Lesley Stafford

Are illness perceptions about coronary artery disease predictive of depression and quality of life outcomes

OBJECTIVE Depression occurs commonly in coronary artery disease (CAD) and is associated with substantial disability. Modifiable cognitive determinants of depression in this population have not been identified. We investigated the impact of potentially modifiable illness beliefs about CAD on depressive symptomatology. We also examined the association between these beliefs and health-related quality of life (HRQOL) and socio-demographic variations in illness beliefs. METHODS A prospective study of 193 recently hospitalized CAD patients was conducted. Data were collected from medical records and by self-report 3 and 9 months post-discharge. Socio-demographic differences were analysed with independent sample t-tests. Predictive models were tested in a series of hierarchical linear regression equations that controlled for known clinical, psychosocial, and demographic correlates of outcome. RESULTS Negative illness beliefs, particularly those associated with the consequences of CAD, were significantly predictive of higher levels of depressive symptomatology at 3 and 9 months. Positive illness perceptions were significantly associated with better HRQOL outcomes. Older and less socially advantaged patients demonstrated more negative illness beliefs. CONCLUSIONS Illness beliefs are significantly associated with depressive symptomatology and HRQOL in CAD patients. These beliefs can be easily identified and constitute a meaningful and clinically accessible avenue for improving psychological morbidity and HRQOL in CAD patients. Older and more socially vulnerable patients may require heightened monitoring of their illness beliefs. Research needs to translate these and other predictive findings into interventions.

The use of statins after a cardiac intervention is associated with reduced risk of subsequent depression: proof of concept for the inflammatory and oxidative hypotheses of depression?

OBJECTIVE Depression is associated with immune activation as well as oxidative stress. Statins have in vitro and in vivo antiinflammatory and antioxidative properties. We prospectively investigated whether the use of statins was associated with a reduced risk of development of depression in individuals who have had a cardiac event or intervention. METHOD Participants were recruited between May 2005 and March 2006 from the Geelong Hospital, Geelong, Australia, a tertiary hospital in regional Australia that serves a catchment area shown to be representative of the broader Australian community. Patients who were hospitalized for angioplasty, myocardial infarction, or coronary artery bypass graft surgery (N = 193) were followed up prospectively for 9 months to assess development of depression. Depression data were collected 3 months postdischarge (T1) by structured clinical interview (using the Mini International Neuropsychiatric Interview, version 5) and 9 months postdischarge (T2) by self-report (using the Hospital Anxiety and Depression Scale). Major depressive disorder, minor depression, and dysthymia were diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria. Data on statins were collected from medical records. The association between statin therapy and depression was tested using both linear and logistic regression models controlling for clinical, psychological, and demographic confounders. RESULTS At discharge, 157 participants (81.3%) were receiving statin therapy. Adjusting for possible confounders, taking statins at discharge had a protective effect on depression at T1, reducing the likelihood of dysthymia, minor depression, or major depression by 69% (95% CI, 0.097-0.972; P = .045). At the T2 end point, statin therapy again had a protective effect and was associated with a 79% reduction in the likelihood of depression (95% CI, 0.052-0.876; P = .032). The linear regression model to predict depression at T2 was significantly different from zero (F(11,180) = 8.686, P < .001) and explained 36.3% of the variance in depression. CONCLUSIONS The use of statins was associated with significant reduction in the risk of depression in individuals who have had a cardiac event. This supports the role of oxidative and inflammatory processes in depression and opens the door to rational and novel pathophysiologically based therapies distinct from conventional antidepressants.

Illness beliefs about heart disease and adherence to secondary prevention regimens.

Objective: We investigated illness beliefs of recently hospitalized patients with coronary artery disease (CAD) and the prospective association between these beliefs and adherence to secondary prevention behaviors. Causal attributions of CAD and their concordance with actual patient risk profiles were also examined. Method: A prospective study of 193 patients was conducted. Data were collected by self-report and from medical records at 3, 6, and 9 months after discharge. Baseline depression was assessed by structured clinical interview. The association between illness beliefs and adherence was tested with hierarchical linear regression controlling for clinical and demographic confounders. Results: Most participants perceived high personal and treatment control and believed CAD to be chronic in duration with severe consequences. A relatively low number of symptoms were endorsed as being part of CAD. Heredity was considered the single most important and most commonly perceived cause of CAD. Smoking, alcohol, emotional state, and heredity were significantly more likely to be endorsed as causal factors by respondents with these risk profiles. In multivariate analysis, illness beliefs contributed an additional 6% of the total variance explained by the model (p = .02). Perceptions of more serious consequences predicted better adherence (p = .03). Social desirability was the best single predictor of adherence. Conclusion: Patient perceptions of risk factors were largely consistent with actual risk factors. Despite modest effect sizes, illness beliefs do contribute to our understanding of adherence to secondary prevention behavior. Interventions aimed at modifying these beliefs, particularly those related to the consequences of CAD, may improve patient outcomes. BMI = body mass index; CABG = coronary artery bypass graft surgery; CAD = coronary artery disease; CR = cardiac rehabilitation; IPQ-R = Revised Illness Perception Questionnaire; LVEF = left ventricular ejection fraction; MI = myocardial infarction; M.I.N.I. = Mini International Neuropsychiatric Interview; MSPSS = Multidimensional Scale of Perceived Social Support; PTCA = percutaneous transluminal coronary angioplasty.

