Assessment and treatment of depression in patients with cardiovascular disease: National heart, lung, and blood institute working group report

A Network Analysis of the Association Between Depressive Symptoms and Patient Activation Among Those With Elevated Cardiovascular Risk

Background

Network analysis provides a new method for conceptualizing interconnections among psychological and behavioral constructs.

Objective

We used network analysis to investigate the complex associations between depressive symptoms and patient activation dimensions among patients at elevated risk of cardiovascular disease.

Methods

This secondary analysis included 200 patients seen in primary care clinics. Depressive symptoms were assessed using the 21-item Beck Depression Inventory. Patient activation was measured using the 13-item Patient Activation Measure. Glasso networks were constructed to identify symptoms/traits that bridge depressive symptoms and patient activation and those that are central within the network.

Results

“Self-dislike” and “confidence to maintain lifestyle changes during times of stress” were identified as important bridge pathways. In addition, depressive symptoms such as “punishment feelings,” “loss of satisfaction,” “self-dislike,” and “loss of interest in people” were central in the depressive symptom–patient activation network, meaning that they were most strongly connected to all other symptoms.

Conclusions

Bridge pathways identified in the network may be reasonable targets for clinical intervention aimed at disrupting the association between depressive symptoms and patient activation. Further research is warranted to assess whether targeting interventions to these central symptoms may help resolve other symptoms within the network.

Psychological and pharmacological interventions for depression in patients with coronary artery disease

BACKGROUND

Depression occurs frequently in individuals with coronary artery disease (CAD) and is associated with a poor prognosis.

OBJECTIVES

To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL databases up to August 2020. We also searched three clinical trials registers in September 2021. We examined reference lists of included randomised controlled trials (RCTs) and contacted primary authors. We applied no language restrictions.

SELECTION CRITERIA

We included RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression. Our primary outcomes included depression, mortality, and cardiac events. Secondary outcomes were healthcare costs and utilisation, health-related quality of life, cardiovascular vital signs, biomarkers of platelet activation, electrocardiogram wave parameters, non-cardiac adverse events, and pharmacological side effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the identified papers for inclusion and extracted data from the included studies. We performed random-effects model meta-analyses to compute overall estimates of treatment outcomes.

MAIN RESULTS

Thirty-seven trials fulfilled our inclusion criteria. Psychological interventions may result in a reduction in end-of-treatment depression symptoms compared to controls (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.92 to -0.19, I² = 88%; low certainty evidence; 10 trials; n = 1226). No effect was evident on medium-term depression symptoms one to six months after the end of treatment (SMD -0.20, 95% CI -0.42 to 0.01, I² = 69%; 7 trials; n = 2654). The evidence for long-term depression symptoms and depression response was sparse for this comparison. There is low certainty evidence that psychological interventions may result in little to no difference in end-of-treatment depression remission (odds ratio (OR) 2.02, 95% CI 0.78 to 5.19, I² = 87%; low certainty evidence; 3 trials; n = 862). Based on one to two trials per outcome, no beneficial effects on mortality and cardiac events of psychological interventions versus control were consistently found. The evidence was very uncertain for end-of-treatment effects on all-cause mortality, and data were not reported for end-of-treatment cardiovascular mortality and occurrence of myocardial infarction for this comparison. In the trials examining a head-to-head comparison of varying psychological interventions or clinical management, the evidence regarding the effect on end-of-treatment depression symptoms is very uncertain for: cognitive behavioural therapy compared to supportive stress management; behaviour therapy compared to person-centred therapy; cognitive behavioural therapy and well-being therapy compared to clinical management. There is low certainty evidence from one trial that cognitive behavioural therapy may result in little to no difference in end-of-treatment depression remission compared to supportive stress management (OR 1.81, 95% CI 0.73 to 4.50; low certainty evidence; n = 83). Based on one to two trials per outcome, no beneficial effects on depression remission, depression response, mortality rates, and cardiac events were consistently found in head-to-head comparisons between psychological interventions or clinical management. The review suggests that pharmacological intervention may have a large effect on end-of-treatment depression symptoms (SMD -0.83, 95% CI -1.33 to -0.32, I² = 90%; low certainty evidence; 8 trials; n = 750). Pharmacological interventions probably result in a moderate to large increase in depression remission (OR 2.06, 95% CI 1.47 to 2.89, I² = 0%; moderate certainty evidence; 4 trials; n = 646). We found an effect favouring pharmacological intervention versus placebo on depression response at the end of treatment, though strength of evidence was not rated (OR 2.73, 95% CI 1.65 to 4.54, I² = 62%; 5 trials; n = 891). Based on one to four trials per outcome, no beneficial effects regarding mortality and cardiac events were consistently found for pharmacological versus placebo trials, and the evidence was very uncertain for end-of-treatment effects on all-cause mortality and myocardial infarction. In the trials examining a head-to-head comparison of varying pharmacological agents, the evidence was very uncertain for end-of-treatment effects on depression symptoms. The evidence regarding the effects of different pharmacological agents on depression symptoms at end of treatment is very uncertain for: simvastatin versus atorvastatin; paroxetine versus fluoxetine; and escitalopram versus Bu Xin Qi. No trials were eligible for the comparison of a psychological intervention with a pharmacological intervention.

