Jacqueline J. M. H. Strik

One year cumulative incidence of depression following myocardial infarction and impact on cardiac outcome

BACKGROUND Major depression has been identified as an independent risk factor for increased morbidity and mortality in mixed patients populations with first and recurrent myocardial infarction (MI). The aim of this study was to evaluate whether incidence of major and minor depression is as high in a population with merely first-MI patients as in recurrent MI populations. Furthermore, it was evaluated whether in first-MI patients major and minor depression, and depressive symptoms, had an impact on cardiac mortality and morbidity up to 3 years post MI. METHODS A consecutive cohort of 206 patients with a first MI were included in this study. One month following MI, all patients were interviewed using the Structured Clinical Interview for DSM-IV (SCID-I-R). Three, six, nine and twelve months following MI, patients filled out three psychiatric self-rating scales for depression, the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale (HADS), and the 90-item Symptom Checklist (SCL-90). Patients, exceeding a previously defined cut-off value on at least one of these scales, were reinterviewed using the SCID. The BDI was applied to assess depressive symptoms in relation to cardiac outcome as the SCL-90 and HADS showed similar results. Cardiac outcome was defined as major cardiac event, i.e., death or recurrent MI, and health care consumption, i.e., cardiac rehospitalisation and/or frequent visits at the cardiac outpatient clinic. Depression outcome was assessed from 1 month post MI up to 1 year post MI whereas cardiac outcome was assessed between 1 month and 3 years post MI. RESULTS A 1-year incidence of 31% of major and minor depression was found in first-MI patients. The highest incidence rate for both major and minor depression was found in the first month after MI. Compared with nondepressed patients, depressed patients were younger (P=.001), female (P=.04) and were known with a previous depressive episode (P=.002). Neither major/minor depression nor depressive symptoms significantly predicted major cardiac events, but did predict health care consumption (P=.04 and P<.001, respectively). CONCLUSIONS Incidence of major and minor depression is similar in this first-MI patients population as in recurrent MI populations. Major/minor depressive disorder nor depressive symptoms predicted neither mortality nor reinfarction.

Recognizing Increased Risk of Depressive Comorbidity after Myocardial Infarction: Looking for 4 Symptoms of Anxiety-Depression

Background: Screening for depression in myocardial infarction (MI) patients must be improved: (1) depression often goes unrecognized and (2) anxiety has been largely overlooked as an essential feature of depression in these patients. We therefore examined the co-occurrence of anxiety and depression after MI, and the validity of a brief mixed anxiety-depression index as a simple way to identify post-MI patients at increased risk of comorbid depression. Methods: One month after MI, 176 patients underwent a psychiatric interview and completed the Beck Depression Inventory (BDI) and the Symptoms of Anxiety-Depression index (SAD4) containing four symptoms of anxiety (tension, restlessness) and depression (feeling blue, hopelessness). Results: Thirty-one MI patients (18%) had comorbid depression and 37 (21%) depressive or anxiety disorder. High factor loadings and item-total correlations (SAD4, α = 0.86) confirmed that symptoms of anxiety and depression co-occurred after MI. Mixed anxiety-depression (SAD4≧3) was present in 90% of depressed MI patients and in 100% of severely depressed patients. After adjustment for standard depression symptoms (BDI; OR = 4.4, 95% CI 1.6–12.1, p = 0.004), left ventricular ejection fraction, age and sex, mixed anxiety-depression symptomatology was associated with an increased risk of depressive comorbidity (OR = 11.2, 95% CI 3.0–42.5, p < 0.0001). Mixed anxiety-depression was also independently associated with depressive or anxiety disorder (OR = 9.2, 95% CI 3.0–27.6, p < 0.0001). Conclusions: Anxiety is underrecognized in post-MI patients; however, the present findings suggest that anxiety symptomatology should not be overlooked in these patients. Depressive comorbidity after MI is characterized by symptoms of mixed anxiety-depression, after controlling for standard depression symptoms. The SAD4 represents an easy way to recognize the increased risk of post-MI depression.

Beta-thromboglobulin and platelet factor 4 levels in post-myocardial infarction patients with major depression

Platelet factor 4 (PF 4) and beta-thromboglobulin (beta-TG) were studied in 12 depressed post-myocardial infarction (MI) patients and 12 matched non-depressed post-MI patients. PF4 was significantly higher in the depressed group than in the non-depressed group. beta-TG was increased in the depressed subgroup, but the difference was not statistically significant.

