|Ahead of print publication
Depressive disorders in angiographic-proven coronary artery disease: Prevalence and risk factors
Nitin Bajaj1, Abhilasha Sharma2, Swati Bajaj3, Rohith R Pisharody4, Seema Patrikar3
1 Department of Cardiology, Command Hospital, Jammu and Kashmir, India
2 Department of Internal Medicine, Command Hospital, Jammu and Kashmir, India
3 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
4 Department of Psychiatry Command Hospital Chandimandir, Haryana, India
|Date of Submission||14-Mar-2020|
|Date of Decision||21-Jun-2020|
|Date of Acceptance||13-Jul-2020|
|Date of Web Publication||02-Sep-2020|
Department of Cardiology, Command Hospital, Udhampur - 182 101, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Objective: Depressive disorders are a common and unrecognized entity in the patients of coronary artery disease (CAD). This study aimed at detecting the prevalence of depressive disorder in patients of angiographic proven CAD and to assess the correlation between depression and various coronary risk factors and clinical variables in patients of CAD. Materials and Methods: We did a prospective, observational study in patients of angiographic proven CAD attending cardiology outpatient department services in a tertiary care hospital. We studied patients in the age group of 25–80 years of CAD. A detailed history clinical evaluation was done, and the prevalence of depression was detected with the help of a questionnaire as per becks depression inventory. Results: A total of 150 patients were studied. Out of these, 113 (75.33%) were male and 37 (24.66%) were female. The mean age of the patients was 54.85 years. In the questionnaire-based screening for depression, 16.6% had normal score, 30% had mild mood disturbance, whereas 26% had borderline clinical depression and another 25.3% had moderate depression. A total of 03 patients (2%) had severe depression and none had extreme depression. Among the associations with depression, the presence of female sex, New York Heart Association class and educational status was shown to have significant association with depression in CAD patients. Conclusions: Our study shows a high prevalence of depression in patients of CAD. This generally goes unnoticed and untreated and can lead to poor quality of life and also increases mortality risk. Thus, the features of depressive disorder should be actively screened and treated in patients of CAD.
Keywords: Coronary artery disease, depression, risk factors
| Introduction|| |
Cardiovascular diseases (CVD) have been recognized as the leading cause of mortality worldwide. As per the World Health Organization (WHO) estimates 17.9 million people died in 2016 due to CVD, out of which 85% were due to coronary artery disease (CAD) and stroke. Over three quarters of these deaths occur in low- and middle-income countries. Depression is a common mental health disorder, and it is estimated that approximately 264 million people of all ages suffer from depression worldwide, and it is a leading cause of morbidity and disability. According to an estimate by the WHO, by the year 2020, both CAD and depression will be the two major causes of disability-adjusted life years.
The relationship between CAD and depression is bidirectional. Depression has been known to coexist with CAD and has also shown to have a worse outcome in patients of CAD. Between 31% and 45% of patients with CAD, including those with stable CAD, unstable angina, or myocardial infarction (MI), suffer from clinically significant depressive symptoms. Most studies have found that younger patients, women, and patients with premorbid histories of depression are more likely to have depression in the context of CAD. Increased incidence of depressive disorders in patients of CAD has been postulated due to the increased levels of inflammation and circulating levels of interleukins and C-reactive proteins which are raised in patients of CAD. Other factors such as endothelial dysfunction and platelet dysfunction which are essential to pathophysiology of CAD have also been linked to depressive disorders.
Although it is well-established that depressive disorders coexist with CAD and have an effect on the outcome of CAD, still the presence of depression is not actively looked for and treated in patients of CAD. There are very few Indian studies on this subject and coexisting mental health disorders such as depression are generally overlooked in a busy cardiology outpatient department (OPD). This study was done with an aim to find out the prevalence of these disorders in patients of CAD, look for risk factors causing depression, and emphasize the importance of screening for psychiatric illnesses such as depression in patients of CAD.
| Materials and Methods|| |
This study was prospective, observational study conducted at a tertiary care hospital in Jammu and Kashmir. The study conforms to the widely accepted ethical principles guiding human participants and was approved by the Institutional Ethics Committee. Patients of age group 25–80 years, who had angiographic proven CAD, attending cardiology OPD were included in the study. Informed consent for participation in the study was obtained from all the participants. A detailed history and clinical examination was carried out, and all old documents studied. History regarding coronary risk factors, duration of illness, and functional status was taken. Details about educational status and social factors such as staying alone or with family were also taken to ascertain the social support of the subjects. Details of angiographic extent of disease and details of any interventions done in the past were obtained from the previous records. Echocardiography was done for the assessment of left ventricular ejection fraction (LVEF). A questionnaire-based survey for the screening of depression was done using the becks depression inventory (BDI). All patients who were found to have significant depression were offered psychiatric consult and further treatment.
