Phillip J. Tully

The role of depression and anxiety symptoms in hospital readmissions after cardiac surgery

The objective of this study was to determine the association between depression, anxiety and general stress symptoms with hospital readmissions after coronary artery bypass graft surgery. Two hundred and twenty six coronary artery bypass graft patients completed baseline self-report measures of depression, anxiety and stress and 222 patients completed these measures after surgery on the hospital ward. The hospital readmission outcomes at six months were analyzed using multivariable proportional hazard models. When analyzed as continuous variables in multivariable analyses, preoperative anxiety and postoperative depression predicted readmissions independent of medical covariates. In multivariable analyses with dichotomized anxiety, depression and stress, more than two-fold increase in readmission risk was attributable to preoperative anxiety and postoperative depression, independent of covariates. These results lend further support to previous research that has shown the symptoms of depression and anxiety are associated with morbidity following coronary artery bypass graft surgery. The findings highlight the need to develop suitable interventions for anxiety and depression among coronary artery bypass graft surgery patients.

Depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery: a contemporary and practical review

Research to date indicates that the number of coronary artery bypass graft (CABG) surgery patients affected by depression (i.e., major, minor, dysthymia) approximates between 30% and 40% of all cases. A longstanding empirical interest on psychosocial factors in CABG surgery patients highlights an association with increased risk of morbidity in the short and longer term. Recent evidence suggests that both depression and anxiety increase the risk for mortality and morbidity after CABG surgery independent of medical factors, although the behavioral and biological mechanisms are poorly understood. Though neither depression nor anxiety seem to markedly affect neuropsychological dysfunction, depression confers a risk for incident delirium. Following a comprehensive overview of recent literature, practical advice is described for clinicians taking into consideration possible screening aids to improve recognition of anxiety and depression among CABG surgery patients. An overview of contemporary interventions and randomized, controlled trials are described, along with suggestions for future CABG surgery research.

A review of the affects of worry and generalized anxiety disorder upon cardiovascular health and coronary heart disease

Objective: The aims of this review article are to present psychophysiological and behavioral pathways for the involvement of worry and generalized anxiety disorder (GAD) upon cardiovascular function. The review will focus on persons with and without coronary heart disease (CHD), and encompass etiological and prognostic studies. Methods: Articles (1975–2011) reporting on GAD or worry affecting CHD prognosis or cardiovascular function were found using MEDLINE, EMBASE, SCOPUS and PsychINFO database searches, and extracted to form a narrative review. Results: Available evidence in experimental and observational studies in CHD free samples consistently showed that worry was associated with diminished heart rate variability (HRV) and elevated heart rate. Worry and GAD were commonly associated with blood pressure and diagnosed hypertension or medication use in both disease-free and established CHD populations. No evidence was found to support worry being beneficial to cardiovascular function or conducive to health promoting behaviors. The literature indicated that measures of worry were associated with fatal and nonfatal CHD in seven etiological studies of initially disease-free individuals; however, females were underrepresented. Three studies reported that GAD was associated with poorer prognosis in establish CHD, independent of depression. The median GAD prevalence was 10.4% in 3266 patients across 15 studies, suggesting that GAD is marginally less common in CHD samples than is depression. Conclusions: A growing literature highlights the association between worry and development of CHD. The association between worry, GAD and CHD risk factors (e.g. blood pressure), and HRV are leading mechanisms of cardiopathogenesis that may affect cardiovascular function. Findings regarding worry and GAD in established CHD are less clear.

The anxious heart in whose mind? A systematic review and meta-regression of factors associated with anxiety disorder diagnosis, treatment and morbidity risk in coronary heart disease

OBJECTIVE To (1) report the prognostic association between anxiety disorder subtypes and major adverse cardiac events (MACE), (2) report anxiety disorder prevalence in coronary heart disease (CHD), and (3) report the efficacy of anxiety disorder treatments in CHD. METHODS A comprehensive electronic database search was performed in November 2013 for studies reporting anxiety disorder prevalence according to structured interview in CHD samples or MACE, and randomized controlled trials (RCTs) comparing anxiety disorder treatment with placebo or usual care. From 4041 articles 42 samples were selected for extraction (8 for MACE prognosis, 39 for prevalence, no RCTs were eligible). RESULTS Five generalized anxiety disorder (GAD) studies reported 883 MACE events (combined n=2851). There was a non-significant association between GAD and MACE (risk ratio=1.20, 95% CI .86-1.68, P=.28) however the effect size was highly significant in outpatient samples (adjusted hazard ratio=1.94, 95% CI 1.45-2.60, P<.001). No other anxiety disorder subtype was associated with MACE. Prevalence data showed high comorbidity with depression (49.06%; 95% CI 34.28-64.01) and substantial heterogeneity between studies. Panic disorder prevalence was higher in psychiatrist/psychologist raters (9.92% vs. 4.74%) as was GAD (18.45% vs. 13.01%). Panic and GAD estimates were also heterogeneous according to DSM-III-R versus DSM-IV taxonomies. CONCLUSIONS The paucity of extant anxiety disorder RCTs, alongside MACE risk for GAD outpatients, should stimulate further anxiety disorder intervention in CHD populations. Research should focus on depression and anxiety, thereby unraveling disorder specific and more generic pathways.

