Base Rates of Depressive Symptoms in Patients with Coronary Heart Disease: An Individual Symptom Analysis

Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments

OBJECTIVE

Patients with persistent somatic symptoms (PSS) experience stigmatising attitudes and behaviours by healthcare professionals. While previous research has focussed on individual manifestations of PSS related stigma, less is known about sound ways to measure stigmatisation by healthcare professionals towards patients with PSS. This review aims to assess the quality of questionnaire measurement instruments and make recommendations about their use.

METHODS

A systematic review using six databases (PubMed, Embase, CINAHL, PsycINFO, Open Grey and EThOS). The search strategy combined three search strings related to healthcare professionals, PSS and stigma. Additional publications were identified by searching bibliographies. Three authors independently extracted the data. Data analysis and synthesis followed COSMIN methodology for reviews of outcome measurement instruments.

RESULTS

We identified 90 publications that met the inclusion criteria using 62 questionnaire measurement instruments. Stereotypes were explored in 92% of instruments, prejudices in 52% of instruments, and discrimination in 19% of instruments. The development process of the instruments was not rated higher than doubtful. Construct validity, structural validity, internal consistency and reliability were the most commonly investigated measurement properties. Evidence around content validity was inconsistent or indeterminate.

CONCLUSION

No instrument provided acceptable evidence on all measurement properties. Many instruments were developed for use within a single publication, with little evidence of their development or establishment of content validity. This is problematic because stigma instruments should reflect the challenges that healthcare professionals face when working with patients with PSS. They should also reflect the experiences that patients with PSS have widely reported during clinical encounters.

Persistent SOMAtic symptoms ACROSS diseases - from risk factors to modification: scientific framework and overarching protocol of the interdisciplinary SOMACROSS research unit (RU 5211)

INTRODUCTION

Persistent somatic symptoms (PSS) are highly prevalent in all areas of medicine; they are disabling for patients and costly for society. The subjective symptom burden often correlates poorly with the underlying disease severity, and patients' needs for effective treatment are far from being met. Initial evidence indicates that, in addition to disease-specific pathophysiological processes, psychological factors such as expectations, somatosensory amplification and prior illness experiences contribute to symptom persistence in functional as well as in somatic diseases. However, prospective studies investigating the transition from acute to chronic somatic symptoms, integrating pathophysiological, psychological and social factors, are scarce. A better understanding of the multifactorial mechanisms of symptom persistence is crucial for developing targeted mechanism-based interventions for effective prevention and treatment of PSS. Thus, the overall aim of the interdisciplinary SOMACROSS research unit is to identify generic and disease-specific risk factors and aetiological mechanisms of symptom persistence across a range of diseases.

METHODS AND ANALYSIS

Seven projects will investigate risk factors and mechanisms of symptom persistence in a total of 3916 patients across 10 medical conditions. All study designs are prospective and share common assessment points, core instruments and outcome variables to allow comparison and validation of results across projects and conditions. Research will focus on the identification of generic and disease-specific mechanisms associated with unfavourable symptom course. The development of a multivariate prediction model will facilitate the understanding of the course of PSS across diseases.

ETHICS AND DISSEMINATION

All individual SOMACROSS studies were approved by the ethics committees of the Medical Chambers Hamburg and Münster, Germany. Findings will be disseminated through peer-reviewed publications, scientific conferences and the involvement of relevant stakeholders, patients and the lay public. This interdisciplinary research unit will fundamentally contribute to earlier recognition of patients at risk, and to the development of prevention and tailored treatment concepts for PSS.

CYP2C19 genotype, physician prescribing pattern, and risk for long QT on serotonin selective reuptake inhibitors

Aim: To examine the impact of CYP2C19 genotype on selective serotonin reuptake inhibitor (SSRI) prescribing patterns. Patients & methods: Observational cohort containing 507 unique individuals receiving an SSRI prescription with CYP2C19 genotype already in their electronic medical record. Genotype was distributed as follows: n = 360 (71%) had no loss of function alleles, 136 (26.8%) had one loss of function allele and 11 (2.2%) had two loss of function alleles. Results & conclusion: For poor metabolizers exposed to sertraline, citalopram or escitalopram, providers changed prescribing patterns in response to alerts in the electronic medical record by either changing the drug, changing the dose or monitoring serial EKGs longitudinally. For intermediate metabolizers exposed to sertraline, citalopram or escitalopram, no alert was needed (mean QTc = 440.338 ms [SD = 31.1273] for CYP2C19*1/*1, mean QTc = 440.371 ms [SD = 29.2706] for CYP2C19*1/*2; p = 0.995).

Assessment of perceived mental health-related stigma: The Stigma-9 Questionnaire (STIG-9)

Mental health-related stigma is common and inhibits help-seeking. It triggers fears of devaluation and can add to the burden of a mental disorder. To counter the consequences of mental health-related stigma, its sound assessment is crucial. Therefore, we developed a new measure, the Stigma-9 Questionnaire (STIG-9), and evaluated its psychometric properties and applicability in patients with mental disorders. Item development was based on the modified labelling theory, psychometric reasoning, and discussion with focus groups including patients and clinicians. Data from 919 consecutive patients from an outpatient clinic for mental disorders (69% female, mean age 41 (SD = 14) years) was used to psychometrically evaluate the measure. The STIG-9 consists of nine items assessing cognitive, behavioural and affective aspects of perceived mental health-related stigma. Higher scores indicate stronger expectations of negative societal beliefs, feelings, and behaviours towards 'mentally ill' people. Confirmatory factor analysis revealed a single factor structure. The scale showed high internal consistency. Male gender, social impairment and higher levels of psychopathology corresponded with higher STIG-9 scores. The STIG-9 is a new, theory-grounded, patient-oriented and psychometrically promising self-report measure of perceived mental health-related stigma. It is brief, comprehensive, and appears to be well accepted by patients with mental disorders.

