| |
American Heart Association Recommends Depression Screening for Cardiovascular Disease Patients Cardiovascular Disease / 'Double the Concern in Older HIV+'
|
| |
| |
Download the PDF here
from Jules: People with HIV also have high rates for depression, and older HIV+ are at even greater risk for depression & anxiety with rates of 35% for anxiety & 50% depression, and up to 50% cognitive impairment having been reported for older HIV+.As well many older HIV+ are suffering worsening physical function which increases the risk for depression. Its estimated that HIV causes an estimated 10 years increase aging compared to HIV-neg so a 65 year old HIV+ person may be similar to a 75 year old HIV-neg person in terms of aging & immunity. We are just NOT screening enough for depression, not putting enough focus on identifying mental health problems particularly in older HIV+ who are experiencing premature & accelerated aging, increasingly ore comorbidities including diabetes which in and of itself could cause depression. With the aging of the HIV+ population it is crucial to address depression, cognitive impairment & overall mental health, We are nt funding HIV clinics & RWCA clinics to provide adequate evaluation & Support service for aging needs & for mental health.
Whom to screen for depression?
All adult patients, including those with acute or chronic CVD, should be screened for depression (7) (Central Illustration). Depression screening also may be conducted in younger patients for cardiovascular risk assessment (60). In patients with a history of depression, self-report assessments should assess for adequate symptomatic control (core depressive symptoms, as well as anxiety, irritability, mania, and/or panic), side effects burden, and adherence to prescribed antidepressants using the measurement-based care (MBC) approach (72,73).
American Heart Association Recommends Depression Screening for Cardiovascular Disease Patients Cardiovascular Disease
NEW YORK (Reuters Health) - Patients with cardiovascular disease should undergo screening to identify and manage depression, according to a JACC state-of-the-art review.
Depression, which affects 1 in 5 patients with coronary artery disease, peripheral artery disease, and heart failure, complicates the management of cardiovascular disease by worsening cardiovascular risk factors and decreasing adherence to healthy lifestyles and medical therapies.
The American Heart Association recommends screening all patients with coronary artery disease for depression, and the US Preventive Services Task Force recommends screening the general adult population for depression, but only an estimated 3% of patients in ambulatory care settings underwent screening for depression in 2015.
Dr. James W. Murrough from Icahn School of Medicine at Mount Sinai, New York and colleagues discuss a practical approach for screening and managing depression in patients with cardiovascular disease in their April 16th Journal of the American College of Cardiology report.
Cardiologists should discuss the importance of depression screening with their patients with cardiovascular disease and then undertake screening of all those who agree.
In the meantime, patients who screen positive for depression should undergo immediate evaluation for acute suicidality, although how best to do this depends upon the availability of resources at the cardiology service and in the community.
Dr. Robert Carney from Washington University School of Medicine, St. Louis, Missouri, who has extensively researched links between depression and coronary artery disease, told Reuters Health by email, "Probably the well documented finding that depression increases the risk of mortality and cardiac morbidity may be the most significant point. However, the evidence that treating depression improves survival in these patients is not as strong as most of us would like. Nevertheless, there is reason to believe that it may, especially if optimal treatment is provided."
"Cardiologists may decide to screen for depression, and perhaps even begin treatment, but primary care docs will follow the patients longer and hopefully see them more often," he said. "Regardless of which treatment is initiated (psychotherapy or antidepressants), the likelihood of achieving remission with the first treatment is about 35%. Also, depression may recur or become more severe, and so ongoing follow up is needed."
"It is important to be aware that depression is common in these patients, and this is often not mentioned to cardiologists unless they ask," Dr. Carney said.
Dr. Benjamin I. Goldstein, director of research in the department of psychiatry at Sunnybrook Health Sciences Center, Toronto, Ontario, Canada, told Reuters Health by email, "Reducing depression symptoms can not only improve quality of life and functioning in the here and now, but it can also potentially improve cardiovascular disease outcomes through both direct (e.g., biological) and indirect (e.g., motivation to participate in cardiac rehabilitation, adherence with treatments) effects of depression on cardiovascular disease."
"While the current article focuses on depression, which is where the data are most abundant, similar themes apply to other serious and recurrent psychiatric disorders, such as bipolar disorder and schizophrenia," he said. "In addition to focusing on depression as a modifiable risk factor for poor outcomes among patients with established cardiovascular disease, we must also employ a preventive lens, and focus on depression as modifiable risk factor for the development of early cardiovascular disease."