Cardiac side-effects of two selective serotonin reuptake inhibitors in middle-aged and elderly depressed patients

Selective serotonin reuptake inhibitors (SSRIs) are the ‘new’ drugs of first choice for the treatment of depression in the older patient. Systematic studies on the effects of SSRIs on cardiac function are scarce, despite the high prevalence of cardiac disorders in the older depressed patient. This is a study which systematically assesed cardiac function by echo-cardiography in middle-aged and elderly depressed patients treated with SSRI. In a double-blind randomized trial, 20 patients were assigned to receive fluvoxamine 20 mg/day or fluoxetine 100mg/day for 6 weeks. Cardiac function was assessed by left ventricle ejection fraction, aortic flow integral and early or passive/late or active mitral inflow, and electrocardiography. Neither SSRI significantly affected cardiac function. Compared with patients without a history of myocardial infarction and/or hypertension, patients with such a history showed a significant improvement in left ventricular ejection fraction. Despite our small study sample, these data indicate that both fluoxetine and fluvoxamine do not affect cardiac function adversely.

Managing complex patients on a medical psychiatric unit: An observational study of university hospital costs associated with medical service use, length of stay, and psychiatric intervention

OBJECTIVE Although there is a suggestion that the medical psychiatric unit (MPU) may reduce length of hospital stay (LOS), little is known about costs in terms of medical service use and psychiatric interventions in MPU care. METHOD A record linkage study was conducted, linking cost data of hospital medical service use, LOS, and hospital psychiatric interventions to patients admitted to the MPU of the Maastricht University Medical Centre (MUMC) between 1998 and 2004. The data set was analyzed to enable comparison between cost changes of the same complex patient population following either MPU index admission or index admissions to reference MUMC medical wards. RESULTS Comparisons revealed lower costs of medical service use in favor of the MPU (-euro104; 95% CI -euro174 to -euro35; P<.01). However, cost of psychiatric intervention and cost of LOS were higher after MPU admission (respectively, +euro165; 95% CI +euro25 to +euro305; P<.05; and +euro202; 95% CI +euro170 to +euro235; P<.001). Total costs were higher after MPU admission compared to medical ward admission (+euro263; 95% CI +euro68 to +euro458; P<.05). These differences were not moderated by somatic diagnosis or previous pattern of admissions. CONCLUSION The findings suggest that patients at the interface of psychiatric and somatic morbidity are diagnosed and treated adequately at the MPU, leading to a decrease in medical service use and an appropriate increase in exposure to psychiatric interventions. These results are specifically generalizable to MPUs with a focus on psychosomatic conditions, for instance, somatoform disorders or affective disorders with comorbid somatic diseases. However, failure to show cost savings in terms of LOS compared to medical wards outweighs cost-benefit derived from lower medical service use, suggesting that MPU activities may gain in cost-effectiveness if shifted more to outpatient psychosomatic care solutions.

Clinical correlates of depression following myocardial infarction.

Objective: Post-MI depression increases mortality, especially in the first 18 months after MI. Identifying patients at risk for post-MI depression is therefore important. In the present study we investigated possible correlates for post-MI depression on an a priori basis. Method: Based on the literature, four clinically easily attainable variables were selected as possible correlates for post-MI depression. These were prescription of benzodiazepines during acute hospitalization, cardiac complications during acute hospitalization, history of depression, and not being able to stop smoking within six months after MI. A consecutive cohort of 173 first-MI patients was screened with the SCL-90 depression scale and DSM-III-R citeria for major depression. Of this cohort 35 depressed patients were compared with 35 non-depressed post-MI patients, matched for gender, age, and severity of MI. Results: In univariate analyses, complications during hospitalisation (OR = 2.14; CI = 0.89–5.14), prescription of benzodiazepines (OR = 3.67; CI = 1.11–12.1), history of depression (OR = 3.0; CI = 0.87–10.4), and not being able to stop smoking (OR = 4.5; CI = 1.11–18.2) were clinical correlates for post-MI depression. Multivariate analyses showed that none of these variables were independent of the others in predicting depression. Conclusions: A number of easily measurable patient characteristics identify those MI-patients at risk of post-MI depression. Further investigations should focus on the predictive value of these factors in relation to post-MI depression.