AUTHORS' CONCLUSIONS

In individuals with CAD and depression, there is low certainty evidence that psychological intervention may result in a reduction in depression symptoms at the end of treatment. There was also low certainty evidence that pharmacological interventions may result in a large reduction of depression symptoms at the end of treatment. Moderate certainty evidence suggests that pharmacological intervention probably results in a moderate to large increase in depression remission at the end of treatment. Evidence on maintenance effects and the durability of these short-term findings is still missing. The evidence for our primary and secondary outcomes, apart from depression symptoms at end of treatment, is still sparse due to the low number of trials per outcome and the heterogeneity of examined populations and interventions. As psychological and pharmacological interventions can seemingly have a large to only a small or no effect on depression, there is a need for research focusing on extracting those approaches able to substantially improve depression in individuals with CAD and depression.

Effect of antidepressants on death in patients with heart failure: a systematic review and meta-analysis

Depression is associated with an increased risk of death in patients with heart failure (HF); however, the association between the use of antidepressants and HF prognoses remains controversial. Therefore, this meta-analysis aimed to evaluate the effect of antidepressants on the risk of death in HF patients. We retrieved data from the PubMed and EMBASE databases until August 2019 for studies reporting the use of antidepressants in HF patients. Data were extracted from the eligible articles, and a random effects model was used to pool the effect estimates (risk ratios (RRs) and 95% confidence intervals (CIs)). A total of 8 studies were included in this meta-analysis. Overall, the use of antidepressants was associated with increased risks of all-cause death (RR = 1.27; 95% CI, 1.21-1.34) and cardiovascular death (RR = 1.14; 95% CI, 1.08-1.20) in HF patients with or without depression. Specifically, HF patients with depression taking antidepressants had increased risks of all-cause death (RR = 1.21; 95% CI, 1.16-1.27) and cardiovascular death (RR = 1.21; 95% CI, 1.13-1.30). Compared with nonusers, the use of selective serotonin reuptake inhibitors (SSRIs), tricyclics (TCAs), and selective serotonin reuptake inhibitors (SNRIs) significantly increased the rate of all-cause death (SSRIs (RR = 1.26; 95% CI, 1.19-1.32), TCAs (RR = 1.30; 95% CI, 1.16-1.46), and SNRIs (RR = 1.17; 95% CI, 1.08-1.26)) but not cardiovascular death (SSRIs (RR = 1.03; 95% CI, 0.84-1.26), TCAs (RR = 1.02; 95% CI, 0.86-1.21), and SNRIs (RR = 0.92; 95% CI, 0.48-1.78)). Based on current publications, the use of antidepressants could increase the risk of all-cause death in HF patients, regardless of whether they have depression or the type of antidepressants they use. Further study is needed to determine the relationship between antidepressant use and cardiovascular death.

Association of Excessive Daytime Sleepiness with the Zung Self-Rated Depression Subscales in Adults with Coronary Artery Disease and Obstructive Sleep Apnea

Excessive daytime sleepiness (EDS) is a factor associated with both obstructive sleep apnea (OSA) and depressive symptoms. Continuous positive airway pressure (CPAP) treatment may decrease EDS in adults with OSA; however, the modulatory role of depressive symptoms on the improvement of EDS is not known. We aimed to explore the association between subscales of the Zung Self-rated Depression Scale (SDS) and Epworth Sleepiness Scale (ESS) over a 2-year period in coronary artery disease (CAD) patients with OSA. This was a post-hoc analysis of the RICCADSA cohort, in which 399 adults with CAD (155 sleepy OSA [apnea-hypopnea index ≥ 15/h] and ESS score ≥ 10, who were offered CPAP; and 244 nonsleepy OSA [ESS < 10]), randomized to CPAP [n = 122] or no-CPAP [n = 122]) were included. Three factors were extracted from the Zung SDS, based on the principal component analysis: F1, cognitive symptoms and anhedonia; F2, negative mood; and F3, appetite. In a mixed model, the ESS score decreased by 3.4 points (p < 0.001) among the sleepy OSA phenotype, which was predicted by the decline in the F2, but not in the F1 and F3 scores. The fixed effects of time were not significant in the nonsleepy OSA groups, and thus, further analyses were not applicable. Additional within-group analyses showed a significant decrease in all subscales over time both in the sleepy and nonsleepy OSA patients on CPAP whereas there was a significant increase in the nonsleepy OSA group randomized to no-CPAP. We conclude that the improvement in negative mood symptoms of depression, but not changes in cognitive symptoms and anhedonia as well as appetite, was a significant predictor of decline in the ESS scores over a 2-year period in this CAD cohort with sleepy OSA on CPAP treatment.

A challenge for psychocardiology: Addressing the causes and consequences of patients' perceptions of enduring somatic threat

The enduring somatic threat (EST) model of posttraumatic stress disorder (PTSD) due to life-threatening medical events suggests that PTSD-like symptoms represent patients' sensitization to cues of ongoing threat in the body. In this article, we review research on the prevalence and consequences of such reactions in cardiovascular disease patients, discuss early tests of the EST model, and then report a new test of the EST model in 143 patients enrolled during their first acute coronary syndrome (ACS; i.e., non-ST elevation myocardial infarction or unstable angina-colloquially, "heart attack"). Invasive coronary revascularization procedures are commonly used to reduce secondary ACS risk and may reduce patients' EST, as revascularized patients often report being "cured." We assessed ACS patients' initial threat perceptions during emergency department (ED) evaluation and followed them for 1 month for PTSD symptoms (specific for ACS, by telephone). We compared PTSD symptoms in participants who were revascularized (n = 65), catheterized but not revascularized (n = 35), and medically managed (n = 43). PTSD symptoms were lower for revascularized versus medically managed participants (B = -5.32, 95% confidence interval [-9.77, -0.87]), t(98.19) = -2.37, p = .020. In a multiple regression model adjusted for clinical and psychosocial covariates, the interaction of threat perception in the ED and ACS management group was significant (greater ED threat predicted greater 1-month PTSD symptoms only in medically managed participants). These findings offer further support for the EST model and suggest that psychological interventions to preempt patients' development of EST should be considered in the hospital. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Internet-Delivered Self-management Support for Improving Coronary Heart Disease and Self-management-Related Outcomes: A Systematic Review

INTRODUCTION

Coronary heart disease (CHD) is associated with significant morbidity and mortality, including mental health comorbidity, which is associated with poor outcomes. Self-management is key, but there is limited access to self-management support. Internet-delivered interventions may increase access.

