François Lespérance

Gender, Depression, and One-Year Prognosis After Myocardial Infarction

OBJECTIVE The purpose of this study was to assess gender differences in the impact of depression on 1-year cardiac mortality in patients hospitalized for an acute myocardial infarction (MI). METHODS Secondary analysis was performed on data from two studies that used the Beck Depression Inventory (BDI) to assess depression symptoms during hospitalization: a prospective study of post-MI risk and a randomized trial of psychosocial intervention (control group only). The sample included 896 patients (283 women) who survived to discharge and received usual posthospital care. Multivariate logistic regression analysis was used to assess the risk of 1-year cardiac mortality associated with baseline BDI scores. RESULTS There were 290 patients (133 women) with BDI scores > or =10 (at least mild to moderate symptoms of depression); 8.3% of the depressed women died of cardiac causes in contrast to 2.7% of the nondepressed. For depressed men, the rate of cardiac death was 7.0% in contrast to 2.4% of the nondepressed. Increased BDI scores were significantly related to cardiac mortality for both genders [the odds ratio for women was 3.29 (95% confidence interval (CI) = 1.02-10.59); for men, the odds ratio was 3.05 (95% CI = 1.29-7.17)]. Control for other multivariate predictors of mortality in the data set (age, Killip class, the interactions of gender by non-Q wave MI, gender by left ventricular ejection fraction, and gender by smoking) did not change the impact of the BDI for either gender. CONCLUSIONS Depression in hospital after MI is a significant predictor of 1-year cardiac mortality for women as well as for men, and its impact is largely independent of other post-MI risks.

Depression and Anxiety as Predictors of 2-Year Cardiac Events in Patients With Stable Coronary Artery Disease

CONTEXT Anxiety and depression are associated with mechanisms that promote atherosclerosis. Most recent studies of emotional disturbances in coronary artery disease (CAD) have focused on depression only. OBJECTIVE To assess the 2-year cardiac prognostic importance of the DSM-IV-based diagnoses of major depressive disorder (MDD) and generalized anxiety disorder (GAD) and self-report measures of anxiety and depression and their co-occurrence. DESIGN, SETTING, AND PATIENTS Two-year follow-up of 804 patients with stable CAD (649 men) assessed using the Beck Depression Inventory II (BDI-II), the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A), and the Structured Clinical Interview for DSM-IV (masked to self-reports) 2 months after acute coronary syndromes. MAIN OUTCOME MEASURES Major adverse cardiac events (MACEs) (cardiac death, myocardial infarction, cardiac arrest, or nonelective revascularization) in the 2 years after baseline. RESULTS Of the 804 patients, 57 (7.1%) met the criteria for MDD [major depressive disorder] and 43 (5.3%) for GAD [generalized anxiety disorder] (11 [1.4%] had comorbidity); 220 (27.4%) had elevated BDI-II [Beck Depression Inventory II] scores (≥14), and 333 (41.4%) had elevated HADS-A [Hospital Anxiety and Depression Scale] scores (≥8), with 21.1% overlap. Major depressive disorder (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.38-4.73), GAD (OR, 2.47; 95% CI, 1.23-4.97), elevated BDI-II (OR, 1.81; 95% CI, 1.20-2.73), elevated HADS-A score (OR, 1.66; 95% CI, 1.12-2.47), and continuous standardized scores on the BDI-II (OR, 1.31; 95% CI, 1.05-1.62) and the HADS-A (OR, 1.43; 95% CI, 1.19-1.73) all predicted MACEs [major adverse cardiac events]. [correction]. After covariate control, only the P value associated with the continuous BDI-II score increased to above .10. Most of the risk associated with elevated symptoms was in patients with psychiatric disorders. However, patients with comorbid MDD and GAD or elevated anxiety and depression symptoms were not at greater MACE risk than those with only 1 factor. CONCLUSION Anxiety and depression predict greater MACE risk in patients with stable CAD, supporting future research into common genetic, environmental, and pathophysiologic pathways and treatments.

Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction

BACKGROUND Increases in life stress have been linked to poor prognosis, after myocardial infarction (MI). Previous research suggested that a programme of monthly screening for psychological distress, combined with supportive and educational home nursing interventions for distressed patients, may improve post-MI survival among men. Our study assessed this approach for both men and women. We aimed to find out whether the programme would reduce 1-year cardiac mortality for women and men. METHODS We carried out a randomised, controlled trial of 1376 post-MI patients (903 men, 473 women) assigned to the intervention programme (n = 692) or usual care (n = 684) for 1 year. All patients completed a baseline interview that included assessment of depression and anxiety. Survivors were also interviewed at 1 year. FINDINGS The programme had no overall survival impact. Preplanned analyses showed higher cardiac (9.4 vs 5.0%, p = 0.064) and all-cause mortality (10.3 vs 5.4%, p = 0.051) among women in the intervention group. There was no evidence of either benefit or harm among men (cardiac mortality 2.4 vs 2.5%, p = 0.94; all-cause mortality 3.1 vs 3.1%, p = 0.93). The programmes impact on depression and anxiety among survivors was small. INTERPRETATION Our results do not warrant the routine implementation of programmes that involve psychological-distress screening and home nursing intervention for patients recovering from MI. The poorer overall outcome for women, and the possible harmful impact of the intervention on women, underline the need for further research and the inclusion of adequate numbers of women in future post-MI trials.

The impact of negative emotions on prognosis following myocardial infarction: is it more than depression?

This study examine the importance of major depression symptoms, history of major depression, anxiety, anger-in, anger-out, and perceived social support, measured in the hospital after a myocardial infarction (MI), in predicting cardiac events over the subsequent 12 months in a sample of 222 patients. Cardiac events included both recurrences of acute coronary syndromes (unstable angina admissions and survived and nonsurvived MI recurrences) and probable arrhythmic events (survived cardiac arrests and arrhythmic deaths). Major depression, depressive symptoms, anxiety, and history of major depression all significantly predicted cardiac events. Multivariate analyses showed that depressive symptoms, anxiety, and history of major depression each had an impact independent of each other, as well as of measures of cardiac disease severity.

Depression in patients with cardiac disease: A practical review.

Some degree of depression affects at least 30% of hospitalized patients with coronary artery disease (CAD), and is associated with increased risks of mortality and continuing depression over at least the first year following hospital discharge. Despite its consequences for prognosis and quality of life, depression is underrecognized and undertreated in cardiac patients. The diagnosis of depression is complicated in patients with medical illness. Their symptoms can reflect physical as well as psychological complaints. Many CAD patients resist the idea of additional medications, and drug interactions can be problematic for those willing to accept antidepressant treatment. Finally, depression tends to recur. Its successful treatment requires a long-term commitment from both physician and patient. This article examines the special challenges involved in diagnosing depression in patients with CAD, outlines available psychotherapeutic and pharmacological treatments, and considers the issues involved in deciding which patients to treat, with what approach, and for how long.

Reflections on depression as a cardiac risk factor.

Objective: Major North American cardiology organizations do not currently list depression among the officially recognized cardiac risk factors, yet many behavioral medicine specialists believe depression to be an important risk. We wondered what was missing from the available data. Methods: The Medline, Current Contents, and PsychInfo databases were used to perform a systematic review of the literature linking depression and depressive symptoms with cardiac disease outcomes. Because of previous reviews, we paid particular attention to publications from 2001 to 2003. Results: We identified 21 etiologic and 43 prognostic publications that had prospective designs, used recognized measures of depression, and included objective outcome measures. We also identified 79 review articles. In addition to issues of sample size, sample characteristics, and timing of measures, we noted heterogeneity in the definitions of depression, frequent repeat publications from the same data sets, heterogeneity of outcome measures, a variety of approaches for covariate selection, and a preponderance of review articles, all factors that cannot help to convince skeptics. Conclusions: Despite these issues, the bulk of the data from prospective studies with recognized indices of depression and objective outcome measures is supportive of depression as a cardiac risk factor. CHD = coronary heart disease; MI = myocardial infarction.

Major depression is associated with lower omega-3 fatty acid levels in patients with recent acute coronary syndromes.

