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General Hospital Psychiatry 34 (2012) 160–166

Anxiety and depression in patients with myocardial infarction:findings from a centre in India

Siddharth Sarkar, M.D.a,⁎, Rakesh K. Chadda, M.D., M.R.C.Psych., F.A.M.S.a,Nand Kumar, M.D.a, Rajiv Narang, M.D.b

aDepartment of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, Delhi–110029, IndiabDepartment of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, Delhi–110029, India

Received 28 June 2011; accepted 20 September 2011

Abstract

Objectives: The study was conducted to assess the occurrence of anxiety and depression in patients with recent myocardial infarction (MI)and also to assess the relationship of these symptoms with other relevant factors and clinical outcome.Methods: A total of 103 patients with recent MI attending the cardiology outpatient department (OPD) of a tertiary care centre in India wereincluded. The patients were evaluated using Hamilton Anxiety Rating Scale (HAM-A), Hamilton Depression Rating Scale (HAM-D) andMini International Neuropsychiatric Interview (MINI), and pertinent demographic and clinical parameters were recorded. The patients werefollowed up at 12 weeks telephonically to ascertain outcome.Results: Significant anxiety and depressive symptoms were present in 48.5% and 25.2% of the sample. Anxiety or depressive disorderdiagnosis was present in 25.2% of the sample. Aspirin use predicted lower anxiety and depressive symptom scores. A multivariate linearregression showed that female sex, history of angina and use of aspirin independently predicted scores on HAM-A. Diagnosis of psychiatricdisorder, use of aspirin and increased body mass index also independently predicted scores on HAM-D.Conclusions: There is a need to screen for anxiety and depressive symptoms in patients with MI, so that appropriate intervention can beincorporated in the management plan.© 2012 Elsevier Inc. All rights reserved.

Keywords: Anxiety, Depression, Myocardial infarction; India

1. Introduction

Cardiovascular problems have emerged as a significanthealth issue worldwide. With increasing longevity, the sizeof the aged population has been burgeoning with eachdecade. Coronary heart diseases that primarily affect theelderly have steadily risen in magnitude and prominenceespecially in developing countries like India.

Acute myocardial infarction (MI), a serious and poten-tially life-threatening disease, has often been associated withsignificant anxiety and depression in patients. A largenumber of studies have been conducted to gather knowledgeabout anxiety and depression in patients with coronary heart

⁎ Corresponding author. Tel.: +91 9891640032.E-mail address: sidsarkar22@gmail.com (S. Sarkar).

0163-8343/$ – see front matter © 2012 Elsevier Inc. All rights reserved.doi:10.1016/j.genhosppsych.2011.09.016

diseases. Studies have focused on the prevalence ofpsychiatric symptoms in patients with MI [1,2]. Patientswith MI have also been followed up over time to assesschange in such symptomatology [3].

The reported incidence of depressive symptoms inpatients with MI varies from one study to another. Whilesome studies report that the rates of depression may be nohigher than the general population [4], other studies reportthem to be present in more than 80% of the subjects [5]. Moststudies, however, report a prevalence rate of depression inthe range of around 15% to 35% [6–10]. Probably, thevariation in the clinical sample, instrument used and thedifferent study conditions account for some of thesedifferences. The prevalence of anxiety has also been foundto be significant in the patients with MI [11,12].

Studies have shown that anxiety and depressive symp-toms after MI are associated with poorer outcome in terms of

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cardiac mortality [8–10,13] as well all-cause mortality[14,15]. Patients with depression have also been reportedto have higher rate of coronary interventions [16]. Lane et al.[17,18] interestingly report that symptoms of depression andanxiety predicted neither cardiac nor all-cause mortality.Depression in patients with MI also leads to poor medicationadherence [19] and may indirectly alter outcome.

Certain factors may act as confounders when oneconsiders their association with anxiety and depressivesymptoms and include use of medications, presence ofdiabetes mellitus, hypertension, body mass index, smokingand alcohol use etc. Sheahan et al. [20] found higher rate ofanxiety in patients with MI who were smokers. Ko et al. [21]found no association of use of β-blocker with depression anassociation that was suggested by Ried et al. [22]. Data aboutmany other factors are sparse.