- All patients with angiographic-proven CAD in the past
- Age group of 25–80 years.
- Patients who had suffered recent acute coronary syndrome in the past 1 month were excluded
- All patients with known psychiatric comorbidities on treatment were excluded
- All patients with other chronic debilitating disorders such as malignancy were excluded from the study.
The data thus obtained were analyzed using the SPSS software Version 22.0 (IBM Corp., Armonk, NY, USA) for ascertaining the prevalence of depression among the participants. All patients having a BDI score of more than 20 were considered to have significant depression. The various factors were then correlated in patients with or without significant depression, and studied for any significant association with the presence of depression.
| Results|| |
A total of 150 patients were studied. Out of the patients studied, 113 (75.33%) were male and 37 (24.66%) were female. The age of the patients ranged from 28 to 80 years, and the mean age was 54.85 years. The age-wise distribution is given as per [Figure 1]. History regarding modifiable coronary risk factors was taken. Among the major risk factors, hypertension was present in 62 (41.33%), diabetes mellitus was present in 45 (30%) of the patients, 76 patients (50.66%) were current or past smokers, and 40 (26.7%) patients gave a positive family history of CAD in first degree relative. The duration of illness varied from 01 to 25 years, and the mean duration of time from the diagnosis of CAD was 4.17 years.
The functional status of the patients was studied using the New York Heart Association (NYHA) classification, and echocardiographic assessment was done to determine the LVEF. 83 (55.3%) of the patients were in NYHA class 1, 61 (40.7%) were in NYHA class 2, and 6 (4%) were in NYHA class 3. None of the patients had NYHA class 4 symptoms. The mean NYHA class of the patients was 1.48.
Echocardiographic evaluation was done to assess the LVEF. Out of 150 patients, 7 (4.66%) had LVEF of <35%, 62 (41.33%) had LVEF of 35%–45%, and 81 (54%) had LVEF of more than 45%. The mean LVEF was 48%. Among the patients studied, 123 (82%) had undergone percutaneous coronary intervention (PCI) and 7 (4.66%) had undergone coronary artery bypass graft (CABG). The rest did not undergo any revascularization procedure and were on medical management alone.
Social indicators such as educational status, whether staying alone or with family was also studied. Among the study participants, 122 (81.33%) were staying with family and 28 (18.66%) were staying alone. In the educational background, out of the 150 patients, 19 (12.6%) were illiterate, 58 (38.66%) had studied less than class X, 42 (28%) had completed school (up to class XII), 27 (18%) were graduates, and 4 (2.66%) were postgraduates. The baseline parameters of the study participants are summarized in [Table 1].
The results of BDI were analyzed to assess the frequency of depressive disorder in these patients. A total score of <10 which is considered as normal was present in 25 (16.66%) of patients. A score of 11–16 which is suggestive of mild mood disturbance is present in 45 (30%) of patients. A score of 17–20 suggestive of borderline clinical depression was present in 39 (26%) patients. Score of 21–30 signifying moderate depression was present in 38 (25.33%) of participants, while only 3 (2%) patients had a score of more than 30 signifying severe depression. The mean score as per the BDI was 17.08. The details are given as per [Figure 2].
A score of less than equal to 20 was considered as the absence of depression and a score more than 20 was considered as having significant depression. Out of 150 patients, 109 (72.7%) had a score of <20 and 41 (27.3%) had a score of more than 20. The variables were studied in these two groups to identify the correlation with the presence of depression, and data were analyzed using the SPSS software. It showed that the incidence of depression was more in females (36.58%) than in males (19.26%), with a P value of 0.027, which is statistically significant. Other risk factors such as smoking, diabetes mellitus, hypertension, and family history of CAD did not have any significant impact on the incidence of depression in these patients.
The presence of depression was also significantly influenced by the NYHA class of the patients. Out of the total patients in NYHA class 2, 51.21% were those with depression and 36.69% were without depression. Similarly, out of the total patients in NYHA class 3, 9.75% were those with depression and 1.8% were without depression. P value of association of NYHA class with the presence of depression was 0.012, which is statistically significant. The presence of PCI or CABG did not show any significant association with depression.