OBJECTIVE

The aim of this study was to conduct a systematic review to (1) determine the effectiveness of Internet-delivered CHD self-management support for improving CHD, mood, and self-management related outcomes and (2) identify and describe essential components for effectiveness.

METHOD

Randomized controlled trials that met prespecified eligibility criteria were identified using a systematic search of 3 healthcare databases (Medline, PsychINFO, and Embase).

RESULTS

Seven trials, which included 1321 CHD patients, were eligible for inclusion. There was considerable heterogeneity between studies in terms of the intervention content, outcomes measured, and study quality. All 7 of the studies reported significant positive between-group effects, in particular for lifestyle-related outcomes. Personalization of interventions and provision of support to promote engagement may be associated with improved outcomes, although more data are required to confirm this. The theoretical basis of interventions was poorly developed though evidence-based behavior change interventions were used.

CONCLUSION

More well-designed randomized controlled trials are needed. These should also explore how interventions work and how to improve participant retention and satisfaction and examine the role of personalization and support within interventions.

Psychological Approaches to the Connection of Health and Behaviour

Although Health Psychology was recognised as a speciality area by the American Psychological Association in 1978, research publications within its domain appeared in the 1930s and earlier. These publications focused on a variety of topics such as treatment for stuttering and rehabilitation from neurological disorders. Current topics in health and behaviour cover a much wider array of issues, and behavioural health research has been described by many investigators as ranging ‘from the cell to society’. This is an ambitious caption for any discipline and it is impossible to cover all aspects of the discipline in this brief summary. The first section of this article, ‘Pathways from society to cell’, describes three themes that characterise much of contemporary behavioural health research. The second section provides a thumbnail sketch of two behavioural health topics: research aimed at disease prevention (primary prevention) and research on stress management, which examines the biological pathways for prevention and the management of existent disease. The third section focuses on the self-management of chronic illness (secondary prevention). It provides a brief overview of research spearheaded by our laboratory and by investigators in laboratories elsewhere. The section pays special attention to the theoretical issues involved in generating a psychological model of health behaviour. We conclude with a brief comment on how these theoretical issues might apply to behavioural health research in emerging nations.

Behavioral Medecine Review: The Lifestyle Factor

Martinsen and Raglin provide a persuasive, evidence-based rationale for lifestyle approaches to the management of anxiety, depressive disorders, and their comorbidities. Yet, their review prompts discussion of the complexities navigating this terrain, including barriers to the identification and management of these common psychological problems in medical settings, the potential of these disorders to complicate health care, and challenges to the implementation of lifestyle interventions for depression and anxiety-related concerns.

The association of comorbid diabetes mellitus and symptoms of depression with all-cause mortality and cardiac rehospitalization in patients with heart failure

BACKGROUND

More than 22% of individuals with diabetes mellitus have concomitant heart failure (HF), and the prevalence of diabetes in those with HF is nearly triple that of individuals without HF. Comorbid depressive symptoms are common in diabetes and HF. Depressive symptoms are an independent predictor of mortality in individuals with diabetes alone, as well as those with HF alone and are a predictor of rehospitalization in those with HF. However, the association of comorbid HF, diabetes and depressive symptoms with all-cause mortality and rehospitalization for cardiac causes has not been determined.

OBJECTIVE

The purpose of this study was to evaluate the association of comorbid HF, diabetes and depression with all-cause mortality and rehospitalization for cardiac cause.

METHOD

Patients provided data at baseline about demographic and clinical variables and depressive symptoms; patients were followed for at least 2 years. Participants were divided into four groups based on the presence and absence of diabetes and depressive symptoms. Cox regression analysis was used to determine whether comorbid diabetes and depressive symptoms independently predicted all-cause mortality and cardiac rehospitalization in these patients with HF.

RESULTS

Patients (n=663) were primarily male (69%), white (76%), and aged 61±13 years. All-cause mortality was independently predicted by the presence of concomitant diabetes and depressive symptoms (HR 3.71; 95% CI 1.49 to 9.25; p=0.005), and depressive symptoms alone (HR 2.29; 95% CI 0.94 to 5.40; p=0.05). The presence of comorbid diabetes and depressive symptoms was also an independent predictor of cardiac rehospitalization (HR 2.36; 95% CI 1.27 to 4.39; p=0.007).

CONCLUSIONS

Comorbid diabetes and depressive symptoms are associated with poorer survival and rehospitalization in patients with HF; effective strategies to regularly evaluate and effectively manage these comorbid conditions are necessary to improve survival and reduce rehospitalization rates.