Research from developing countries exploring theassociation of anxiety and depression patients with MIhas been limited [23,24]. Mohapatra et al. [23] foundsignificant depressive symptoms in up to 34% of admittedinpatients. Another study from Pakistan found anxiety anddepressive symptoms in 50% of the patients with MI [24].The studies have a limitation of being cross sectional innature. The present study was planned to assess anxietyand depression in patients with recent MI, their relationshipwith demographic and clinical factors and short-termoutcome of the MI.

2. Methods

2.1. Sample

The sample of the study comprised of outpatientsfollowing up in the cardiology outpatient department(OPD) of the All India Institute of Medical Sciences, atertiary care hospital in New Delhi, India. The centre catersto patients referred from all over the country. Some patientsmay also directly seek treatment at the centre. The centrecaters to more than 1500 cardiology patients per week, seenby various consultants. Consultants in the OPD wererequested to refer patients with recent MI to the researchteam. Patients aged between 40 and 75 years who had anepisode of MI in the preceding 3 months and were clinicallystable for an interview were included in the study. Only thosepatients who were conversant in English or Hindi wereincluded and informed consent was sought from them.

2.2. Procedure

Patients fulfilling the inclusion criteria were identified inthe cardiology OPD and informed consent was sought fromthem. Information was gathered from the patients and theirrelatives. All these assessments were conducted in a singlesession during the patient's visit to the hospital. Theinformation was gathered using a structured questionnaireand information regarding the results of investigations was

obtained from the medical records. Those patients fulfillingthe criteria for a psychiatric diagnosis were referred todepartment of psychiatry for further management. Thepatients were subsequently followed up telephonically at12±1 weeks. Data collection started in July 2009 and wascarried out until August 2010.

2.3. Assessments

A structured questionnaire was used to gather and recordinformation about the patient. The demographic details ofthe patient were noted and per capita income was calculatedfrom household income and number of family members.Clinical history of the patient was gathered and includeddetails about the recent MI. The patient was asked if heor she had a previous MI and whether there was a historyof episodes of angina. History of smoking and alcohol usewere recorded and it was asked whether the patient hadhypertension or diabetes mellitus. A record of the currentmedications was made and family history of anxiety anddepression was obtained. Smokers and alcohol users weredefined as those who had consumed the above-mentionedsubstances within 1 month before MI. Family history ofanxiety and depressive illness was taken as positive in thosewith a known diagnosis anxiety or depressive disorder in afirst-degree relative.

A focussed physical examination was done and includedresting pulse rate in beats per minute, blood pressure in rightarm in sitting position, weight in kilograms, height incentimetres and waist size in centimetres. Body mass Index(BMI) was calculated from the weight and height of thepatient. The results of the recent investigations done in thepatient were also recorded.

The patients were then administered Mini InternationalNeuropsychiatric Interview (MINI) [25], Hamilton AnxietyRating Scale (HAM-A) [26] and Hamilton DepressionRating Scale (HAM-D) [27]. The MINI is a brief structureddiagnostic interview for psychiatric disorders, which givesdiagnoses in Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition (DSM-IV) and InternationalStatistical Classification of Diseases, Tenth Revision (ICD-10). The instrument is divided into modules corresponding todiagnostic categories. MINI elicits all the symptoms listed inthe symptom criteria for DSM-IV and ICD-10 for 15 majorAxis I diagnostic categories, 1 Axis II disorder and forsuicidality. It consists of a screening questionnaire followedby modules regarding various psychiatric diagnoses. It takesabout 20 min to administer.

HAM-A and HAM-D are structured questionnaires toassess symptoms of anxiety and depression, respectively.HAM-A comprises of 14 questions rated on a scale of 0 to 4.It includes questions relating to anxious mood, tension, fears,insomnia, somatic complaints and an assessment ofbehaviour at the interview. The score on this scale predictsthe severity of anxiety, with values of 5 and less representingno significant anxiety. The 17 item version of HAM-D was

Table 1Demographic and clinical variables

Sex Male 94 (91.3%)Female 9 (8.7%)

Age 40–50 41 (39.8%)51–60 29 (28.2%)61–75 33 (32.0%)

Education Up to 10th grade 62 (60.2%)Above 41 (39.8%)

Occupation Sedentary 57 (55.3%)Nonsedentary 46 (44.7%)

Income (in rupees per month) Up to 2000 59 (57.3%)Above 2000 44 (42.7%)

History of smoking Yes 61 (59.2%)No 42 (40.8%)

History of alcohol use Yes 56 (54.4%)No 47 (45.6%)

History of hypertension Yes 40 (38.8%)No 63 (61.2%)

