Depressive Symptoms, Health Behaviors, and Risk of Cardiovascular Events in Patients With Coronary Heart Disease

VA Medical Center, San Francisco, California, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 12/2008; 300(20):2379-88. DOI: 10.1001/jama.2008.711
Source: PubMed


Depressive symptoms predict adverse cardiovascular outcomes in patients with coronary heart disease, but the mechanisms responsible for this association are unknown.
To determine why depressive symptoms are associated with an increased risk of cardiovascular events.
The Heart and Soul Study is a prospective cohort study of 1017 outpatients with stable coronary heart disease followed up for a mean (SD) of 4.8 (1.4) years.
Participants were recruited between September 11, 2000, and December 20, 2002, from 12 outpatient clinics in the San Francisco Bay Area and were followed up to January 12, 2008.
Baseline depressive symptoms were assessed using the Patient Health Questionnaire (PHQ). We used proportional hazards models to evaluate the extent to which the association of depressive symptoms with subsequent cardiovascular events (heart failure, myocardial infarction, stroke, transient ischemic attack, or death) was explained by baseline disease severity and potential biological or behavioral mediators.
A total of 341 cardiovascular events occurred during 4876 person-years of follow-up. The age-adjusted annual rate of cardiovascular events was 10.0% among the 199 participants with depressive symptoms (PHQ score > or = 10) and 6.7% among the 818 participants without depressive symptoms (hazard ratio [HR], 1.50; 95% confidence interval, [CI], 1.16-1.95; P = .002). After adjustment for comorbid conditions and disease severity, depressive symptoms were associated with a 31% higher rate of cardiovascular events (HR, 1.31; 95% CI, 1.00-1.71; P = .04). Additional adjustment for potential biological mediators attenuated this association (HR, 1.24; 95% CI, 0.94-1.63; P = .12). After further adjustment for potential behavioral mediators, including physical inactivity, there was no significant association (HR, 1.05; 95% CI, 0.79-1.40; P = .75).
In this sample of outpatients with coronary heart disease, the association between depressive symptoms and adverse cardiovascular events was largely explained by behavioral factors, particularly physical inactivity.