Zung scale factor invariance in male coronary patients and healthy people

The objective of this study was, firstly, to determine the factor structure and factor invariance of the Zung Self-Rating Depression Scale (ZSDS) and, secondly, to justify its use in coronary patients (CPs) and healthy people (HP). Two comparable samples of males were studied: 217 CPs and 191 HP. Exploratory and confirmatory factor analyses (EFA and CFA) for ordinal data were carried out with Mplus. Two models obtained from all participants in this study and another two, the model of Shafer (2006) from a meta-analysis and that of Barefoot et al. (2000) with CPs, were analyzed in CFA. A two-factor structure was supported by EFA in both samples, but none of the models showed adequate goodness-of-fit for the CPs and the HP in CFA. Only the two and three-factor models obtained from the combined sample of CPs and HP showed adequate goodness-of-fit for HP. The ZSDS showed good reliability, replicated the prevalence of depressive symptoms found in other studies and was able to distinguish between CPs and HP. We conclude that the best fit is obtained from the two-factor solution in HP, that the factor structure of the ZSDS is not invariant and is linked to positively and negatively worded items.

Frequency of depression and anxiety before and after insertion of a continuous flow left ventricular assist device

Our objective was to investigate the course of depression and anxiety symptoms in patients treated with continuous flow (CF) left ventricular assist devices (LVADs). Depression and anxiety are associated with poor outcomes in patients with heart failure, yet few studies have examined such symptoms in patients with CF-LVADs. Depression and anxiety were measured as part of routine clinical care in patients who received a CF-LVAD at our institution from October 2009 to April 2012. Sixty-six patients completed the Patient Health Questionnaire-9, and 48 of 66 patients also completed the Generalized Anxiety Disorder Questionnaire-7. Nineteen of 66 patients completed measures before implantation. Patients who completed measures before and after implantation demonstrated significant improvements in depression and anxiety scores. All patients showed significant improvements in depression and anxiety scores from implantation to the first time point after implantation. Pairwise mean comparisons between time intervals after implantation were not significant. In conclusion, depression and anxiety scores improve after CF-LVAD implantation and remain stable up to 1 year. The improvement does not depend on baseline psychotropic medication use and may be related to improved physical health.

A decline in inflammation is associated with less depressive symptoms after a dietary intervention in metabolic syndrome patients: a longitudinal study

Background

Metabolic syndrome (MetS) and depression have become two prevalent diseases worldwide, whose interaction needs further investigation. Dietary treatment for weight loss in patients with MetS may improve depressive manifestations, however, the precise interactive pathways remain uncertain. Therefore, the aim of this study was to examine the effects of a hypocaloric diet designed to reduce MetS features on self-perceived depression and the possible underlying factors.

Methods

Sixty subjects (Age: 50 ± 1 y; BMI: 36.1 ± 0.6 kg/m²) with MetS were selected from the RESMENA study (control and intervention) after they completed the 6-months hypocaloric treatment and rated for depressive symptoms using the Beck Depression Inventory (BDI). Anthropometric and biochemical measurements including leptin, C-reactive protein (CRP) and insulin levels were evaluated.

Results

Depressive symptoms decreased during the weight loss intervention, with no differences between both dietary groups (control group −4.2 ± 0.8 vs RESMENA group −3.2 ± 0.6, P = 0.490). The number of criteria of the MetS was higher among subjects with more somatic-related depressive symptoms at baseline (B = 1.032, P-trend = 0.017). After six months of dietary treatment, body weight decreased in all subjects (−8.7%; confidence interval (95% CI) = 7.0-9.7) and also self-perceived depression (−37.9%; 95% CI = 2.7-4.9), as well as circulating leptin (−20.1%; 95% CI = 1.8-6.8), CRP (−42.8%; 95% CI = 0.6-3.0) and insulin (−37.7%; 95% CI = 4.1-7.2) concentrations. The decrease in BDI was significantly associated with declines in body fat mass (B = 0.34, 95% CI = 0.11-0.56) and also with the decrease in leptin (B = 0.16, 95% CI = 0.04-0.28) and CRP (B = 0.24, 95% CI = 0.01-0.46) concentrations.

Conclusions

The decrease in depressive manifestations after a weight loss intervention was related with adiposity, CRP and leptin in subjects with MetS.

Trial registration

ClinicalTrials.gov: NCT01087086.

Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association

BACKGROUND

Although prospective studies, systematic reviews, and meta-analyses have documented an association between depression and increased morbidity and mortality in a variety of cardiac populations, depression has not yet achieved formal recognition as a risk factor for poor prognosis in patients with acute coronary syndrome by the American Heart Association and other health organizations. The purpose of this scientific statement is to review available evidence and recommend whether depression should be elevated to the status of a risk factor for patients with acute coronary syndrome.

METHODS AND RESULTS

Writing group members were approved by the American Heart Association's Scientific Statement and Manuscript Oversight Committees. A systematic literature review on depression and adverse medical outcomes after acute coronary syndrome was conducted that included all-cause mortality, cardiac mortality, and composite outcomes for mortality and nonfatal events. The review assessed the strength, consistency, independence, and generalizability of the published studies. A total of 53 individual studies (32 reported on associations with all-cause mortality, 12 on cardiac mortality, and 22 on composite outcomes) and 4 meta-analyses met inclusion criteria. There was heterogeneity across studies in terms of the demographic composition of study samples, definition and measurement of depression, length of follow-up, and covariates included in the multivariable models. Despite limitations in some individual studies, our review identified generally consistent associations between depression and adverse outcomes.

CONCLUSIONS

Despite the heterogeneity of published studies included in this review, the preponderance of evidence supports the recommendation that the American Heart Association should elevate depression to the status of a risk factor for adverse medical outcomes in patients with acute coronary syndrome.