History of diabetes mellitus Yes 25 (24.3%)No 78 (75.7%)

History of a previous MI Yes 21 (20.4%)No 82 (79.6%)

History of angina Yes 36 (35%)No 67 (65%)

Family history of anxiety/depression Yes 12 (11.7%)No 91 (88.3%)

Increased BMI (N25 kg/m2) Yes 30 (29.1%)No 73 (70.9%)

Increased waist size (N102 cm Yes 6 (5.8%)

162 S. Sarkar et al. / General Hospital Psychiatry 34 (2012) 160–166

used in our study. A cutoff value of 8 on the scale is used todetermine presence of depression, with higher scoresreflecting severity of depression.

2.4. Follow-up

The patients were followed up telephonically at 12±1weeks. Information was sought from the patients andinformants regarding further adverse cardiac events, whichincluded MI, stroke and death. Such events were consideredas poor outcome. Absence of such events meant favourableoutcome. The patients were contacted in the evenings (6–8 pm) and a second attempt was made to contact them ifthey were not available on the first attempt. Of the 103patients enrolled, follow-up information was available for79 patients.

2.5. Statistical analysis

It was done using SPSS (version 14; SPSS, Chicago, IL).Descriptive statistics were used for the demographic andclinical variables. χ2 and t-tests were used to find differencebetween the groups when considering the associationbetween anxiety and depression scores and other factors.Multivariate linear regression was used to find factors thatwere independent predictors of HAM-A and HAM-D.

in men, 88 cm in women) No 97 (94.2%)Dyslipidaemiaa (informationavailable in 83)

Yes 43 (51.8%)No 40 (48.2%)

LVEF b55% (informationavailable in 87)

Yes 67 (77%)No 20 (23%)

HAM-A scores N5 Yes 50 (48.5%)No 53 (51.5%)

HAM-D scores N7 Yes 26 (25.2%)No 77 (74.8%)

Any psychiatric diagnosis Yes 26 (25.2%)No 77 (74.8%)

LVEF=left ventricular ejection fraction.a As defined in Adult Treatment Panel III Guidelines, NIH (2001) [28].

3. Results

A total of 112 patients were approached for participationin the study, of whom 5 did not meet the inclusion criteriaand 4 refused to give consent. The total number ofparticipants in this study was 103. The demographic andclinical variables are depicted in Table 1. Majority of theparticipants were men and the mean age of the sample was54.6±9.35 years. The mean per capita income stood at 2473Indian rupees (45 rupees roughly equal US$1). Nearly 48%of the sample scored above the cutoff on HAM-A and 25%above the cutoff on HAM-D. The mean HAM-A scores were6.27±4.40 and mean HAM-D scores were 5.44±3.89. Thepsychiatric diagnoses included major depression (15.5%),agoraphobia (8.7%), generalized anxiety disorder (4.9%),panic disorder (1.9%) and social phobia (1%). The subjectswere on a range of medications including angiotensin-converting enzyme inhibitors and angiotensin receptorblockers (81.6%), β-blockers (74.8%), statins (60.2%),nitrates (58.3%) and aspirin (48.5%). Use of aspirin wasassociated with lower scores on HAM-A as well as HAM-D(Pb.01). Use of other medications did not predict anydifference in anxiety or depression scores. Forty-one percentof the patients had anterior wall MI and 31% had inferiorwall MI. Table 2 shows the relationship HAM-A and HAM-D scores with different variables.

Outcome data were available for 79 patients. Of these,poor outcome was present in 10 (2 died and 8 had adversecardiac event in the form of another attack of MI or stroke).

The remaining 69 patients had a favourable course. Therewas no significant difference between the patients whoseoutcome data were available and for those whose outcomedata were not available except on 3 variables, i.e., aspirinuse, β-blocker use, anxiety scores. The relationship of theoutcome with clinical variables has been depicted in Table 3.

HAM-A and HAM-D scores were highly correlated(r=.823, Pb.001) with each other. Per capita income nega-tively correlated with HAM-A (r=−0.312, P=.001) as wellas HAM-D scores (r=−.255, P=.009). HAM-D scoreswere negatively correlated with waist circumference(r=−.247, P=.012), implying higher waist sizes wereassociated with lesser scores for depressive symptoms.

A stepwise multivariate linear regression analysis showedthat after adjusting for interrelationships between factors,three variables were independent predictors of scores onHAM-A: female sex, history of angina episodes and use

Table 2Relationship of HAM-A and HAM-D scores with clinical variables

Variable Mean HAM-A score (S.D.) Mean HAM-D score (S.D.)

