Morten Birket-Smith

Effects of escitalopram in prevention of depression in patients with acute coronary syndrome (DECARD).

OBJECTIVE Depression is a major problem in patients after acute coronary syndrome (ACS) with negative impact on survival and quality of life. No studies have examined prevention of post-ACS depression. We examined whether treatment with escitalopram can prevent post-ACS depression. METHODS We have conducted a randomised controlled trial. Between November 2004 and December 2007, 240 patients in 2 university hospitals in Copenhagen, Denmark, with ACS were randomised. Patients were randomised to a double-blind treatment with escitalopram or matching placebo for 1 year. Main outcome measure was the incidence of ICD-10 depressive episode. RESULTS Of 120 patients treated with escitalopram 2 developed depression versus 10 in placebo treated group (log rank, p=0.022). In multivariate analysis treatment with placebo and high Hamilton Depression Scale score at baseline were associated with development of depression. Patients were well matched at baseline. CONCLUSION Twelve months treatment with escitalopram prevented depression in post-ACS patients.

Mental disorders and general well-being in cardiology outpatients--6-year survival.

OBJECTIVE Long-term survival in a sample of cardiology outpatients with and without mental disorders and other psychosocial risk factors. METHODS In a cardiology outpatient setting, 103 consecutive patients were asked to participate in the study. Of these, 86 were included and screened for mental disorder with the Primary Care Evaluation of Mental Disorders; Structured Clinical Interview for DSM-III-R, Non-Patient Edition, psychosis screening; the Clock Drawing Test; and the WHO-5 Well-Being Index. The cardiologists were asked in each patient to rate the severity of somatic disease and mental problems on visual analogue scales (VAS-somatic and VAS-mental). Cardiac diagnosis, noncardiac comorbidity, history of mental disorder, and the number of daily social contacts were noted. Survival was followed for 6 years. RESULTS At baseline, 33 (38.4%) patients had mental disorder, 6 dementia, 11 major depression, 6 minor depression, 6 anxiety disorder, 2 unspecified somatoform disorder, 1 alcohol abuse, and 1 psychosis. At 6 years of follow-up, 40 (47%) patients were deceased, 17 (48%) of those with and 23 (46%) of those without mental disorder. In a survival analysis, mortality was significantly predicted by age [hazard ratio (HR), 1.058], WHO-5 (HR, 0.977), the number of social contacts (HR, 0.699), VAS-somatic (HR, 1.016), and cardiac diagnosis (HR, 0.333). CONCLUSION In chronic heart disease, well-being and social support seem related to long-term survival.

Health Care Use by Patients with Somatoform Disorders: A Register-Based Follow-Up Study

OBJECTIVE Studies have shown a greater use of medical than mental health services in patients with somatoform disorders. However, not many studies are based on structured interviews and include the entire somatoform spectrum of diagnoses. We conducted a register-based case-control study to investigate medical care use prior to and three years after diagnosis in patients with somatoform disorders. METHODS We included 380 patients with somatoform diagnoses (SCID-NP for DSM-IIIR) in a case-control study and compared them with 174 patients with anxiety disorders and 5540 controls from the background population. Data from the Danish National Registers were used to assess health care use in both primary and secondary care. RESULTS Somatoform patients incurred 2.11 (2.09-2.12) times the primary care visits of controls. They had 3.12 (3.08-3.16) times as many somatic bed-days than controls and 3.94 (3.91-3.97) as many psychiatric bed-days. Primary care use remained stable 3 years after diagnosis (p = 0.14) and the award of disability pension (p = 0.82). However, the number of somatic admissions decreased from 5.64 to 2.76 (p = 0.0004) 3 years after diagnosis. Somatization had an independent effect on health care use when controlling for psychiatric comorbidity. CONCLUSIONS Patients with somatoform disorders make significantly greater use of health care services than do controls and patients with anxiety. Somatoform patients made more use of psychiatric services than expected. The use of somatic health care was independent of psychiatric comorbidity. Primary care use and disability pension award were not influenced by proper diagnosing of somatoform disorders whereas number of somatic admissions were halved.

Cardiovascular Safety of One-Year Escitalopram Therapy in Clinically Nondepressed Patients With Acute Coronary Syndrome: Results From the DEpression in Patients With Coronary ARtery Disease (DECARD) Trial.