-----------------------------------------
Screening and Management of Depression in Patients With Cardiovascular Disease
JACC State-of-the-Art Review
Conclusions
Depression represents a common comorbidity in patients with a broad range of cardiovascular conditions and identifies patients at heightened risk of short- and long-term adverse cardiovascular events, excess health care expenditures, and adverse quality of life. Screening for depression utilizing standardized and guideline-supported simple questionnaires can be efficiently integrated into cardiovascular practices and should be routinely considered in patients with CVD. Although SSRIs are considered safe and effective first-line treatment for depression in most patients with CVD, nonpharmacological approaches may be more appropriate for patients with heart failure where the superiority of SSRIs is not well established. Clinicians should be mindful of polypharmacy, treatment adherence challenges, and potential for adverse drug-drug interactions in patients with depression and CVD. While studies of antidepressant treatments so far have focused on measures of depressive symptom severity or adverse cardiovascular events, future studies should also evaluate patient-centered outcomes such as quality of life and functional improvement. Future randomized clinical trials comparing different pharmacological and nonpharmacological approaches may further our understanding of personalized care plans for individual patients with CVD and depression. Cardiologists represent an important node of patient entry and identification in the multidisciplinary care model (involving primary care physicians, mental health clinicians, therapists, social workers, pharmacists, and care coordinators) in the comprehensive management of patients with depression. Similar to other chronic cardiometabolic conditions, depression has emerged as a prevalent, clinically important, and potentially modifiable risk factor of CVD.
Routine systematic screening with validated self-report measures is needed for early and accurate identification of depression in CVD patients, as depression is often unrecognized or inaccurately diagnosed in nonpsychiatric medical care settings (62). The burden of under-recognition and undertreatment of depression is likely to be higher in minority and underserved populations. More than 50% of patients with depression go unrecognized in medical settings, and the diagnosis of depression ascribed by clinicians has only a moderate level of agreement with gold-standard structured diagnostic evaluations
patients with depression may have less engagement in health behaviors that mitigate the risk of future cardiovascular events, such as physical activity, dietary modifications, smoking cessation, stress management, and substance abuse treatment.
Patients with depression have higher levels of inflammatory cytokines, acute phase proteins, and adhesion molecules including interleukin-1β and -6, tumor necrosis factor-alpha, and C-reactive protein (50), which may in turn be associated with cardiovascular events.
Insulin resistance
The risk of cardiovascular events is higher in individuals with insulin resistance and diabetes mellitus (51), the incidence of which is significantly increased in depression. Depression may result in immune-mediated destruction of the pancreatic β-cells contributing to insulin resistance and diabetes mellitus, both of which are important risk factors for CVD (52). Insulin resistance in depression may be related to lifestyle-related factors and mediated through visceral fat accumulation and central obesity from the chronic activation of the hypothalamic-pituitary-adrenal axis.
Prevalence of depression in patients with CVD
Prevalence of depression varies according to the type and severity of CVD. Approximately 15% to 20% of patients with CAD have depression; up to two-thirds of patients with myocardial infarction (MI) develop depression either during index hospitalization or in follow-up (13). Compared with the general population, patients with MI are at 3-fold higher risk of depression
Depression as a risk factor for CVD
Depression is associated with increased risk of future CVD. Depression and psychosocial factors (perceived stress, low locus of control, and major life events) were associated with a 2.5- to 3.5-fold higher risk of CVD in a large international study of patients with MI (n = 15,152) and control subjects (n = 14,820) even after controlling for lifestyle factors and other medical disorders (4). Presence of depression at baseline was associated with higher risk of MI (>70%) and all-cause mortality (>60%) in community dwelling adults over 27-year follow-up independent of age, sex, and other risk factors (23). A meta-analysis of 8 prospective cohort and case-control studies showed a 60% higher adjusted risk of incident CVD in patients with depression (24).
------------------------------
Screening and Management of Depression in Patients With Cardiovascular Disease
JACC State-of-the-Art Review
Manish K. Jha, Arman Qamar, Muthiah Vaduganathan, Dennis S. Charney and James W. Murrough
Highlights
• Depression is a common problem and is associated with increased mortality and reduced quality of life in patients with CVD.
• Depression complicates the optimal management of CVD by worsening cardiovascular risk factors and decreasing adherence to healthy lifestyles and evidence-based medical therapies.
• Standardized screening pathways for depression in patients with CVD offer the potential for early identification and optimal management of depression to improve health outcomes.