Screening for depression and anxiety in women with breast and gynaecologic cancer: course and prevalence of morbidity over 12 months

This study aims to investigate the course and prevalence of anxiety and depression symptoms over 56 weeks in women with newly diagnosed breast and gynaecologic cancer and determine the acceptability and efficiency of incorporating routine screening into practice.

Tobacco smoking predicts depression and poorer quality of life in heart disease

BackgroundWe report on the prospective association between smoking and depression and health-related quality of life (HRQOL) in patients with coronary artery disease (CAD).MethodsProspective study of 193 patients with assessment of depression occurring 3-, 6- and 9- months (T1, 2, and 3, respectively) following discharge from hospital for a cardiac event. HRQOL was assessed at T3. T1 depression was assessed by clinical interview; T2 and T3 depression was assessed by self-report. Smoking at time of cardiac event was assessed by self-report. Multivariate analyses controlled for known demographic, psychosocial and clinical correlates of depression.ResultsSmoking at the time of index cardiac event increased the likelihood of being diagnosed with Major Depressive Disorder (MDD) at T1 by 4.30 [95% CI, 1.12-16.46; p < .05]. The likelihood of receiving a diagnosis of minor depression, dysthymia or MDD as a combined group was increased by 8.03 [95% CI, 2.35-27.46; p < .01]. Smoking did not reliably predict depression at T2 or T3 and did not reliably predict persistent depression. Smoking increased the likelihood of being classified as depressed according to study criteria at least once during the study period by 5.19 [95% CI, 1.51-17.82; p < .01]. Smoking independently predicted worse mental HRQOL.ConclusionsThe findings support a role for smoking as an independent predictor of depression in CAD patients, particularly in the first 3 months post-cardiac event. The well-established imperative to encourage smoking cessation in these patients is augmented and the findings may add to the evidence for smoking cessation campaigns in the primary prevention of depression.

Palliative models of care for later stages of mental disorder: maximizing recovery, maintaining hope, and building morale

Background: The concept of staging of disease in psychiatry has developed over the past years. A neglected component of this model pertains to people in the advanced stages of a mental illness, who remain symptomatic and functionally impaired despite treatment. These patients are often high service utilizers, receiving complex multimodal treatments where the balance of risk and benefit shifts perceptibly. In this paper, we argue the need to adopt ‘palliative’ models of care for some individuals, and consider changing the therapeutic goals to follow care pathways similar to those used in other chronic and refractory medical illnesses. Method: Data was sourced by a literature search using Medline and a hand search of scientific journals. Relevant articles were selected. Results: Clinical staging can help us better define subgroups of patients who will benefit from different goals and treatment. In the most advanced stage group, we find patients with persistent symptoms and treatment resistance. In these situations, it may be preferable to follow some of the principles of palliative care, which include the setting of attainable goals, reduction of side-effects, limited symptom control, targeting identified psychological and social problems, and attempting to attain the best quality of life for these patients and their families. Conclusions: It is in the interest of those in the advanced phases of a disorder that clinicians acknowledge the limitations of treatment and actively attempt to plan treatment utilizing alternate models. It is essential to be clear that such approaches do not equate to the abandonment of care, but rather to the reconceptualizing of feasible and personalized treatment goals, a rebalancing of the risks and benefits of intervention, the management of illness behaviour, and the approaches that allow the patient to live gainfully within their limitations.

Mental health and occupational wellbeing of Australian gynaecologic oncologists

OBJECTIVE To investigate the prevalence of psychiatric morbidity and occupational burnout among Australian gynaecologic oncologists and to assess job stress and job satisfaction in this group. METHOD Anonymous, self-report questionnaires containing validated measures were sent to all practicing Australian gynaecologic oncologists in October 2008. RESULTS The response rate was 78.4% (N=29). More than one-third (35.7%) had high levels of emotional exhaustion, the central component of burnout. In the past 6 months, 42.9%, 57.1%, and 28.6% had seriously considered leaving for another position, reducing the number of hours worked, and taking early retirement, respectively. The most commonly reported source of stress (80.8%) was home-life disruption due to work. Compared to general population data and recommended national guidelines, rates of alcohol consumption were high. Psychological morbidity, global job stress and burnout were significantly correlated and each was associated with harmful alcohol use. Other factors associated with burnout were administrative/organizational demands and patient volume. More than half of respondents (58.6%) had high levels of job satisfaction and most had high levels of personal accomplishment (70.4%). Perceived adequacy of the training curriculum and proposed changes to the curriculum are reported. CONCLUSION Australian gynaecologic oncologists experience considerable occupational distress while possessing high levels of personal accomplishment and job satisfaction. To maintain a healthy workforce, it is important to build on existing supports while conducting further research to identify suitable evidence-based strategies for improving the mental health of these surgeons.