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    • "Depressed patients have a standardized mortality rate for suicide of 20.9 in men and 27.0 in women, and adults with depression show increased risk of all-cause mortality, cardiovascular death, and stroke mortality (Gump et al., 2005; Osby et al., 2001). Major depression is associated with greater numbers of chronic conditions such as hypertension and diabetes, and patients with depression often exhibit health behaviors that worsen their outcomes from chronic conditions such as poor adherence to treatment regiments, limited self-care, and lack of physical activity (Green et al., 2010; Gunn et al., 2012; Whooley et al., 2008). Depression is also associated with a sizeable economic burden to society. "
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    ABSTRACT: Background: This study examines the relationship between patient activation, a measure of individuals' knowledge, skill, and confidence for managing their health, and rates of depression remission and response among patients with depression. Methods: Patients from Fairview Health Services in Minnesota with moderate to severe depression in 2011 and a PHQ-9 score in 2012 were included in the analysis (n=5253). Patient activation in 2011 and other health and demographic features were extracted from the electronic health record. We examined how patient activation predicted depression remission and response rates and changes in depression severity over one year using regression models. We also explored how activation predicted healthy behaviors among depressed patients. Results: Higher baseline patient activation predicted lower depression severity and higher depression remission and response rates a year later. The most activated patients had PHQ-9 scores in 2012 two points lower than the lowest activated patients, and they had twice the odds of remission. Activation also predicted increase in healthy behaviors. Limitations: We were unable to examine the use of mental health services or control for the number of prior depressive episodes and duration of the current depressive episode in the analysis. Conclusions: We found that higher patient activation predicted better depression outcomes. While we are unable to explore the mechanism of this association, we observed that more activated patients are also engaged in more healthy behaviors, suggesting that the mechanism may be behavioral. Support of patient activation may be an effective approach for providers to reduce patients depression severity.
    Journal of Affective Disorders 07/2014; 169C:1-6. DOI:10.1016/j.jad.2014.07.030 · 3.38 Impact Factor
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    • "One explanation is that this could be due to decreased levels of monocytes found in depressed patients (Whooley et al., 2008). Secretion of IL-6 by monocytes is a major source of IL-6 concentration that can be measured in the circulation (Whooley et al., 2008). Another potential explanation is that elevated levels of cortisol are found in depressed compared to nondepressed subjects (Burke et al., 2005), and it is well known that cortisol has anti-inflammatory properties (Duivis et al., 2011). "
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    ABSTRACT: Inflammation is one possible mechanism underlying the associations between mental disorders and cardiovascular diseases (CVD). However, studies on mental disorders and inflammation have yielded inconsistent results and the majority did not adjust for potential confounding factors. We examined the associations of several pro-inflammatory cytokines (IL-1β, IL-6 and TNF-α) and high sensitive C-reactive protein (hsCRP) with lifetime and current mood, anxiety and substance use disorders (SUD), while adjusting for multiple covariates. The sample included 3’719 subjects, randomly selected from the general population, who underwent thorough somatic and psychiatric evaluations. Psychiatric diagnoses were made with a semi-structured interview. Major depressive disorder was subtyped into “atypical”, “melancholic”, “combined atypical-melancholic” and “unspecified”. Associations between inflammatory markers and psychiatric diagnoses were assessed using multiple linear and logistic regression models. Lifetime bipolar disorders and atypical depression were associated with increased levels of hsCRP, but not after multivariate adjustment. After multivariate adjustment, SUD remained associated with increased hsCRP levels in men (β= 0.13 (95% CI: 0.03,0.23)) but not in women. After multivariate adjustment, lifetime combined and unspecified depression were associated with decreased levels of IL-6 (β= -0.27 (-0.51,-0.02); β= -0.19 (-0.34,-0.05), respectively) and TNF-α (β= -0.16 (-0.30,-0.01); β= -0.10 (-0.19,-0.02), respectively), whereas current combined and unspecified depression were associated with decreased levels of hsCRP (β= -0.20 (-0.39,-0.02); β= -0.12 (-0.24,-0.01), respectively). Our data suggest that the significant associations between increased hsCRP levels and mood disorders are mainly attributable to the effects of comorbid disorders, medication as well as behavioral and physical CVRFs.
    Journal of Psychiatric Research 07/2014; DOI:10.1016/j.jpsychires.2014.07.012 · 3.96 Impact Factor
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    • "Depressive symptoms occur in 20–40% of patients with coronary heart disease (Allen et al. 2011). Depressive symptoms impair quality of life (Ruo et al. 2003), and are associated with an increased risk for future cardiac events and death (Nicholson et al. 2006; Whooley et al. 2008). Antidepressants reduce depressive symptoms in coronary heart disease patients (Baumeister et al. 2011), and rates of antidepressant use in cardiac patients have risen from less than 5% before 1995 to 10–15% after 2000 (Czarny et al. 2011). "
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    ABSTRACT: Background: Antidepressants reduce depressive symptoms in patients with coronary heart disease, but they may be associated with increased mortality. This study aimed to examine whether the use of tricyclic antidepressants (TCA) or selective serotonin reuptake inhibitors (SSRI) is associated with mortality in patients with coronary heart disease, and to determine whether this association is mediated by autonomic function. Method: A total of 956 patients with coronary heart disease were followed for a mean duration of 7.2 years. Autonomic function was assessed as heart rate variability, and plasma and 24-h urinary norepinephrine. Results: Of 956 patients, 44 (4.6%) used TCA, 89 (9.3%) used SSRI, and 823 (86.1%) did not use antidepressants. At baseline, TCA users exhibited lower heart rate variability and higher norepinephrine levels compared with SSRI users and antidepressant non-users. At the end of the observational period, 52.3% of the TCA users had died compared with 38.2% in the SSRI group and 37.3% in the control group. The adjusted hazard ratio (HR) for TCA use compared with non-use was 1.74 [95% confidence interval (CI) 1.12-2.69, p = 0.01]. Further adjustment for measures of autonomic function reduced the association between TCA use and mortality (HR = 1.27, 95% CI 0.67-2.43, p = 0.47). SSRI use was not associated with mortality (HR = 1.15, 95% CI 0.81-1.64, p = 0.44). Conclusions: The use of TCA was associated with increased mortality. This association was at least partially mediated by differences in autonomic function. Our findings suggest that TCA should be avoided in patients with coronary heart disease.
    03/2014; 3(14):1-10. DOI:10.1017/S003329171400066X
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