Abstract
Depression is a common problem in patients with cardiovascular disease (CVD) and is associated with increased mortality, excess disability, greater health care expenditures, and reduced quality of life. Depression is present in 1 of 5 patients with coronary artery disease, peripheral artery disease, and heart failure. Depression complicates the optimal management of CVD by worsening cardiovascular risk factors and decreasing adherence to healthy lifestyles and evidence-based medical therapies. As such, standardized screening pathways for depression in patients with CVD offer the potential for early identification and optimal management of depression to improve health outcomes. Unfortunately, the burden of depression in patients with CVD is under-recognized; as a result, screening and management strategies targeting depression have been poorly implemented in patients with CVD. In this review, the authors discuss a practical approach for the screening and management of depression in patients with CVD.
Major depressive disorder, commonly referred to simply as depression, affects 1 of 5 adults during their lifetime and is the second leading cause of disability in the United States (1,2). Depression is a major cause of morbidity and poor quality of life among patients with cardiovascular disease (CVD) (3) and is also considered an independent risk factor for major adverse cardiovascular events (4). Epidemiological studies suggest that fewer than 20% of individuals with depression are adequately treated (5). These rates are even lower in patients with CVD; in a study of those admitted to cardiac inpatient services, only 11% of patients with depression received adequate antidepressant therapy (6). To improve identification of patients with depression, the U.S. Preventive Services Task Force (USPSTF) recently issued recommendations to screen for depression in the general adult population while emphasizing that patients with CVD are at an increased risk of depression (7). Similar to these recommendations, the American Heart Association (AHA) issued an advisory in 2008 to screen all patients with coronary artery disease (CAD) for depression (8). However, the uptake of the USPSTF recommendations in clinical practice remains poor. While screening for depression has increased gradually since 2009, it is estimated that only 3% of patients in ambulatory care settings were screened for depression in 2015 (9). Standardized screening pathways for depression in CVD patients offer the potential for early identification and improved management of both CVD and depression (10-12). In this review, we discuss a practical approach for the screening and management of depression in patients with CVD.
Impact of Depression in CVD
Prevalence of depression in patients with CVD
Prevalence of depression varies according to the type and severity of CVD. Approximately 15% to 20% of patients with CAD have depression; up to two-thirds of patients with myocardial infarction (MI) develop depression either during index hospitalization or in follow-up (13). Compared with the general population, patients with MI are at 3-fold higher risk of depression (14). In a prospective cohort study examining the prevalence of depression in approximately 1,000 patients undergoing coronary artery bypass graft (CABG) surgery, 38% of patients met criteria for depression, with 26% having mild depression and 12% moderate-to-severe depression (15). Depression is also present in 20% of patients with peripheral artery disease (PAD) (16,17) and heart failure (18). Patients with New York Heart Association (NYHA) functional class IV have nearly 4-fold higher rates of depression compared with NYHA functional class I heart failure (18). A pooled analysis of 5 studies reported comorbid depression in 11%, 20%, 38%, and 42% of patients with NYHA functional class I, II, III, and IV heart failure, respectively. Younger patients with heart failure (19) and those requiring implantable-cardioverter defibrillator insertion (20) or who experience attendant implantable-cardioverter defibrillator firing (21,22) are particularly at risk for comorbid depression.
Depression as a risk factor for CVD
Depression is associated with increased risk of future CVD. Depression and psychosocial factors (perceived stress, low locus of control, and major life events) were associated with a 2.5- to 3.5-fold higher risk of CVD in a large international study of patients with MI (n = 15,152) and control subjects (n = 14,820) even after controlling for lifestyle factors and other medical disorders (4). Presence of depression at baseline was associated with higher risk of MI (>70%) and all-cause mortality (>60%) in community dwelling adults over 27-year follow-up independent of age, sex, and other risk factors (23). A meta-analysis of 8 prospective cohort and case-control studies showed a 60% higher adjusted risk of incident CVD in patients with depression (24).
Prognosis of patients with CVD and depression
Depression in patients with CVD is associated with poor prognosis. Presence of depression after MI is independently associated with a 2-fold to 4-fold higher risk of subsequent cardiovascular events (25-27). This risk is directly proportional to depression severity (28). Patients with depressive symptoms that are refractory to antidepressant treatment remain at an increased risk for subsequent cardiovascular events (29). Similarly, depression is associated with higher cardiovascular event rates after CABG (15,30) and in patients with PAD and heart failure. Patients with PAD and concomitant depression experience higher vascular complications, suboptimal functional improvement after lower extremity revascularization, and an increased need for revascularization than those without depression (31-33). Depression is associated with a 2-fold to 3-fold higher risk of death or rehospitalization within 3 to 12 months after hospitalization for heart failure (34-37). Furthermore, depression in patients with heart failure is associated with greater health care utilization (38), poor quality of life (39), and greater risk of social isolation, economic burden, and caregiver fatigue (40).