Sex Male (n=94) 5.83 (3.183) 5.21 (3.669)Female (n=9) 9.89 (7.865) 7.78 (5.449)

History of smoking Absent (n=42) 6.02 (4.021) 5.02 (3.665)Present (n=61) 6.44 (4.671) 5.72 (3.971)

History of alcohol use Absent (n=47) 6.72 (5.266) 5.64 (4.425)Present (n=56) 5.89 (3.525) 5.27 (3.408)

History of hypertension Absent (n=63) 5.63 (3.548) 5.27 (3.488)Present (n=40) 7.28 (5.383) 5.70 (4.485)

History of diabetes mellitus Absent (n=78) 6.58 (4.557) 5.55 (3.747)Present (n=25) 5.32 (3.805) 5.08 (4.368)

History of angina Absent (n=82) 5.42⁎ (4.366) 5.10 (3.239)Present (n=21) 7.86 (4.647) 6.06 (5.718)

History of a previous MI Absent (n=67) 6.32 (3.239) 5.39 (3.829)Present (n=36) 6.10 (5.718) 5.62 (4.213)

Family history of anxiety/depression Absent (n=91) 6.05 (4.249) 5.31 (3.863)Present (n=12) 7.92 (5.351) 6.42 (4.122)

Increased BMI Absent (n=73) 6.46 (4.459) 5.76 (3.909)Present (n=30) 5.84 (4.306) 4.68 (3.798)

Increased waist size Absent (n=97) 6.24 (4.358) 5.48 (3.900)Present (n=6) 6.83 (5.492) 4.67 (3.983)

Dyslipidaemia Absent (n=40) 6.40 (4.072) 5.14 (3.509)Present (n=43) 5.58 (4.722) 4.88 (3.871)

LVEF b55% Absent (n=20) 7.00 (3.584) 4.85 (2.815)Present (n=67) 5.90 (4.543) 5.48 (4.035)

Any psychiatric diagnosis Absent (n=77) 5.27⁎⁎ (3.287) 4.71⁎⁎ (3.332)Present (n=26) 9.23 (5.833) 7.58 (4.649)

Outcome (available for 79) Favourable (n=69) 5.74 (3.928) 4.74 (3.522)Poor (n=10) 5.30 (3.093) 5.70 (3.401)

⁎Significant at Pb.05, ⁎⁎significant at Pb.01.LVEF=left ventricular ejection fraction.

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of aspirin. These variables contributed to 32.5% of thevariation in the scores according to the model. Similaranalysis showed that three variables were independentpredictors of HAM-D scores: increased BMI, use of aspirinand any previous psychiatric diagnosis. These factorscontributed to 22.8% of the variation in the scores accordingto the model. Logistic regression for the outcome did notreveal any clinical factors predicting difference between theoutcome groups.

4. Discussion

Over the last couple of decades, there has been concertedfocus on the evaluation of symptoms of anxiety anddepression in patients who experienced MI as has beenreflected by a multitude of studies.

The sample in the present study had comprised ofprimarily men. This probably reflects the health seekingpatterns in India and also the profile of patients coming withdiagnosis of MI in an outpatient setting. This pattern issimilar to other studies from India [29]. Sex differences inhealthcare access and utilization in South Asia have beenreported [30], putting women at a disadvantage throughouttheir life cycle for health seeking. Also, coronary heart

diseases are more common in men who are exposed tomultiple risk factors, including alcohol use, smoking etc,and are bereft of the putative protective effects of estrogen.The mean age of treatment seekers was around 55 years,which is in keeping with the earlier occurrence of MI inSouth Asians [31]. Fairly significant proportion of thesubjects had history of smoking, alcohol use, hypertensionand diabetes mellitus.

In the present study, about a quarter of the patients hadincreased scores of depressive symptoms as measured onHAM-D. Earlier studies in the subject have reported a rate ofdepression ranging from 13.6% using HADS [4] to as highas 87% using HAM-D [5]. In an earlier study from India,Mohapatra et al. [23] found the rate of depression amongsubjects to be 34%, comparable to the present study. Ourstudy also shows that a significant proportion of the subjectsalso had prominent anxiety symptoms measured by theHAM-A. This may be due to the prominence of somaticsymptoms in the HAM-A, which are akin to the physicalsymptoms such as chest discomfort and indigestion reportedby patients of heart problems. Alternately, it may be due toexpression of distress in form of somatic symptoms [32].