Frequency and predictors of depression in congestive heart failure

Background

Depression in congestive heart failure (CHF) patients can increase morbidity and mortality. Given the ever-rising prevalence of CHF patients with depression, it is vital that we understand the predictors of depression in these patients to identify and better manage these patients. The main objective of this study was to evaluate the frequency and predictors of depression in CHF patients.

Methods

A cross-sectional study was conducted in a tertiary care hospital. Patients with a diagnosis of CHF for more than 6 months based on signs and left ventricular ejection fraction <40% were included. Patients were interviewed with the Patient Health Questionnaire-9 (PHQ-9) consisting of nine items in line with the Diagnostic and Statistical Manual (DSM) - IV criteria to assess depression. Each item was scored from 0 to 3, and a PHQ-9 score of 10 or greater suggested clinical depression. Data were analyzed on SPSS, v22, and a p < 0.05 was considered significant.

Results

Of 170 participants, 102 (60%) had depression. Among these 102 patients, 42% (n = 43) had mild depression, and the rest (n = 59) had moderate-to-severe depression. Predictors of depression were New York Heart Association stage 3 or 4 (p = 0.001), previous myocardial infarction (p = 0.001), living without a partner (p = 0.001), lack of a joint family system (p = 0.001), sedentary lifestyle (p = 0.001), aged 70 years or more (p = 0.01), and having been admitted in a hospital at least once in the past two months (p = 0.002).

Conclusion

Depression is common among patients with CHF. It is associated with multiple factors and needs to be addressed and targeted urgently.

Symptom patterns and clinical outcomes in women versus men with systolic heart failure and depression

BACKGROUND

Depression is more common in females than in males and is 3-5 times more prevalent in patients with heart failure (HF) than in the general population. The 9-item Patient Health Questionnaire (PHQ-9) is a validated depression screening instrument; higher sum-scores predict adverse clinical outcomes. Sex- and gender differences in PHQ-9 symptom profile, diagnostic and prognostic properties, and impact on health-related quality of life (HRQOL) have not been comprehensively studied in HF patients.

METHODS AND RESULTS

This post hoc analysis from the Interdisciplinary Network Heart Failure program enrolled 852/1022 participants (67 ± 13 years, 28% female) who completed the PHQ-9 at hospital discharge after cardiac decompensation. All had a left ventricular ejection fraction ≤ 40%. Women had a higher mean PHQ-9 sum-score than men (8.4 ± 5.6 vs. 7.4 ± 5.5; p = 0.027), and higher proportions rated the following items ≥ 2 (i.e., present on ≥ 50% of days): 'feeling down, hopeless' (25.8 vs. 18.0%; p = 0.011); 'fatigue' (51.9 vs. 37.2%; p < 0.001); and 'trouble concentrating' (21.6 vs. 15.4%; p = 0.032). A PHQ-9 sum-score ≥ 10 predicted increased mortality in women [hazard ratio 1.91 (95% confidence interval 1.06-3.43); p = 0.030] and men [2.10 (1.43-3.09); p < 0.001] and was associated with worse HRQOL (p < 0.001 for all comparisons). Sum-scores ≥ 10 predicted higher re-hospitalization rates in men only [1.35 (1.08-1.69); p = 0.008].

CONCLUSIONS

Differences in several PHQ-9 items indicated sex- or gender-specific depression symptomatology in HF. For both sexes, HRQOL and survival were worse when PHQ-9 sum-score was ≥ 10, but higher sum-scores predicted higher re-hospitalization rates in men only. Considering these specific aspects might help optimize care strategies in HF.

Suicidal ideation in patients with coronary heart disease and hypertension: Baseline results from the DEPSCREEN-INFO clinical trial

BACKGROUND

A high proportion of cardiac patients suffers from depression, which is an antecedent for suicidal ideation. This study identifies clinical vulnerabilities for suicidal ideation in cardiac patients.

METHODS

The primary outcome of the study was severity of suicidal ideation as measured with the Patient Health Questionnaire (PHQ-9) item No. 9. Covariates were demographics, cardiac characteristics (i.e., Canadian Cardiovascular Society angina rating of chest pain and New York Heart Association rating of shortness of breath), depression (PHQ-8,i.e., PHQ-9 minus item No. 9), anxiety (Generalized Anxiety Disorder-7, GAD-7), somatic symptoms (PHQ-15), illness perception (Brief-Illness Perception Questionnaire), and health-related quality of life (EuroQol-5D, EQ 5D).

RESULTS

Data from 1,976 patients were analysed. At least 14% (95% CI [12%, 16%]) of patients indicated suicidal ideations within the last 2 weeks. Bivariate analyses yielded associations between suicidal ideation and higher levels of depression severity, anxiety severity, somatic symptom burden, chest pain, shortness of breath, negative illness perceptions, reduced health-related quality of life, and a higher probability of living alone (all p < 0.001). A multivariable ordinal regression revealed depression severity and anxiety severity to show the highest associations with suicidal ideation (OR_PHQ-8  = 1.22, p < 0.001; OR_GAD-7  = 1.09, p < 0.001). Having a defibrillator implant was associated with a lower probability of suicidal ideation (OR = 0.27, p = 0.017).

CONCLUSIONS

This study identified several clinical vulnerabilities of suicidal ideation. The results stress the importance of screening for suicidal ideation in clinical practice.