Depression, Vital Exhaustion and recurrent heart disease
Lecture 9 references
Standard texts, Kop paper, and Krantz & Lundgren paper.
Depression and CHD is very current topic and good reviews are just appearing. Psychosomatic Medicine has made a complete special issue on the topic available over the internet (free). Go to www.psychosomaticmedicine.org
Kubzansky & Kawachi 2000. Going to the heart of the matter: do negative emotions cause coronary heart disease? J Psychosomatic Res., 48, 323-327 Review that includes depression.
Carney, R M., Freedland, Miller, M (2002) Depression as a risk factor for cardiac mortality and morbidity:A review of potential mechanisms. J Psychosomatic Res., 53, 897-902. Thoughtful discussion that is worth reading.
Depression: what is it?
DSM-IV
Five of following for at least 2 weeks
Sad mood most of day, most days
Loss of interest & pleasure in usual activities
Sleeping difficulties
Change in activity level
Change in eating patterns
Fatigue
Negative view of self
Less efficient thinking
Recurrent thoughts of suicide or death
Frasure-Smith et al, 1999. Gender, depression and one-year prognosis after myocardial infarction. Psychosomatic Med. 61, 26-37. (On web through library, worth reading). See also her paper on special issue of Psychosomatic Medicine referred to earlier
Nancy Frasure-Smith major figure in proposing that depression makes reinfarction more likely. In this paper she combines her earlier studies to get large enough sample to examine effects of gender.
Sample. Women 283, Men 613.
Frasure-Smith, 1999
Barefoot et al, 2000 Depressive symptoms and survival of patients with coronary artery disease. Psych. Med. 62, 790-795.
1250 patients with CAD seen between 1974 & 1980 followed up for up to 19.4 years.
Measure Negative Affect. 6 item covering
Sad, crying, suicidal thoughts, irritability, restlessness
High negative affect (overlaps with depression), associated with lower survival in younger patients
Vital Exhaustion (Ad Appels), see Kop
Features
lack of energy
increased irritability
demoralization
Vital exhaustion is short term predictor of MI, Rotterdam Civil Servant study. 3877 healthy men followed up for 4.2 years.
year 1 year 2 year 3 year 4
Years of follow up
0
3
6
9
12
15
Rela
tive R
isk o
f exh
au
sted
men
Rotterdam Civil Servants Study
RR
RR=1
More coronary events in “exhausted” patients who received angioplasty, Kop.
Mechanisms for Depression CHD link
Reactivity. Preliminary evidence that reactivity may be increased in depression. Perhaps associated with anger/irritation.
Anti-depressants
Other Risk factors
Heart disease severity
Adherence and other behavioural mechanisms
Autonomic tone
Blood clotting processes. PF4 and BTG increased in depressed CHD patients
Inflammatory processes. Evidence of increased inflammation related to chlamydia in exhausted patients with CAD (Appels 2000). See Kop in special issue of Psychosomatic Medicine.
Studies in Health populationsKuper Marmot & Hemingway (2002), Seminars in Vascular Medicine,2, 267-313
Psychological process positive/no. of studies
Type A / Hostility 6/18
Depression 15/22
Anxiety 4/8
Work characteristics 10/13
(Social Support 6/9)
Studies in Populations with Cardiovascular Disease
Type A/Hostility 2/15
Depression 18/34
Anxiety 8/18
Work characteristics 2/4
(Social Support 14/21)
Seen as positive support overall By K,M & H
Evidence from interventions
ENRICHD (2003). Treatment of depression and low perceived social support after myocardial infarction
JAMA, 289, 3106-3116
Effects on Depression
BDI at only 6 months
Pre 6 month
Usual Care 18.0 12.2
Intervention 17.79.1
ENRICHD trial of reduction of Depression and/or increase in Perceived Social Support. No effect on Recurrent MI but very little effects on Depression or Social Support
Appels, A et al., (2005) Effects of treating exhaustion in angioplasty patients on new coronary events. Psychosom Med 67, 217-223
Effects on Exhaustion at 18 months
No history of CAD Int. Cntrl % %
Not Exhausted 56 38Exhausted 44 62
History of CAD Int. Cntrl
% %
Not Exhausted 47 47Exhausted 53 53
Reduction in Vital Exhaustion after Angioplasty. No effect on new coronary events but effect on Exhaustion restricted to sub-sample of patients
Recruit Discharge 2Mnth 6Mnth 1 Year
Time
0
2
4
6
8
10M
ean D
epre
ssio
n (
HA
DS)
Patients
Control
Inpatient
Extended
Johnston,M, Foulkes J, Johnston, D, Pollard, B, Gudmundsdottir, H (1999) Psychosomatic Medicine, 61, 225-233
Depression reduced in patients after MI by simple Counselling intervention
Recruit Discharge 2Mnth 6Mnth 1 Year
Time
0
2
4
6
8
10
Mean D
epre
ssio
n (
HA
DS)
Partners/Carers
Control
Inpatient
Extended
Johnston,M, Foulkes J, Johnston, D, Pollard, B, Gudmundsdottir, H (1999) Psychosomatic Medicine, 61, 225-233
Depression reduced in partners of MI patients who received counselling