BACKGROUND Polyunsaturated fatty acids (PUFAs) are intrinsic cell membrane components and closely involved in neurotransmission and receptor function. Lower omega-3 levels are associated with increased risk of coronary artery disease (CAD), increases in cardiac events in CAD patients, and depression. We sought to examine relationships between depression and serum levels of omega-3 and omega-6 PUFAs in patients recovering from acute coronary syndromes (ACS). METHODS We carried out a case-control study of serum PUFA levels and current major depression in 54 age- and sex-matched pairs approximately 2 months following ACS. RESULTS Depressed patients had significantly lower concentrations of total omega-3 and docosahexaenoic acid (DHA), and higher ratios of arachidonic acid (AA) to DHA, AA to eicosapentaenoic acid (EPA), and n-3 to n-6 than controls. There were no baseline differences in any potential risk or protective factors for depression. CONCLUSIONS Results are consistent with previous reports in depressed patients without CAD, and with literature concerning omega-3 levels and risk of CAD events. Dietary, genetic, and hormonal factors may all play a role in both depression and CAD. Both prospective studies and randomized trials are needed to help clarify the interrelationships.

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.

Assessment and treatment of depression in patients with cardiovascular disease: National Heart, Lung, and Blood Institute Working Group Report.

Objective: The National Heart, Lung, and Blood Institute convened an interdisciplinary working group of experts to develop recommendations for the assessment and treatment of depression in patients with coronary heart disease (CHD). Method: Consensus of experts. Results: Our current recommendations are that the Beck Depression Inventory-I be employed for epidemiological studies of depression and CHD, that the Patient Health Questionnaire 2-item version be employed for screening for trial eligibility, that the Depression Interview and Structured Hamilton (DISH) be employed for diagnostic ascertainment for trial inclusion, and that the Hamilton rating scale, which is part of the DISH, be employed for both depression symptom reduction and the remission criterion in any trial. We further recommend that a randomized controlled trial be undertaken to determine whether selective serotonin reuptake inhibitors, psychotherapy, or combined treatment can reduce the risk of CHD events and mortality associated with depression in CHD patients. Conclusions: This report summarizes the recommendations made by the working group and discusses the rationale for each recommendation, the strengths and weaknesses of alternative approaches to assessment and treatment, and the implications for future research in this area. ACS = acute coronary syndrome; BDI = Beck Depression Inventory; CBASP = Cognitive Behavioral Analysis System of Psychotherapy; CBT = cognitive behavior therapy; CIDI = Composite International Diagnostic Interview; CHD = coronary heart disease; CVD = cardiovascular disease; DISH = Depression Interview and Structured Hamilton; ENRICHD = Enhancing Recovery in Coronary Heart Disease; HAM-D = Hamilton Rating Scale for Depression; IDS-SR = Inventory of Depressive Symptomatology, self-report; IMPACT = Improving Mood–Promoting Access to Collaborative Treatment; IPT = interpersonal therapy; MI = myocardial infarction; NHLBI = National Heart, Lung, and Blood Institute; PHQ = Patient Health Questionnaire; RCT = randomized controlled trial; SADHART = Sertraline Antidepressant Heart Attack Randomized Trial; SCID = Structured Clinical Interview for DSM-IV; SSRI = selective serotonin reuptake inhibitor; STAR*D = Sequenced Treatment Alternatives to Relieve Depression.

Depression and health-care costs during the first year following myocardial infarction

OBJECTIVE Depression in the hospital after myocardial infarction (MI) has been associated with a substantial increase in the long-term risk of cardiac mortality, but little is known about other outcomes. This study uses Quebec Medicare data to examine the relationship between post-MI depression and physician costs, including both out-patient care and hospital readmissions. METHODS The sample consists of 848 1-year survivors of an acute MI who had completed the Beck Depression Inventory (BDI) in hospital. Two hundred sixty subjects had BDI scores of >/=10 (30.7%), indicative of mild to moderate symptoms of depression. Quebec Medicare data during the index admission for an acute MI and during the year following discharge were compared for the patients with elevated BDI scores and those with normal scores. RESULTS Total costs, in Canadian dollars (out-patient physician charges plus physician costs during admissions plus estimates of associated direct costs), were about 41% higher (p = 0.004) for patients with elevated BDI scores. The difference was primarily related to out-patient and emergency room visits and readmission costs associated with longer stays in hospital wards, and was not accounted for by use of psychiatric services or readmissions for revascularization. CONCLUSION Results suggest that, in addition to the survival risks associated with post-MI depression, there are increased health care costs linked to both readmissions and out-patient contacts among depressed patients who survive the first post-MI year. The extent to which the increased use of health care may have reduced depression and enhanced survival remains unclear.