs, 714 (78.6%) used aspirin, 694 (76.4%) clopidogrel, 756 (83.3%) statins, and 735 (81.0%) beta-blockers.

CONCLUSION

After three months, there is a considerable potential for further rehabilitation of MI patients. In particular, the long-term CR should focus on mental health, smoking cessation, and cardioprotective drugs.

The effects of interpersonal counselling on health-related quality of life after myocardial infarction

AIM

To evaluate the effects of interpersonal counselling on health-related quality of life after myocardial infarction.

BACKGROUND

Depression is a risk factor for poor health-related quality of life after myocardial infarction. Interpersonal counselling seems to reduce depressive symptoms and distress after myocardial infarction.

METHODS

Myocardial infarction patients (n=103) were randomised into an intervention group (n=51) with 1-6 (mean 4·6) interpersonal counselling-sessions focusing on managing depressive symptoms and a control group (n=52). Health-related quality of life after myocardial infarction was measured with EuroQol-5D (EQ-5D) in hospital, at six and 18 months after discharge.

RESULTS

No differences in the changes of health-related quality of life were found between the groups during follow-up. However, health-related quality of life improved significantly in the intervention group. In the group of patients under 60 years, the effect of interpersonal counselling was significant in the intervention group compared with the control group.

CONCLUSIONS

Interpersonal counselling does not seem to improve health-related quality of life better than standard care after myocardial infarction in general, but it does seem to be beneficial with younger myocardial infarction patients.

RELEVANCE TO CLINICAL PRACTICE

There is a need to study the effects of interpersonal counselling further with younger myocardial infarction patients and to develop the intervention further, before using it systematically as part of nursing practice.

The association between physical illness and major depressive episode in general practice

OBJECTIVE

Physical illness and depression are associated. However, it remains unclear whether this association is sufficiently strong to merit systematic screening for depression among primary care patients suffering from physical illness. In the present study, we investigated the strength of the association between physical illness and depression among patients in general practice.

METHOD

Four thousand two hundred and seventy-one consecutive primary care patients completed a diagnostic depression questionnaire. The general practitioner evaluated the patients' physical health, which was then compared to their diagnostic status of depression.

RESULTS

Physical illness was associated with the presence of depression. Two hundred and thirty-six patients (5.5%) fulfilled diagnostic criteria for depression. Fourteen of these suffered from extreme physical illness, 27 from at least severe physical illness and 96 from at least moderate physical illness. The number needed to screen decreased with increasing severity and chronicity of the physical illness.

CONCLUSIONS

Depression is relatively common in primary care patients suffering from physical illness, particularly if the illness is severe and chronic. However, relatively few depressed patients suffer from a comorbid physical illness. Screening for depression among patients with physical illness may therefore only have a modest impact on the under-recognition of depression in general practice.

Older adults' preferences for religion/spirituality in treatment for anxiety and depression

OBJECTIVES

To examine patient preferences for incorporating religion and/or spirituality into therapy for anxiety or depression and examine the relations between patient preferences and religious and spiritual coping styles, beliefs and behaviors.

METHOD

Participants (66 adults, 55 years or older, from earlier studies of cognitive-behavioral therapy for late-life anxiety and/or depression in primary care) completed these measures by telephone or in-person: Geriatric Anxiety Inventory, Client Attitudes Toward Spirituality in Therapy, Patient Interview, Brief Religious Coping, Religious Problem Solving Scale, Santa Clara Strength of Religious Faith, and Brief Multidimensional Measure of Religiousness and Spirituality. Spearman's rank-order correlations and ordinal logistic regression examined religious/spiritual variables as predictors of preferences for inclusion of religion or spirituality into counseling.

RESULTS

Most participants (77-83%) preferred including religion and/or spirituality in therapy for anxiety and depression. Participants who thought it was important to include religion or spirituality in therapy reported more positive religious-based coping, greater strength of religious faith, and greater collaborative and less self-directed problem-solving styles than participants who did not think it was important.

CONCLUSION

For individuals like most participants in this study (Christians), incorporating spirituality/religion into counseling for anxiety and depression was desirable.

Screening for major depression in post-myocardial infarction patients: operating characteristics of the Beck Depression Inventory-II

OBJECTIVE

To assess the operating characteristics of the Beck-Depression Inventory-II (BDI-II) and the BDI-II cognitive subscale (BDI-II-cog) in screening for major depression (MDD) in post-myocardial infarction (MI) patients.