About one fourth of the study subjects received adiagnosis of anxiety or depressive disorder. The commondiagnoses included depressive episode, agoraphobia and

Table 3Relationship of outcome with clinical variables

Variable Outcome Significance

Favourable Poor

Sex Male (n=94) 64 9 0.569Female (n=9) 5 1

History of smoking Absent (n=42) 28 3 0.392Present (n=61) 41 7

History of alcohol use Absent (n=47) 31 5 0.763Present (n=56) 38 5

History of hypertension Absent (n=63) 44 5 0.402Present (n=40) 25 5

History of diabetes mellitus Absent (n=78) 52 6 0.252Present (n=25) 17 4

History of previous MI Absent (n=82) 56 7 0.326Present (n=21) 13 3

History of angina Absent (n=67) 48 5 0.190Present (n=36) 21 5

Family history of anxiety/depression Absent (n=91) 58 10 0.202Present (n=12) 11 0

Increased BMI Absent (n=73) 47 8 0.359Present (n=30) 22 2

Increased waist size Absent (n=97) 63 10 0.431Present (n=6) 6 0

LVEF b55% Absent (n=40) 13 3 0.444Present (n=43) 44 7

Dyslipidaemia Absent (n=20) 32 2 0.189Present (n=67) 27 5

HAM-A scores N5 Absent 38 7 0.296Present 31 3

HAM-D scores N7 Absent 57 7 0.286Present 12 3

Any psychiatric diagnosis Absent (n=77) 54 8 0.633Present (n=26) 15 2

LVEF=left ventricular ejection fraction.

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generalized anxiety disorder. This figure is lower ascompared to that reported by Bankier et al. [33] but issimilar to the results of Abrams et al. [34]. HAM-A scoresalso showed a positive correlation to HAM-D scores,suggesting that anxiety and depression symptoms coexistwith each other in MI patients. Such finding has also beenreported by other studies [4,24,33,35,36].

In our study, β-blockers did not predict either anxiety ordepressive symptoms as also reported in some recent studies[21,37]. Aspirin use was associated with lesser scores onboth HAM-A and HAM-D. Use of aspirin has been foundto be associated with lesser anxiety and depressive symp-toms [38]. A significant negative weak correlation was foundbetween the waist size and the HAM-D scores. This hintsthat the thinner a person, the more the depressive symptoms.This corroborates to findings from some Asian studies thatsuggest that higher waist circumference is associated withless depressive symptoms in the elderly [39,40] and is incontrast to Western data, which reveal that higher waistcircumference is associated with more depressive symptoms.

The study had certain limitations. Results of blood andimaging investigations were not available for all the subjects.The sample size was limited by purposive sampling, with

more representation from the male sex. A larger sample sizewith more representation of women may have foundsignificant differences between the groups. Another limita-tion involves the emphasis on somatic symptoms in theHAM-A and HAM-D. Since many of the patients hadpreceding chest symptoms and angina attacks and somepatients may have had other morbidities, it could not beclearly ascertained whether the somatic anxiety anddepression symptoms were due to the physical symptomsor due to the psychological distress only. The follow-up datawere based on reports from a telephonic interview and couldnot be obtained for some of the patients. A follow-up of 3months may not be enough for an illness like MI. A longerfollow-up may have come up with more definitive results.

This study highlights the occurrence of anxiety anddepression in patients with MI in South Asian scenario andlooks at short-term outcome. A variety of clinical factorshave been taken into consideration. It is important to look forthe presence of depression in patients with MI, as it may gounnoticed in the clinical population [41,42]. Hence, there is aneed to keep in mind anxiety and depression as comorbid-ities in patients with MI, so that appropriate intervention canbe incorporated in the management plan.

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The study shows high prevalence of anxiety anddepressive symptoms in patients with a recent MI. Thus, itis important to look for such symptoms in patients withMI, so they can be identified at the earliest and managedeffectively, otherwise they could interfere with the recoveryand prognosis. As high as 70% of the cases of depressionmay be missed. The situation may be worse in low- andmiddle-income countries like India with the overburdenedresources and limited time that can be spent per patient.There is a need for long-term follow-up studies with largersample sizes, especially from the low- and middle-incomecountries, to assess the impact of anxiety and depression onlong-term outcome of MI.

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