Biological Links Between Depression and CVD
Several biological mechanisms have been proposed to explain the unfavorable prognosis of patients with CVD and depression, including lifestyle factors, autonomic dysfunction, neuroendocrine imbalance, inflammation, insulin resistance, and increased platelet reactivity (Figure 1). There is considerable functional overlap and interplay between these systems in regulating both cardiac and neuropsychiatric functioning.
Figure 1
Biological Mechanisms and Behavioral Mediators Linking Depression and Cardiovascular Disease
Depression and cardiovascular diseases share a variety of biological mechanisms and behavioral mediators as indicated by the bidirectional arrows. The arrows also represent the vicious cycle of declining health outcomes that may occur with depression in patients with cardiovascular disease due to worsening of lifestyle and socioeconomic factors.
Lifestyle factors
Depression is associated with increased risk of nonadherence to cardioprotective medications and healthy lifestyle in patients with CVD (41,42). Furthermore, patients with depression may have less engagement in health behaviors that mitigate the risk of future cardiovascular events, such as physical activity, dietary modifications, smoking cessation, stress management, and substance abuse treatment (43,44), which may partially mediate the adverse cardiovascular health consequences of depression. Increased physical activity has been shown to improve depressive symptoms and improve cardiovascular outcomes (45).
Autonomic dysfunction
Both depression and common forms of CVD are associated with autonomic dysfunction, which have the potential for increasing the risk for adverse cardiovascular events (46). As a result, depression is associated with resting tachycardia, reduced heart rate variability, and hypertension, which may underlie associated left ventricular hypertrophy, risk of ventricular arrhythmias, endothelial dysfunction, and myocardial supply/demand mismatch observed with depression (47,48).
Neuroendocrine imbalance
Hyperactivity of the hypothalamic-pituitary-adrenal axis is common in depression, and the ensuing hypercortisolemia may be a biological link with CVD and other chronic cardiometabolic conditions (49). High cortisol is associated with hypertension, premature atherosclerosis, prothrombotic effects, and heightened risk of diabetes mellitus.
Inflammation
Patients with depression have higher levels of inflammatory cytokines, acute phase proteins, and adhesion molecules including interleukin-1β and -6, tumor necrosis factor-alpha, and C-reactive protein (50), which may in turn be associated with cardiovascular events.
Insulin resistance
The risk of cardiovascular events is higher in individuals with insulin resistance and diabetes mellitus (51), the incidence of which is significantly increased in depression. Depression may result in immune-mediated destruction of the pancreatic β-cells contributing to insulin resistance and diabetes mellitus, both of which are important risk factors for CVD (52). Insulin resistance in depression may be related to lifestyle-related factors and mediated through visceral fat accumulation and central obesity from the chronic activation of the hypothalamic-pituitary-adrenal axis.
Increased platelet reactivity
Enhanced platelet reactivity has been proposed as a potential mechanism for increased susceptibility to atherothrombosis in depression, as suggested by in vivo studies (53). Mechanisms for enhanced platelet reactivity in depression are comprised of augmented platelet thrombin response and an increased expression of platelet factors (54). Increased platelet aggregation in patients with depression has also been attributed to decreased endothelial nitric oxidase synthase activity. Additionally, exaggerated serotonin response, high platelet serotonin density, reduced serotonin transporter binding, and decreased platelet serotonin levels may also increase platelet reactivity in depression (54). Heightened platelet reactivity is attenuated with improvement in depressive symptoms (55).
Practicality of routine screening for depression in CVD
Routine systematic screening with validated self-report measures is needed for early and accurate identification of depression in CVD patients, as depression is often unrecognized or inaccurately diagnosed in nonpsychiatric medical care settings (62). The burden of under-recognition and undertreatment of depression is likely to be higher in minority and underserved populations. For instance, although prevalence rates of depression were similar in white and black patients with CVD, black patients were >50% less likely to use antidepressant medications (63). More than 50% of patients with depression go unrecognized in medical settings, and the diagnosis of depression ascribed by clinicians has only a moderate level of agreement with gold-standard structured diagnostic evaluations (62,64). Median duration of delay in treatment initiation after initial contact with a health care provider for depression is 8 years (65), and this may be reduced with early and accurate identification of depression. Screening for diagnosis of depression may also help with reducing inappropriate or overprescription of antidepressant medications (66), which are the third most commonly prescribed class of medications (after analgesics and lipid-lowering therapies) in ambulatory care settings (67). Additionally, screening efforts can also help identify patients who have an established psychiatric/mental health provider but have failed to attain adequate symptom control.
