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