Revealing causal heterogeneity using time series analysis of ambulatory assessments: application to the association between depression and physical activity after myocardial infarction

OBJECTIVE

Studies in psychosomatic medicine are characterized by analyses that typically compare groups. This nomothetic approach leads to conclusions that apply to the average group member but not necessarily to individual patients. Idiographic studies start at the individual patient and are suitable to study associations that differ between time points or between individuals. We illustrate the advantages of the idiographic approach in analyzing ambulatory assessments, taking the association between depression and physical activity after myocardial infarction as an example.

METHODS

Five middle-aged men who had myocardial infarction with mild to moderate symptoms of depression were included in this study. Four of these participants monitored their physical activity and depressive symptoms during a period of 2 to 3 months using a daily self-registration form. The time series of each individual participant were investigated using vector autoregressive modeling, which enables the analysis of temporal dynamics between physical activity and depression.

RESULTS

We found causal heterogeneity in the association between depression and physical activity. Participants differed in the predominant direction of effect, which was either from physical activity to depression (n = 1, 85 observations, unstandardized effect size = -0.183, p = .03) or from depression to physical activity (n = 2, 65 and 59 observations, unstandardized effect sizes = -0.038 and -0.381, p < .001 and p = .04). Also, the persistency of effects differed among individuals.

CONCLUSIONS

Vector autoregressive models are suitable in revealing causal heterogeneity and can be easily used to analyze ambulatory assessments. We suggest that these models might bridge the gap between science and clinical practice by translating epidemiological results to individual patients.

Depressive symptoms after a myocardial infarction and self-care

This descriptive study examined depressive symptoms impacting the performance of self-care behaviors in patients (N = 62) who have experienced a myocardial infarction (MI). Having had a prior MI is inversely associated with decreased self-care behaviors at 30 days. Depressive symptoms of agitation and loss of energy significantly impacted self-care performance 30 days after discharge from the hospital. A variance of 21% (P < .05) in patients who experienced a prior MI and exhibited depressive symptoms of agitation and loss of energy at 30 days suggests patient vulnerability after discharge and a window for therapeutic interventions.

Are somatic symptoms of depression better predictors of cardiac events than cognitive symptoms in coronary heart disease?

Several recent studies have found that somatic symptoms of depression predict cardiac events in patients with established coronary heart disease but cognitive symptoms of depression do not. However, other studies have not supported this finding, and the research in this area is complicated by methodological differences and inconsistencies in the classification of "cognitive" and "somatic" symptoms. In addition, somatic symptoms are more common than cognitive symptoms in cardiac patients and are often associated with more severe depression. These factors may confound the relationship between somatic symptoms and cardiac outcomes. Some reasons why somatic symptoms may be more common than cognitive symptoms in cardiac patients are considered, as well as whether somatic symptoms are likely to be symptoms of depression or of medical illness. Finally, some directions for future research are proposed.

The psychometric properties of the Brief Symptom Inventory depression and anxiety subscales in patients with heart failure and with or without renal dysfunction

More than 5 million Americans have heart failure (HF); approximately one third have concomitant renal dysfunction. Anxiety and depressive symptoms are the most common psychological responses of these individuals and may influences outcomes; thus a reliable valid instrument to measure these is needed. This article reports a psychometric evaluation of the Brief Symptom Inventory (BSI) depression and anxiety subscales in patients with HF and with or without renal dysfunction, as these scales are commonly used in this population for research studies. This rigorous psychometric analysis used existing data from 590 patients with HF with an average ejection fraction of 35% ± 15% and average age of 63 ± 13 years. Patients were categorized as normal renal function (n = 495) or renal dysfunction (n = 95), and groups were compared and analyzed separately. Cronbach's alpha for the BSI subscales was .82 for those with normal renal function and .88 for those with renal dysfunction. Factor analysis determined that the subscales evaluated one dimension, psychological distress, in both groups. Construct validity was examined using hypothesis testing, and construct validity was supported in patients with HF and with normal renal function by significant associations of the BSI subscales with another measure of depression and a measure of perceived control. Construct validity in patients with HF and renal dysfunction was not strongly supported. Only the BSI depression subscale predicted poorer outcomes in patients with HF and with normal renal function; neither subscale was associated with event-free survival at 12 months in those with renal dysfunction. The BSI anxiety and depression subscales provide reliable and valid data in patients HF and normal renal function. Although reliability is excellent, construct validity was weak in those patients with HF and with concomitant renal dysfunction, which may reduce the validity of those data.

Psychological and pharmacological interventions for depression in patients with coronary artery disease

BACKGROUND

Depression occurs frequently in patients with coronary artery disease (CAD) and is associated with a poor prognosis.

OBJECTIVES

To determine the effects of psychological and pharmacological interventions for depression in CAD patients with comorbid depression.

SEARCH STRATEGY

CENTRAL, DARE, HTA and EED on The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ISRCTN Register and CardioSource Registry were searched. Reference lists of included randomised controlled trials (RCTs) were examined and primary authors contacted. No language restrictions were applied.

SELECTION CRITERIA

RCTs investigating psychological and pharmacological interventions for depression in adults with CAD and comorbid depression were included. Primary outcomes were depression, mortality and cardiac events. Secondary outcomes were healthcare costs and health-related quality of life (QoL).

DATA COLLECTION AND ANALYSIS

Two reviewers independently examined the identified papers for inclusion and extracted data from included studies. Random effects model meta-analyses were performed to compute overall estimates of treatment outcomes.