Among the social indicators, education status showed a significant association with the presence of depression, 31.7% of patients with depression were illiterate as compared to only 5.50% without depression being illiterate. Other social indicator of staying alone or with family did not show any significant association. The results of the analysis are as per [Table 2].
|Table 2: Comparative variables of participants with and without significant depression|
Click here to view
| Discussion|| |
Depressive disorders in patients with angiographic-proven CAD have been studied and reported in previous studies ranging from 17% to 44%.,,, The results of these studies indicate a high significant prevalence of major depression in the patients with CAD, compared with healthy populations, in whom the prevalence of depression is only of 6.6%. The largest of these studies, the enhancing recovery in coronary heart disease patients, examined 9279 patients and reported a prevalence of 20%. In spite of the strong associations of depression and CAD, there are few Indian studies on this topic and depression is not actively screened for in most patients attending cardiology clinics.
Our study showed a prevalence of moderate and severe depression in 27.33% and borderline clinical depression in another 26% of cases. In a previous study by Agarwal et al., major depressive disorder was seen in 23.8% and subsyndromal symptoms were seen in 20.8% of patients post MI. In another study from Brazil, depression was present in 26.8% of cases. Severe depression was found in 31% of patients in post MI setting in another Indian study from Coimbatore.
In our study, 75.3% participants were males. In previous studies, males constituted 64.8%–75% of the participants included.,, The sex difference in the prevalence of depression was significant in our study, wherein 36.5% of patients with significant depression were females as compared to 19.26% of females who did not have significant depression. These findings are consistent with previous studies where depressive disorders were seen significantly more in females as compared to males.,,
Among the traditional risk factors, it was seen that there was a trend of significant depression in diabetics as compared to nondiabetics (41.46% vs. 25.68%), though this was not statistically significant. Other major risk factors such as hypertension, smoking, and family history of CAD were present in both groups and there was no significant difference. In previous studies, depression was found more in diabetics and hypertensives, and in another study significant difference was seen in women who were diabetics, and in a recent study by May et al., depression was found to be significantly more in patients of CAD having diabetes, hypertension, hyperlipidemia, and family history; however, there was no significant difference in depression among smokers and nonsmokers.
The NYHA functional class was studied in the two groups of patients, and it was concluded that there was significant difference in the NYHA class and higher percentage of patients in the depressed group were in functional class 2 and 3 as compared to the group having no depression. We could not find previous studies showing similar differences. There were no significant differences in patients undergoing PCI or CABG in the depression scores.
Among the social indicators, we studied the education status and the number of respondents staying alone or with family. We found a significant difference in the education status and the prevalence of depression, with 31.70% of patients having significant depression were illiterate and only 5.50% of patients without significant depression were illiterate. In previous studies, it was seen that significant more number of illiterate and uneducated subjects had depression.,, There was no significant difference noted in the prevalence of depression with staying alone or with family in our study. In previous studies, staying single was significantly associated with depression as compared to staying with spouse.
Adverse outcomes of depression in CAD have been elucidated in various studies in the past. A meta-analysis of 22 trials of depression in post-MI setting found that depression was associated with an odds ratio of 2.38 for all-cause mortality. A recent study showed by Szpakowski et al. showed the prevalence of depression in about 18% of patients of chronic stable angina, and patients who had coexistent depression had a significant higher all-cause mortality. The presence of depression has been associated with poor functional outcomes in patients undergoing CABG, with more peril-operative complications, and worse quality of life.,, The association of depression with CAD has shown to have increased incidence of heart failure and sudden cardiac death. Depression is also related unhealthy lifestyle such as lack of exercise and quitting smoking in patients with CAD. Due to the strong correlation of CAD and depression, the American Heart Association recommends such screening using the 2-and 9-item Patient Health Questionnaires (PHQ-2 and PHQ-9).
| Conclusions|| |
Our study reiterates that CAD has strong correlation with depression. The major risk factors as per our study our female sex and educational status. As it has been already proven that depression is associated with the poor outcomes in CAD, so it is recommended that effective screening of depression be carried out in all patients of CAD, as effective treatment can have definite mortality benefit in patients of CAD.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017. The Lancet 2018:392:1789-858.
Celano CM, Huffman JC. Depression and cardiac disease: A review. Cardiol Rev 2011;19:130-42.
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.
Parashar S, Rumsfeld JS, Spertus JA, Reid KJ, Wenger NK, Krumholz HM, et al
. Time course of depression and outcome of myocardial infarction. Arch Intern Med 2006;166:2035-43.
Carney RM, Freedland KE, Steinmeyer B, Blumenthal JA, Berkman LF, Watkins LL, et al
. Depression and five year survival following acute myocardial infarction: A prospective study. J Affect Disord 2008;109:133-8.