METHODS

Between October 2003 and July 2005, 131 post-MI patients admitted to an urban academic medical center completed the BDI-II and a semi-structured interview for depression within 72 hours of symptom onset. Sensitivity, specificity, positive and negative predictive values, overall correct classification, and likelihood ratios for various cutoff values on both scales were evaluated by comparing scores to interview diagnosis of MDD. Receiver-operator curves (ROC) were also calculated and area under the curve (AUC) measured.

RESULTS

The optimal cutoff value for the BDI-II was > or = 16, with a sensitivity of 88.2% and a specificity of 92.1%. Cutoff values of > or = 3 or > or = 4 were both acceptable for the BDI-II-cog (sensitivity = 88.2% and 82.4%, respectively; specificity = 81.6% and 88.6 %, respectively). AUC was 0.96 for the BDI-II and 0.89 for the cognitive subscale.

CONCLUSIONS

Effective depression screening is important in post-MI patients because of depression's independent association with morbidity and mortality following MI. Our results suggest that the BDI-II and its cognitive subscale are effective tools for screening for MDD in post-MI patients.

Psychometric properties of three instruments to measure fatigue with myocardial infarction

The purpose of this study was to evaluate the psychometric properties of three questionnaires to measure fatigue with myocardial infarction. The Fatigue Symptom Inventory Interference Scale, Profile of Moods States Fatigue subscale (POMS-F), and Short Form 36 (SF-36) Vitality Scale were completed during hospitalization (n = 116) and 30 days after hospital admission (n = 49). Moderate to strong correlations were found among each of these fatigue scales and between each fatigue scale and measures of other variables to include vigor, depressed mood, anxiety, and physical functioning. POMS-F scores decreased significantly at Time 2, but this decline in fatigue was not validated on the other fatigue scales. Patients' Time 1 scores reflected significantly more fatigue compared to published scores for healthy adults. The ability to discriminate between groups suggests that the instruments may be useful for identifying patients with cardiovascular risk factors who report clinically significant fatigue.

Pathophysiological basis of cardiovascular disease and depression: a chicken-and-egg dilemma

OBJECTIVE

To describe the pathophysiological basis linking cardiovascular disease (CVD) and depression; to discuss the causal relationship between them, and to review the effects of antidepressant treatment on cardiovascular disease.

METHOD

A review of the literature based on the PubMed database.

DISCUSSION

Depression and cardiovascular disease are both highly prevalent. Several studies have shown that the two are closely related. They share common pathophysiological etiologies or co-morbidities, such as alterations in the hypothalamic-pituitary axis, cardiac rhythm disturbances, and hemorheologic, inflammatory and serotoninergic changes. Furthermore, antidepressant treatment is associated with worse cardiac outcomes (in case of tricyclics), which are not observed with selective serotonin reuptake inhibitors.

CONCLUSION

Although there is a strong association between depression and cardiovascular disease, it is still unclear whether depression is actually a causal factor for CVD, or is a mere consequence, or whether both conditions share a common pathophysiological etiology. Nevertheless, both conditions must be treated concomitantly. Drugs other than tricyclics must be used, when needed, to treat the underlying depression and not as mere prophylactic of cardiac outcomes.

Physical and cognitive function in midlife: reciprocal effects? A 5-year follow-up of the Whitehall II study

BACKGROUND

Cognitive and physical functions are closely linked in old age, but less is known about this association in midlife. Whether cognitive function predicts physical function and whether physical function predicts cognitive function were assessed in middle-aged men and women.

METHODS

Data were from Whitehall II, an ongoing large-scale, prospective occupational cohort study of employees from 20 London-based white-collar Civil Service departments. The participants, 3446 men and 1274 women aged 45-68 years at baseline (1995-1997), had complete data on cognitive performance and physical function at both baseline and follow-up (2002-2004). A composite cognitive score was compiled from the following tests: verbal memory, inductive reasoning (Alice Heim 4-I), verbal meaning (Mill Hill), phonemic and semantic fluency. Physical function was measured using the physical composite score of the short form (SF-36) scale. Average follow-up was 5.4 years.

RESULTS

Poor baseline cognitive performance predicted poor physical function at follow-up (beta = 0.08, p<0.001), while baseline physical function did not predict cognitive performance (beta = 0.01, p = 0.67). After full adjustment for sociodemographic, behavioural and biological risk factors, baseline cognitive performance (beta = 0.04 p = 0.009) remained predictive of physical function.

CONCLUSION

Despite previous work indicating that the association between physical and cognitive performance may be bidirectional, these findings suggest that, in middle age, the direction of the association is predominantly from poor cognition to poor physical function.