MAIN RESULTS

The database search identified 3,253 references. Sixteen trials fulfilled the inclusion criteria. Psychological interventions show a small beneficial effect on depression compared to usual care (range of SMD of depression scores across trials and time frames: -0.81;0.12). Based on one trial per outcome, no beneficial effects on mortality rates, cardiac events, cardiovascular hospitalizations and QoL were found, except for the psychosocial dimension of QoL. Furthermore, no differences on treatment outcomes were found between the varying psychological approaches. The review provides evidence of a small beneficial effect of pharmacological interventions with selective serotonin reuptake inhibitors (SSRIs) compared to placebo on depression outcomes (pooled SMD of short term depression change scores: -0.24 [-0.38,-0.09]; pooled OR of short term depression remission: 1.80 [1.18,2.74]). Based on one to three trials per outcome, no beneficial effects regarding mortality, cardiac events and QoL were found. Hospitalization rates (pooled OR of three trials: 0.58 [0.39,0.85] and emergency room visits (OR of one trial: 0.58 [0.34,1.00]) were reduced in trials of pharmacological interventions compared to placebo. No evidence of a superior effect of Paroxetine (SSRI) versus Nortriptyline (TCA) regarding depression outcomes was found in one trial.

AUTHORS' CONCLUSIONS

Psychological interventions and pharmacological interventions with SSRIs may have a small yet clinically meaningful effect on depression outcomes in CAD patients. No beneficial effects on the reduction of mortality rates and cardiac events were found. Overall, however, the evidence is sparse due to the low number of high quality trials per outcome and the heterogeneity of examined populations and interventions.

Review of major measuring instruments in comorbid depression and coronary heart disease

Depression and coronary heart disease (CHD) are common comorbid conditions in which each may be a risk factor for the other condition. However, treating depression does not appear to favorably alter cardiac outcome when depression and CHD are comorbid. The National Heart Lung and Blood Institute working group convened in August, 2004 reviewed and recommended instruments to assess and treat depression in subjects with CHD. This paper focuses on these instruments and their limitations when compared and contrasted with the robust instruments available to assess CHD. As a result of our observations about the limitations of instruments and scales available to assess depression and depressive symptoms in subjects with comorbid CHD, we propose using the objectivity of CHD parameters to assess the efficacy of psychiatric interventions in patients with comorbid depression and to better define the link between depression and these cardiac conditions.

Cognitive therapy for depression in patients with heart failure: a critical review

Depression is a significant problem in patients with heart failure (HF). This article examines the evidence for the use of cognitive therapy (CT) in treating depression and depressive symptoms in patients with HF and cardiovascular related illnesses. In 8 of the 14 studies reviewed, researchers found that CT reduced depressive symptoms; however, the limitations of the studies prevent wide generalization of the results. Evidence to support the use of CT for the treatment of depressive symptoms in patients with cardiovascular illness is insufficient at this time. Large randomized controlled trials that demonstrate the efficacy of CT are needed before clinicians routinely refer patients with HF to CT for the purpose of improving depression or depressive symptoms.

Predictors of physical activity at 1 year in a randomized controlled trial of family members of patients with cardiovascular disease

BACKGROUND AND OBJECTIVE

Recommendations for physical activity to lower risk of cardiovascular disease (CVD) are widely known but not often followed. The purpose of this study was to determine the demographic, lifestyle, and psychosocial variables that predict improved physical activity among participants in a CVD prevention lifestyle intervention trial.

SUBJECTS AND METHODS

Adult family members (N = 501; 66% female; 36% nonwhite; mean age, 48 years) of cardiac patients were randomized to a 1-year special intervention that received education on physical activity or to a control intervention. Demographics, physical activity, stage of change, and CVD risk factors were measured systematically at baseline and 1 year (94% follow-up). Lipids were analyzed in a core laboratory. Linear regression models were adjusted for confounders.

RESULTS

At baseline, 21% of participants reported exercising more than 3 d/wk, which did not differ by group assignment. The special intervention and control intervention experienced significant increases in physical activity at 1 year with mean physical activity days per week in the special intervention significantly greater than the control intervention (2.5 vs 2.0 d/wk, P = .03). Significant predictors of increased physical activity at 1 year were group assignment (P = .03), female sex (P = .04), nonminority status (P <.01), greater readiness to change (P <.01), and baseline measurements of lower body mass index (P <.01) and waist size (P <.01), greater diet adherence (P <.01), higher high-density lipoprotein cholesterol (P <.01), lower high-sensitivity C-reactive protein (P = .02), less depression (P <.01), and higher social support (P = .03). In multiple regression models, group assignment, female, and nonminority status remained independent predictors of higher physical activity levels at 1 year.

CONCLUSION

Several predictors of improved physical activity levels at 1 year were documented among clinical trial participants. Racial/ethnic minorities and men were significantly less likely to make positive changes and may need more targeted efforts to improve physical activity levels.

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.

Primary and secondary prevention of cardiovascular diseases: a practical evidence-based approach

Despite the fact that we possess highly effective tools for the primary and secondary prevention of myocardial infarction and other complications of atherosclerosis, coronary heart disease remains the most common cause of death in our society. Arterial inflammation and endothelial dysfunction play central roles in the pathogenesis of atherosclerosis and adverse cardiovascular (CV) events. Therapeutic lifestyle changes in conjunction with an aggressive multidrug regimen targeted toward the normalization of the major CV risk factors will neutralize the atherogenic milieu, reduce vascular inflammation, and markedly decrease the risk of adverse CV events and need for revascularization procedures. Specific CV risk factors and optimal therapies for primary and secondary prevention are discussed.