Background: Selective serotonin reuptake inhibitors are commonly used for treatment of depression in patients with cardiac diseases. However, evidence of cardiovascular (CV) safety from randomized trials is based on studies of no longer than 6-month duration. We examined the CV safety of 1-year treatment with Selective serotonin reuptake inhibitor escitalopram compared with placebo in patients with recent acute coronary syndrome (ACS). Methods: The DECARD (DEpression in patients with Coronary ARtery Disease) trial assessed the prophylactic effect of escitalopram on depression after ACS. Two hundred forty patients were randomized to escitalopram 10-mg daily or matching placebo for 1 year. Serial measures of CV safety including clinical and biochemical parameters, 24-hour electrocardiogram monitor, resting electrocardiogram, and echocardiographic assessment were obtained. Results: Escitalopram and placebo groups were comparable at baseline with regard to age, gender, sociodemography, depression score, risk factor profile, severity of heart disease, and medications. Dropout rates defined as withdrawal for any reason or lost to follow-up during the 12-month study period was 27.2% in the escitalopram group and 23.4% in the placebo group (NS). There were no statistically significant differences between intervention groups in any of CV safety measures including the incidence of ventricular arrhythmia and episodes of ST-segment depression, length of QTc, and systolic and diastolic echocardiographic measures at the 12-month follow-up between groups. After 12 months, 16 and 13 major adverse events (death, recurrent ACS, or acute revascularization) were recorded in the escitalopram and placebo group, respectively (NS). Conclusions: One-year escitalopram treatment was safe and well tolerated in patients with recent ACS.

Rationale, design and methodology of a double-blind, randomized, placebo-controlled study of escitalopram in prevention of Depression in Acute Coronary Syndrome (DECARD)

BackgroundThe prevalence of depression in patients with acute coronary syndrome, i.e. myocardial infarction and unstable angina, is higher than in the general population. The prevalence of anxiety is higher as well. Both depression and anxiety are associated with poor cardiac outcomes and higher mortality. Comorbid depression in patients with acute coronary syndrome often goes undiagnosed, and it is therefore a challenging task to prevent this risk factor. The study of DEpression in Coronary ARtery Disease (DECARD) is designed to examine if it is possible to prevent depression in patients with acute coronary syndrome.MethodsTwo hundred forty non-depressed patients with acute coronary syndrome are randomized to treatment with either escitalopram or placebo for 1 year. Psychiatric and cardiac assessment of patients is performed to evaluate the possibility of preventing depression. Diagnosis of depression and Hamilton Depression Scale are the primary outcome measures.DiscussionThis is the first study of prevention of depression in patients after acute coronary syndrome with a selective serotonin reuptake inhibitor.Trial Registrationhttp://www.ClinicalTrials.gov Identifier: NCT00140257

Screening for mental disorders in cardiology outpatients.

The objective of the study was to compare the frequency of mental disorders in cardiology outpatients to the number of patients with psychological problems identified by cardiologists. In a cardiology outpatient service, 103 consecutive patients were asked to participate in the study. Of these 86 were included and screened for mental disorder with the Primary Care Evaluation of Mental Disorders (PRIME-MD), Structured Clinical Interview for DSM-IV (SCID) psychosis screening, the Clock Drawing Test, and the WHO-5 Well-being Index. The cardiologists were asked to rate the severity of somatic and mental problems in each patient on visual analogue scales (VAS-som and VAS-men). The current treatments, including psychiatric and psychological treatments, were noted, and the survival was followed for 3 years. Of the 86 patients included, 34 (40%) had a diagnosis of mental disorder. Eleven (12.8%) had major depression, six (7.0%) minor depression, six (7.0%) anxiety disorder, two unspecified somatoform disorder, seven (8.1%) dementia, one alcohol abuse and one psychosis. Three of the patients were in long-term psychopharmacological treatment. Although the cardiologists predicted mental disorder significantly better than chance, none of the patients was in relevant treatment for their mental disorder. At 3-year follow-up, 20 (24%) of the patients had died. Age and severity of heart disease predicted mortality, while the presence of a mental disorder did not. Mental disorders, especially depression, were frequent in cardiology outpatients. Even in cases where the cardiologists identified psychological problems, the diagnosis had no consequence, as none of the patients was offered relevant treatment.