Lane D, Carroll D, Ring C, Beevers DG, Lip GY. Mortality and quality of life 12 months after myocardial infarction: Effects of depression and anxiety. Psychosom Med 2001;63:221-30.
Lauzon C, Beck CA, Huynh T, Dion D, Racine N, Carignan S, et al
. Depression and prognosis following hospital admission because of acute myocardial infarction. CMAJ 2003;168:547-52.
Meneghetti CC, Guidolin BL, Zimmermann PR, Sfoggia A. Screening for symptoms of anxiety and depression in patients admitted to a university hospital with acute coronary syndrome. Trends Psychiatry Psychother 2017;39:12-8.
Berkman LF, Blumenthal J, Burg M, Carney RM, Catellier D, Cowan MJ, et al
. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA 2003;289:3106-16.
Agarwal M, Trivedi JK, Sinha PK, Dalal PK, Saran RK. Depression in patients of myocardial infarction – A cross-sectional study in Northern India. JAPI 2011;59:636-9.
Manoj MT, Joseph KA, Vijayaraghavan G. Association of depression, anxiety, and stress with myocardial infarction: A case-control study. J Clin Prev Cardiol 2018;7:86-92. [Full text]
Bokhari SS, Samad AH, Hanif S, Hadique S, Cheema MQ, Fazal MA, et al
. Prevalence of depression in patients with coronary artery disease in a tertiary care hospital in Pakistan. J Pak Med Assoc 2002;52:436-9.
Frasure-Smith N, Lespérance F, Juneau M, Talajic M, Bourassa MG. Gender, depression, and one-year prognosis after myocardial infarction. Psychosom Med 1999;61:26-37.
Mallik S, Spertus JA, Reid KJ, Krumholz HM, Rumsfeld JS, Weintraub WS, et al
. Depressive symptoms after acute myocardial infarction: Evidence for highest rates in younger women; Arch Intern Med 2006;166:876-83.
May HT, Horne BD, Knight S, Knowlton U, Bair TL, Lappé DL, et al
. The association of depression at any time to the risk of death following coronary artery disease diagnosis. Europ Heart J Quality Care Clin Outcomes 2017;3:296-302.
Sharma Dhital P, Sharma K, Poudel P, Dhital PR. Anxiety and depression among patients with coronary artery disease attending at a cardiac center, Kathmandu, Nepal. Nurs Res Pract 2018;2018:4181952. DOI:10.1155/2018/4181952.
van Melle JP, de Jonge P, Spijkerman TA, Tijssen JGP, Ormel J, Veldhuisen J, et al
. Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: A meta-analysis. Psychosom Med 2004;66:814-22.
Szpakowski N, Bennell MC, Qiu F, Ko DT, Tu JV, Kurdyak P, et al
. Clinical impact of subsequent depression in patients with a new diagnosis of stable angina: A population-based study. Circ Cardiovasc Qual Outcomes 2016;9:731-9.
Beresnevait M, Benetis R, Taylor GJ, Jurnien K, Kin-duris S, Barauskien V. Depression predicts perioperative outcomes following coronary artery bypass graft surgery. Scandinavian Cardiovascular J 2010;44:289-94.
Morone NE, Weiner DK, Belnap BH, Karp JF, Mazumdar S, Houck PR, et al
. The impact of pain and depression on recovery after coronary artery bypass grafting. Psychosom Med 2010;72:620-5.
Burg MM, Benedetto MC, Rosenberg R, Soufer R. Presurgical depression predicts medical morbidity 6 months after coronary artery bypass graft surgery. Psychosom Med 2003;65:111-8.
Empana JP, Jouven X, Lemaitre RN, Sotoodehnia N, Rea T, Raghunathan TE, et al
. Clinical depression and risk of out-of- 55. hospital cardiac arrest. Arch Intern Med 2006;166:195-200.
Bonnet F, Irving K, Terra JL, Nony P, Berthezène F, Moulin P. Anxiety and depression are associated with unhealthy life style in patients at risk of cardiovascular disease. Atherosclerosis 2005;178:339-44.
Lichtman JH, Bigger JT Jr., Blumenthal JA, Frasure-Smith N, Kaufmann PG, Lesperance F, et al
. Depression and coronary heart disease: Recommendations for screening, referral, and treatment-a science advisory from the American heart association prevention committee of the coun-cil on cardiovascular nursing, council on clinical cardiology, council on epidemiology and prevention, and interdisciplinary council on quality of care and outcomes research. Circulation 2008;118:1768-75.
[Figure 1], [Figure 2]
[Table 1], [Table 2]