Long-term quality of life in Australian women previously diagnosed with gynaecologic cancer

PurposeThe purpose of this study is to investigate challenges to quality of life (QOL) among women previously diagnosed with gynaecologic cancer accessing a metropolitan Australian oncology service. Indices of QOL investigated were anxiety, depression, sexual morbidity, body image and supportive care needs. Findings are to inform service planning and research priorities.MethodsThis study is a cross-sectional analysis of 176 women diagnosed with gynaecologic cancer from 1997 to 2006. Data were collected from medical records and via self-report questionnaire comprising validated measures of QOL indices.ResultsRespondents have cancers of the endometrium (n = 56, 32%), ovary (n = 71, 40%), cervix (n = 27, 15%) and other less common types (n = 22, 13%). Mean (SD) age and time since diagnosis were 58.6 (13.2) and 4.7 (2.9) years, respectively. Using cut-offs of ≥8 and ≥11 on the Hospital Anxiety and Depression Scale, 55 (31%) and 27 (15%) women reported anxiety and 28 (16%) and 10 (6%) women reported depression, respectively. On average, 5.26 unmet needs were reported. Concerns about recurrence were the most common unmet need (30%). Two thirds had not been sexually active in the preceding month. Most (87%) were not worried about their sex life or lack thereof. Mean (SD) score on the Body Image Scale was 7.21 (7.37). Tumour groups did not differ on any outcomes.ConclusionsDespite limitations, these data shed light on challenges to QOL of a heterogeneous group of gynaecologic cancer survivors. Sexual and psychological morbidity outcomes compare favourably with the literature while body image disturbance may present a useful target for clinical intervention.

Cognitive-Personality Style as Vulnerability to Depression in Patients With Coronary Artery Disease : Roles of Sociotropy and Autonomy

Objective: To investigate whether the cognitive-personality styles of sociotropy and autonomy and their component subscales are useful for explaining depressogenic vulnerability in a population of individuals with coronary artery disease (CAD) and to better understand the psychosocial etiology of depression in CAD. Depression occurs commonly in patients with CAD and is associated with substantial disability. Method: A prospective study of 193 recently hospitalized CAD patients was conducted. Data were collected from medical records and by self-report at 3 (Time 1, T1) and 9 (Time 2, T2) months post discharge. The association between cognitive-personality styles and depression was tested in hierarchical linear regression equations controlling for clinical and demographic confounders. Results: High levels of autonomy were significantly associated with increased depressive symptomatology at T1 (p < .001) and T2 (p < .001). The association between autonomy and change in depression approached significance (p = .07). Sociotropy was not a significant predictor of depression at any time. The component subscales of the sociotropy and autonomy measures explained more variance in depressive symptomatology at T1 and T2 as well as change in depression than did the composite measures. The perfectionism subscale of autonomy was the most important predictor of depression at T1 and T2 contributing 5.3% and 5.1% of unique variance in depression, respectively. There was a trend for the association between perfectionism and change in depression (p = .06). Conclusion: Cognitive-personality characteristics are an important predictor of depression in recently hospitalized patients with CAD. The findings suggest a clinical benefit in early detection of highly autonomous patients, particularly those who exhibit perfectionism, coupled with appropriate cognitive intervention and collaborative treatment planning. CABG = coronary artery bypass graft surgery; CAD = coronary artery disease; HADS = Hospital Anxiety Depression Scale; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angioplasty.

Comparison of the acceptability and benefits of two mindfulness-based interventions in women with breast or gynecologic cancer: a pilot study.

PurposeThe aim of this study was to compare the relative benefits and acceptability of two different group-based mindfulness psychotherapy interventions among women with breast and gynecologic cancer.MethodsData from 42 women who completed an 8-week mindfulness-based cognitive therapy (MBCT) program comprising 22 contact hours were compared to data from 24 women who completed a 6-week mindfulness meditation program (MMP) comprising 9 contact hours. Distress, quality of life (QOL), and mindfulness were evaluated pre- (T1) and post-intervention (T2). ANCOVA was used to analyse the relationship between intervention type and T1 score on outcome variable change scores. Participants’ perceptions of benefit and acceptability were assessed.ResultsThe participants did not differ on clinical or demographic variables other than MBCT participants were more likely than MMP participants to have a past history of anxiety or depression (p = .01). Scores on distress, QOL, and mindfulness improved from T1 to T2 with medium to large effect sizes for the MMP (p = .002, d = .07; p = .001, d = .08; p = .005, d = .06, respectively) and MBCT (p < .001, d = .06; p = .008, d = .04; p < .001, d = .09, respectively) interventions. ANCOVA showed no main effect for intervention type on outcome change scores and no interaction between intervention type and respective T1 score. Distress and mindfulness scores at T1 had a main effect on respective change scores (p = .02, ηp2 = .87; p = .01, ηp2 = .80, respectively). Both programs were perceived as beneficial and acceptable with no differences between the intervention types.ConclusionsWithin the limits of a small, non-randomized study, these findings provide preliminary support for the utility of a brief mindfulness intervention for improving distress and QOL in a heterogeneous group of women with cancer. Abbreviated interventions are less resource intensive and may be attractive to very unwell patients.