Mental vulnerability as a predictor of early mortality.

Background: Studies have demonstrated that mental vulnerability (ie, a tendency to experience psychosomatic symptoms or inadequate interpersonal interactions) is associated with various diseases. The objective of our study is to evaluate whether mental vulnerability is a risk factor for early mortality. Methods: We conducted a prospective cohort study of 3 random samples of the population in Copenhagen County, Denmark selected in 1976, 1982–1984, and 1991 (n = 6435). Baseline data collection included measures of mental vulnerability, social factors, comorbidity, biologic risk markers (eg, blood pressure, lipid levels), and lifestyle factors. We determined vital status of the study sample through linkage to the Civil Registration System until 2001 and to the Cause of Death Registry until 1998. The mean follow-up time was 15.9 years for analysis of total mortality and 13.6 years for analysis of mortality as the result of natural causes. The association between mental vulnerability and survival was examined using Kaplan-Meir plots and Cox proportional-hazard models adjusting for possible confounding factors. Results: With respect to mental vulnerability, 79% of the sample was classified as not vulnerable, 13% as moderately vulnerable, and 8% as highly vulnerable. Compared with the nonvulnerable group, highly vulnerable persons showed increased total mortality (hazard ratio = 1.6; 95% confidence interval = 1.3–1.9) and increased mortality from natural causes (1.6; 1.2–2.0). The inclusion of the mental vulnerability score as a continuous variable gave similar results. Conclusions: Mental vulnerability may be an independent risk factor for premature mortality. The biologic mechanisms that may underlie this association need further exploration.

The Mental Vulnerability Questionnaire: A psychometric evaluation

The Mental Vulnerability Questionnaire was originally a 22 item scale, later reduced to a 12 item scale. In population studies the 12 item scale has been a significant predictor of health and illness. The scale has not been psychometrically evaluated for more than 30 years, and the aim of the present study was both to evaluate the psychometric properties of the 22 and 12 item scales and of three new scales. The main study sample was a community sample comprising more than 6,000 men and women. In this sample the coefficients of homogeneity were all over 0.30 for the three new scales, but below 0.30 for the 12 and the 22 item scales. All five Mental Vulnerability scales had positively skewed score distributions which were associated significantly with both SCL-90-R symptom scores and NEO-PI-R personality scales (primarily Neuroticism and Extraversion). Coefficient alpha was highest for the 22 and 12 item scales, and the two scales also showed the highest long-term stability. The three new scales reflect relatively independent dimensions of Psychosomatic Symptoms, Mental Symptoms, and Interpersonal Problems, but because of reliability problems it remains an open question whether they will prove useful as predictors of health and morbidity.

Comparison of participants and non-participants in a randomized study of prevention of depression in patients with acute coronary syndrome.

Background: The prevalence of depression and anxiety in patients after acute coronary syndrome (ACS) is higher than in the general population. In a study on prevention of post-ACS depression, more than half of eligible patients declined participation. Aims: The aim of this study was to evaluate whether symptoms of depression and anxiety in participants and non-participants predicted participation in the study. Methods: This substudy was conducted between May 2005 and April 2007. Patients with ACS, eligible for the study (n=302) were asked four questions on depression and anxiety from the Primary Care Evaluation of Mental Disorders (PRIME-MD) screening questionnaire. Results: The PRIME-MD screening data were available on 232 patients (76.8% of eligible patients). Thirty-eight (35.5%) of 107 participants and 30 (24.0%) of 125 non-participants had a positive screening for depression (NS), and 47 (43.9%) participants and 55 (44%) non-participants were screened positive for anxiety (NS). Non-participants were older (P=0.002), while no significant differences in gender or cardiac diagnosis were found. Conclusions: Symptoms of depression and anxiety were highly prevalent in patients after ACS but did not predict participation in the study of prevention of depression.

Prevention of depression in patients with acute coronary syndrome (DECARD) randomized trial: effects on and by self-reported health.

Escitalopram may prevent depression following acute coronary syndrome. We sought to estimate the effects of escitalopram on self‐reported health and to identify subgroups with higher efficacy.