Depression, anxiety disorders and Type D personality as risk factors for delirium after cardiac surgery.

Objectives: To determine the prognostic risk of incident delirium after cardiac surgery attributable to preoperative affective disorders and Type D personality. Methods: Patients awaiting elective coronary revascularization surgery (N = 158; 20.9% female; 11.4% concomitant valve surgery; age M = 64.7, SD = 10.6) underwent the structured MINI International Neuropsychiatric Interview and completed a measure of Type D personality. Postoperative incident delirium was established prior to discharge from the index hospitalization with structured psychiatric interview. Results: The prevalence of psychiatric disorders before cardiac surgery was 17.1% for major depression, 7.6% for panic disorder, 10.1% for generalized anxiety disorder, and 13.3% for Type D personality, while there were 49 (31% of total) cases of delirium after surgery. After adjustment for sex, older age, cross-clamp time, haemoglobin (Hb) and psychotropic drug use, major depression was significantly associated with delirium, odds ratio (OR) = 3.86 (95% confidence interval (CI) 1.42 to 10.52, p = 0.001). Adjustment for clinical covariates suggested that Type D personality was not significantly associated with delirium, OR = 2.85 (95%CI 0.97 to 8.38, p = 0.06). Conclusions: Major depression was significantly associated with incident delirium after cardiac surgery. These findings suggest that the risk of incident delirium attributable to major depression was not merely a reflection of common diagnostic features in prospectively examined cardiac surgery patients.

Cardiac morbidity risk and depression and anxiety: A disorder, symptom and trait analysis among cardiac surgery patients

The aim of this study was to examine depression and anxiety disorders and their characteristic symptoms (anhedonia/low positive affect and anxious arousal, respectively), along with measures of state negative affect (NA) and Type D personality, in relation to cardiac surgery related morbidity. Patients awaiting elective coronary artery bypass graft surgery (n = 158; 20.9% female; 11.4% concomitant valve surgery; age M = 64.7, SD = 10.6) underwent the structured MINI International Neuropsychiatric Interview to determine current affective disorders. Patients also completed the Mood and Anxiety Symptom Questionnaire and a measure of Type D personality traits. Postoperative cardiac morbidity was confirmed after surgery during the index hospitalization and included stroke,renal failure, ventilation >24 h, deep sternal wound infection, reoperation, arrhythmia and 30-day mortality at any location (n = 59, 37.3% of total). After adjustment for age, recent myocardial infarction, heart failure, hypertension, urgency of surgery and time spent on cardiopulmonary bypass generalized anxiety disorder was associated with cardiac morbidity (odds ratio [OR] = 3.26, 95% confidence interval [CI] 1.10–9.67, p = 0.03). Adjusted analysis of personality traits revealed the NA component of Type D personality was associated with cardiac morbidity (OR = 1.07, 95% CI 1.01–1.14, p = 0.03). The Mood and Anxiety Symptom Questionnaire subscales were not associated with increased morbidity risk. Affective disorders, affective phenotypes, and personality traits were differentially associated with post-cardiac surgery morbidity outcomes independent of cardiac surgery morbidity risk factors. Concurrent investigation of depression and anxiety with respect to cardiac outcomes warrants further research.

Confirmatory factor analysis of the Beck Depression Inventory-II and the association with cardiac morbidity and mortality after coronary revascularization:

This study examined the Beck Depression Inventory-II (BDI-II) with Confirmatory Factor Analysis and followed up cardiac morbidity and mortality for a median of 4.9 years among 226 coronary artery bypass graft patients. Cardiac morbidity and mortality events (n = 65, 28.8%) were associated with BDI-II cognitive factor z-score (adjusted hazard ratio = 1.36, 95% confidence interval 1.02 — 1.82, p = .04), controlling for left ventricular impairment, age, respiratory disease, heart failure, renal disease and diabetes. A cognitive depression factor marked by pessimism, past failure, self-criticalness and worthlessness was consistently associated with cardiac morbidity and mortality, contrasting to other work.