Catatonia and refractory agitation in an updated flow chart for the evaluation of emotional-behavioral disturbances in severely ill children

Dear Editor, A flow chart regarding the evaluation and management of emotional– behavioral disturbances in severely ill children admitted to a pediatric intensive care unit (PICU) was presented to the scientific community of intensive care medicine in 2009 [1]. At that time we concluded that future refinements were expected to be unveiled. Despite the overall satisfactory experiences with the initial flow chart we increasingly experienced that it needs to be expanded with at least two additional items, i.e., (1) ‘‘Catatonic features’’ and (2) ‘‘Refractory agitation’’ (Fig. 1). Regarding catatonia: adding this item is a necessary adaptation due to the fact that there is an increasing amount of scientific literature, coming from both neurology and psychiatry, regarding a re-appraisal of catatonic features in general and of catatonia in pediatric neuro-psychiatry in particular [2]. These new developments have resulted in a proposed whole new chapter exclusively devoted to catatonia in the forthcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [3]. Catatonia (meaning pervasive (motor) tension) is defined as a severe psychomotor disturbance with a primary presentation due to a mood disorder or schizophrenia. Besides, and in our context much more importantly, it has a secondary presentation attributable to any of the ‘acronymic’ I WATCH DEATH causes of delirium. The most characteristic features of catatonia are: catalepsy (bizarre postural fixity, especially of the limbs and head), opisthotonus (severe backwards hyperextension and rigidity of the whole body) and/or (a)typical motor agitation. Other symptoms are negativism (apparently motiveless resistance), stupor (extreme hypoactivity, minimally responsive to stimuli), and stereotypy (repetitive, non-goal directed motor activity such as finger-play, repeatedly touching, patting or rubbing self). According to a growing consensus, two or more symptoms suffice to diagnose catatonia. The above mentioned features deserve in their own right—especially in critical illness—a thorough evaluation and so we have added them to our updated flow chart. Treatment consists of treating the I WATCH DEATH causes and/or administering benzodiazepines in high dosages and/ or giving electroconvulsive therapy. Refractory agitation is a common and important issue in everyday critical care medicine. It can be defined as: lasting agitation after repeatedly checking the aforementioned flow chart items and its treatment results. If agitation still persists, this leads to the new and last box: ‘‘Refractory agitation’’. This extra item is of clinical importance: for it can be a sign of (1) ongoing agitation in the course of delirium—which is also a very known and common problem in acute adult psychosis [4]; (2) paradoxal agitation due to the administration of possibly any drug, but especially

Atypical cognitive profile in patients with depression after myocardial infarction

BACKGROUND We evaluated the cognitive profile of 48 patients with major depression following their first myocardial infarction (MI). METHODS The cognitive performance of the patients was compared with the performance of 48 non-depressed MI patients and 48 healthy controls. RESULTS Depressed MI patients performed slower on a simple cognitive speed related measure compared with non-depressed MI patients and healthy controls. Attention and speed-related aspects of cognitive functioning were not affected. Surprisingly, (depressed) MI patients showed even better performances with respect to memory function. LIMITATION No patients with non-MI-related depression were included. CONCLUSIONS The cognitive profile of major depression after MI differs from that of non-cardiac-related depressive disorder, as described in the literature. This may reflect a different etiology of post MI depression from non-cardiac-related depression.

Observational evidence that urbanisation and neighbourhood deprivation are associated with escalation in chronic pharmacological pain treatment: a longitudinal population-based study in the Netherlands.

Objective To examine, in the light of the association between urban environment and poor mental health, whether urbanisation and neighbourhood deprivation are associated with analgesic escalation in chronic pharmacological pain treatment and whether escalation is associated with prescriptions of psychotropic medication. Design Longitudinal analysis of a population-based routine dispensing database in the Netherlands. Setting Representative sample of pharmacies, covering 73% of the Dutch nationwide medication consumption in the primary care and hospital outpatient settings. Participants 449 410 patients aged 15–85 years were included, of whom 166 374 were in the Starter group and 283 036 in the Continuation group of chronic analgesic treatment. Main outcome measure Escalation of analgesics (ie, change to a higher level of analgesic potency, classified across five levels) in association with urbanisation (five levels) and dichotomous neighbourhood deprivation was analysed over a 6-month observation period. Methods Ordered logistic multivariate model evaluating analgesic treatment. Results In both Starter and Continuation groups, escalation was positively associated with urbanisation in a dose–response fashion (Starter group: OR (urbanisation level 1 compared with level 5): 1.24, 95% CI 1.18 to 1.30; Continuation group: OR 1.18, 95% CI 1.14 to 1.23). An additional association was apparent with neighbourhood deprivation (Starter group: OR 1.07, 95% CI 1.02 to 1.11; Continuation group: OR 1.04, 95% CI 1.01 to 1.08). Use of somatic and particularly psychotropic co-medication was associated with escalation in both groups. Conclusions Escalation of chronic analgesic treatment is associated with urban and deprived environments and occurs in a context of adding psychotropic medication prescriptions. These findings suggest that pain outcomes and mental health outcomes share factors that increase risk and remedy suffering.

Prophylactic Haloperidol for Critically Ill Adults

Author Contributions: Mr Puthumana and Dr Ross had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Puthumana, Ross. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Puthumana. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Puthumana. Supervision: Ross.