Primary and secondary prevention of cardiovascular diseases: a practical evidence-based approach

Despite the fact that we possess highly effective tools for the primary and secondary prevention of myocardial infarction and other complications of atherosclerosis, coronary heart disease remains the most common cause of death in our society. Arterial inflammation and endothelial dysfunction play central roles in the pathogenesis of atherosclerosis and adverse cardiovascular (CV) events. Therapeutic lifestyle changes in conjunction with an aggressive multidrug regimen targeted toward the normalization of the major CV risk factors will neutralize the atherogenic milieu, reduce vascular inflammation, and markedly decrease the risk of adverse CV events and need for revascularization procedures. Specific CV risk factors and optimal therapies for primary and secondary prevention are discussed.

Mental disorders and cardiovascular disease among adults in the United States

OBJECTIVE

Numerous population-based studies have found an association between major depression and CVD, though these studies did not assess anxiety disorders. Patient samples have shown associations between anxiety disorders and cardiovascular disease (CVD), but without consideration of depressive disorders. Therefore, it remains unclear whether: (a) both anxiety and depressive disorder are associated with CVD; (b) these associations are generalizable to adults in the community.

MATERIALS AND METHODS

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of 43,093 civilian non-institutionalized participants aged 18 and older.

RESULTS

CVD (total prevalence 3.3%) was associated with increased likelihood of any anxiety disorder (OR=1.43, (1.20, 1.71)), after adjusting for depressive disorders, as well as Generalized Anxiety Disorder (OR=1.48 (1.09, 2.01)), Panic disorder (OR=1.46 (1.12, 1.91)), and specific phobia (OR=1.29 (1.04, 1.59)). CVD was significantly associated with any mood disorder (OR=1.34 (1.13, 1.58)) after adjusting for anxiety disorders, though neither the link with major depression, nor other specific mood disorders remained significant after adjustment.

CONCLUSIONS

Our findings suggest that anxiety disorders, mood disorders, and CVD are highly comorbid among adults in the United States, and demonstrate the importance of including anxiety disorder assessment in studies of mental and physical comorbidity. These results reveal how the lack of investigation into specific relationships between CVD and the range of mental disorders in population-based studies of risk factors for CVD may obscure important relationships.

Introduction: chronic medical conditions and depression--the view from primary care

Martin Hickman maneuvered his way into the office and pulled up his sleeve as the medical assistant put the brake on his wheelchair and attached the blood pressure cuff around his oversized upper arm. A bulky 56-year-old man with a heavy shock of gray hair teetering on the edge of his forehead, his problem list included type 2 diabetes, chronic obstructive pulmonary disease, hypertension, obesity, and hyperlipidemia. For the past 15 years he has used a wheelchair due to T4 paraplegia from a gunshot wound. He has also suffers from bouts of major depression that respond to sertraline but never fully remit. As the medical assistant inflated the cuff, Mr. Hickman smiled weakly and maintained a cheerful façade even after she informed him that his blood pressure was 164/88 mm Hg and his glucose was 267 mg/dl (both well above goal). Later, on more careful questioning by his primary care physician, Hickman admitted that he was feeling “more down than usual” and that he sometimes neglected to take his diabetes medicine and blood pressure pills. Thinking back over the years he had cared for this patient, the physician recalled that December tended to be a particularly bad month. Social isolation, tolerable for most of the year, became painful around the holidays. December also happened to mark the anniversary of Hickman's spinal cord injury. The clock was running, the waiting room was full, and the physician realized he was already falling behind.

Depression in patients with coronary heart disease

Approximately 20% of patients with coronary heart disease (CHD) have major depression and 20% have minor depression at any given point in the course of their illness. Depression causes significant psychological and social morbidity, and is a risk factor for further cardiac morbidity and mortality. Although there are many possible biological and behavioral mechanisms, the causal pathways through which depression increases the risk for cardiac events and death are not well understood. Despite the morbidity associated with depression, and the devastating impact it has on the quality of life of patients with CHD, it is underdiagnosed and often left untreated. This article describes screening techniques for use in primary care and cardiology settings, and discusses the safety and efficacy of available treatments for depression in patients with CHD.

Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association

Depression is commonly present in patients with coronary heart disease (CHD) and is independently associated with increased cardiovascular morbidity and mortality. Screening tests for depressive symptoms should be applied to identify patients who may require further assessment and treatment. This multispecialty consensus document reviews the evidence linking depression with CHD and provides recommendations for healthcare providers for the assessment, referral, and treatment of depression.

Are cholesterol and depression inversely related? A meta-analysis of the association between two cardiac risk factors

BACKGROUND

Cholesterol and depression are both cardiac risk factors, but the direction and magnitude of the association between these risk factors is unclear.

PURPOSE

Meta-analytic techniques were used to evaluate the associations among total, high-, and low-density cholesterol (TC, HDL, LDL, respectively) and depression in empirical studies.

METHODS

PubMed, CINAHL, PsycINFO, and manual search strategies were used to identify descriptive studies reporting associations among TC, HDL, LDL, and depression; 30 reports were found for TC, 16 for HDL, and 11 for LDL. Effect sizes were computed and aggregated in accord with Hedges and Olkin's (Statistical methods for meta-analysis. New York: Academic Press; 1985) procedures.

RESULTS

Higher TC was associated with lower levels of depression, d = -0.29; this association was substantially larger among medication-free samples (d = -0.51). An inverse, non-significant association was observed between LDL and depression (d = -0.17). High HDL was related to higher levels of depression, especially in women (d = 0.20).

CONCLUSIONS

TC and depression were inversely related, with the strongest associations in medically naïve samples, which is noteworthy because such samples should involve fewer confounds. One clinical implication is that the lipids of patients treated for depression should be monitored.