Anxiety, depression, and stress as risk factors for atrial fibrillation after cardiac surgery

OBJECTIVE We sought to determine whether preoperative and postoperative anxiety, depression, and stress symptoms were associated with atrial fibrillation (AF) after cardiac surgery. METHODS Two hundred and twenty-six cardiac surgery patients completed measures of depression, anxiety, and general stress before surgery, and 222 patients completed these measures after surgery. The outcome variable was new-onset AF, confirmed before the median day of discharge (day 5) after cardiac surgery during the index hospitalization. RESULTS Fifty-six (24.8%) patients manifested incident AF, and they spent more days in hospital (mean [M], 7.3; standard deviation [SD], 4.6) than patients without AF (M, 5.5; SD, 1.4; P < .001). No baseline psychological predictors were associated with AF. When postoperative distress measures were considered, anxiety was associated with increased odds of AF (odds ratio, 1.09; 95% confidence interval, 1.00 to 1.18; P = .05). This analysis also showed that age was significantly associated with AF (odds ratio, 1.07; 95% confidence interval, 1.03 to 1.12; P < .001). Analyses specific to the symptomatic expression of anxiety indicated that somatic (ie, autonomic arousal) and cognitive-affective (ie, subjective experiences of anxious affect) symptoms were associated with incident AF. CONCLUSION Anxiety symptoms in the postoperative period were associated with AF. Hospital staff in acute cardiac care and cardiac rehabilitation settings should observe anxiety as related to AF after cardiac surgery. It is not clear how anxious cognitions influence the experience of AF symptoms, and whether symptoms of anxiety commonly precede AF.

Selective serotonin reuptake inhibitors, venlafaxine and duloxetine are associated with in hospital morbidity but not bleeding or late mortality after coronary artery bypass graft surgery.

BACKGROUND No Australian study has reported the association between selective-serotonin reuptake inhibitor (SSRI) and serotonin noradrenaline reuptake inhibitor (SNRI) with coronary artery bypass graft (CABG) surgery morbidity and mortality. METHODS 4136 patients underwent CABG surgery between January 1996 and December 2008 and 105 (2.5%) were SSRI/SNRI users. Bleeding events included platelet, fresh frozen plasma and packed red blood cell transfusion, reoperation for bleeding and gastrointestinal bleeding. In-hospital morbidity included renal failure, stroke, ventilation >24h, deep sternal wound infection, reoperation (any cause), myocardial infarction and mortality. RESULTS Median follow-up was 4.7 years (interquartile range, 2.3-7.9 years) and there were 727 deaths (17.6% of total). Use of SSRI/SNRI was associated with new requirement for renal dialysis (adjusted OR = 2.18; 95% CI, 1.06-4.45, p = .03) and ventilation >24h (adjusted OR = 1.69; 95% CI, 1.03-2.78, p = .04). Neither SSRI/SNRI use nor SSRI/SNRI and concomitant anti-platelet medication increased the odds for any bleeding events (all p>.20). No association was evident with all-cause mortality (adjusted hazard ratio = 1.60; 95% CI .59-4.35, p = .36), or cardiac mortality (adjusted hazard ratio = .31; 95% CI, .04-2.26, p = .25). CONCLUSIONS SSRI/SNRI users experienced an increased risk of renal dysfunction and prolonged ventilation, but not bleeding events or long-term mortality after CABG surgery.

Generalized anxiety disorder prevalence and comorbidity with depression in coronary heart disease: a meta-analysis.

Generalized anxiety disorder prevalence and comorbidity with depression in coronary heart disease patients remain unquantified. Systematic searching of Medline, Embase, SCOPUS and PsycINFO databases revealed 1025 unique citations. Aggregate generalized anxiety disorder prevalence (12 studies, N = 3485) was 10.94 per cent (95% confidence interval: 7.8–13.99) and 13.52 per cent (95% confidence interval: 8.39–18.66) employing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria (random effects). Lifetime generalized anxiety disorder prevalence was 25.80 per cent (95% confidence interval: 20.84–30.77). In seven studies, modest correlation was evident between generalized anxiety disorder and depression, Fisher’s Z = .30 (95% confidence interval: .19–.42), suggesting that each psychiatric disorder is best conceptualized as contributing unique variance to coronary heart disease prognosis.