Persistence of posttraumatic stress symptoms 12 and 36 months after acute coronary syndrome

OBJECTIVES

To assess the prevalence and predictors of posttraumatic stress symptoms in patients at 12 and 36 months post hospital admission for an acute coronary syndrome (ACS). There is increasing recognition that posttraumatic stress may develop in the aftermath of an acute cardiac event. However, there has been little research on the longer-term prevalence of posttraumatic stress disorder (PTSD).

METHODS

Posttraumatic stress symptoms were assessed at 12 months in 213 patients with ACS and in 179 patients at 36 months. Predictor variables included clinical, demographic, and emotional factors measured during hospital admission.

RESULTS

At 12 months post ACS, 26 (12.2%) patients qualified for a diagnosis of PTSD; 23 (12.8%) patients were identified with PTSD at 36 months. Posttraumatic symptoms at 12 months were associated with younger age, ethnic minority status, social deprivation, cardiac symptom recurrence, history of depression, depressed mood during admission, hostility, and Type D personality. In multiple regression, depressed mood during admission and recurrent cardiac symptoms were independent predictors of posttraumatic symptoms (R(2) = 0.507, p < .001). At 36 months, posttraumatic stress symptoms were independently predicted by posttraumatic symptom levels at 12 months and depressed mood during admission (R(2) = 0.635, p < .001).

CONCLUSION

Posttraumatic stress symptoms persist for at least 3 years after an acute cardiac event. Early emotional responses are important in predicting longer-term posttraumatic stress. It is important to identify patients at risk for posttraumatic stress as they are more likely to experience reduced quality of life.

Cognitive behavioral therapy for depression in patients with heart failure: a critical review

Depression is a significant problem in patients with heart failure. Cognitive behavioral therapy (CBT) has been proposed as a potential non-pharmacological treatment for depression in patients with heart failure. The purpose of this review is to examine the evidence for the use of CBT in treating depression and depressive symptoms in patients with cardiovascular illness. In six of the ten studied reviewed, researchers found that CBT reduced depressive symptoms; however, the limitations of the studies prevent wide generalization of the results. There is insufficient evidence to support the use of CBT for the treatment of depressive symptoms in patients with cardiovascular illness at this time. Large randomized, controlled trials that demonstrate the efficacy of CBT are needed before nurses routinely refer patients with heart failure to CBT for the purpose of improving depression or depressive symptoms.

The role of depression in the etiology of acute coronary syndrome

Recent research has confirmed that depression is a risk factor for the development and prognosis of coronary heart disease (CHD). Depressive symptoms are associated with the progression of underlying coronary atherosclerosis and clinical events such as acute coronary syndrome (ACS). Depression is poorly recognized and undertreated in patients following ACS, but progress is being made in developing abbreviated measurement tools that can be used in clinical cardiologic practice. Depressive symptoms emerging at various stages of CHD presentation may have different effects on CHD prognosis. The mechanisms mediating the relationship between depression and CHD include vascular inflammation, autonomic and endothelial dysfunction, and behavior patterns such as poor adherence to medication and advice. The optimal methods of managing depression following ACS have not yet been established.

What do general medical guidelines say about depression care? Depression treatment recommendations in general medical practice guidelines

PURPOSE OF REVIEW

Depression is one of the most costly and prevalent mental disorders, and it often co-occurs in patients with general medical conditions. This review identifies the extent to which depression treatment is being addressed in guidelines for general medical illness treatment.

RECENT FINDINGS

We conducted a review of the literature published within the past year pertaining to depression treatment guidelines in medical care. We also conducted a systematic review of available practice guidelines listed by the Agency for Research and Quality to assess the extent to which depression treatment is being addressed in current general medical treatment guidelines. Overall, only a handful of articles addressed treatment of depression within the context of general medical care, and most only addressed screening. Among 199 available practice guidelines for general medical conditions, only 83 mentioned depression treatment, and the majority of these only addressed depression screening.

SUMMARY

To improve outcomes in patients with co-occurring general medical conditions, general medical guidelines should include specific recommendations for treating and co-managing depression. Additional strategies that facilitate the translation of guidelines into routine practice, address the management of multiple chronic illnesses, and reduce the stigma of mental illness are also needed.

Recent evidence linking coronary heart disease and depression

OBJECTIVES

To review the recent literature on the relation between depression and coronary heart disease (CHD), including both etiologic studies (that is, depression preceding development of CHD) and prognostic studies (that is, depression predicting prognosis in established CHD), and to assess the degree to which the literature supports a causal interpretation of the link between depression and CHD.

METHOD

We searched the MEDLINE, Current Contents, and PsycINFO databases for articles published between December 15, 2003, and December 15, 2005, containing combinations of several key words related to CHD, prognosis, and depression. We reviewed papers for evidence of 6 rule-of-thumb criteria for making causal inferences: objective CHD outcome measures, prospective designs, results showing consistent and strong dose-response relations, adequate covariate adjustment, biological plausibility, and evidence from clinical trials that changing depression alters CHD risk.

RESULTS

We found 8 recent etiologic studies, 16 prognostic studies, 2 publications with both types of data, and 23 review papers. Although there was much methodological variability concerning measurement of depression and assessment of cardiac outcomes, the recent etiologic studies increase the evidence of a role for depression. Recent prognostic data are less consistent. Small studies showing no link between depression and CHD prognosis continue to appear, despite lack of adequate statistical power.

CONCLUSIONS

The recent literature continues to support both an etiologic and a prognostic role for depression in CHD. Despite this evidence, there have been few clinical trials of depression treatment in CHD patients and no clinical trials of depression prevention. Additional trials are needed.