Routine screening for depression requires minimal time and resources in hospital and ambulatory care cardiovascular settings, but may require increased downstream support from mental health clinicians as depression is more frequently identified. As >35% of the U.S. population lives in a mental health profession-shortage area (68), patients who screen positive and are referred to mental health providers may not be able to access prompt services. Hence, Ziegelstein et al. (69) support increased education of CVD patients and their providers about depression and developing closer relationships between cardiologists and mental health providers, instead of a strategy of routinely screening for depression. While additional data are needed regarding the effects of routine screening of depression on cardiovascular outcomes (70), active engagement of cardiologists in screening for depression may not only reduce the stigma associated with depression, but also improve the quality of life of patients (71).
Routine screening for depression using a 2-step process starting with the 2-item Patient Health Questionnaire (PHQ)-2 followed by focused screening with the 9-item PHQ-9 is recommended to minimize the burden on patients and systematically assess depressive symptoms, including suicidality (ninth item of PHQ-9). Management of those who screen positive for depression should incorporate a multidisciplinary team-based approach including primary care providers and mental health clinicians.
Suicide risk assessment
Among specific depressive symptoms, AHA emphasizes screening for the presence of suicidal ideation as measured by the ninth item of PHQ-9 (8). While AHA recommends immediate evaluation for acute suicidality, practical steps to follow-up on this recommendation were not provided (69). In a cross-sectional study of 1,976 patients with CVD, >14% reported suicidal ideation in the past 2 weeks (93). Although rapid evaluation of suicidality may be feasible in hospital settings, it may be considerably more challenging in the outpatient settings with limited access to mental health providers (68). Key factors to ascertain risk of suicide include the chronicity of symptoms to differentiate acute versus chronic risk, presence of passive (weary or tired of life, wishing to be dead, or feel better off dead than alive) versus active suicidal ideations (thinking about killing oneself or committing suicide), presence of any intent or plan to commit suicide, previous history of suicide attempt, presence of comorbid psychiatric disorders, and lack of protective factors (94). A simplified scheme for risk assessment is provided in Figure 2, which might be utilized if access to mental health clinicians is limited.
Adverse effects of pharmacotherapy
Antidepressant medications may be associated with a wide range of cardiovascular adverse effects (Table 4) (97). The use of antidepressant medications in patients with CVD has not been associated with increased mortality, especially after controlling for the presence of depressive symptoms (97,118,119). All SSRIs cause some degree of QT-interval prolongation, with the risk being greatest with citalopram (97), prompting U.S. and European regulatory warnings in 2011 advising against the prescription of citalopram at doses >40 mg/day. Use of SNRIs is associated with an increased risk of hypertension, especially at higher doses (97). All tricyclic antidepressants cause significant QT interval prolongation, increase the risk for ventricular arrhythmias, and should be avoided in patients with CVD (97). Similarly, trazodone and nefazodone should be avoided due to QT prolongation and risk for ventricular arrhythmias. Antidepressant medications are also subject to significant drug-drug interactions with medications commonly used to treat CVD (Table 4) (97). For instance, monoamine oxidase inhibitors should be avoided due to significant drug-drug interactions with certain cardiovascular therapies and increased risk of hypertension. Antidepressants, when discontinued, may cause withdrawal symptoms that are typically mild and can be remembered easily with the FINISH mnemonic: "Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbances, and Hyperarousal (anxiety/agitation)" (120). These symptoms are most common with paroxetine and least common with fluoxetine among SSRIs (120). Additionally, SGAs (quetiapine, olanzapine, aripiprazole, and brexpiprazole) are associated with a broad range of adverse cardiovascular effects, including stroke, sudden cardiac death, hypertension, QT prolongation, and orthostatic hypotension (121,122). Use of quetiapine and olanzapine are also associated with obesity and dyslipidemia, which can further increase cardiometabolic risk (122).
Conclusions
Depression represents a common comorbidity in patients with a broad range of cardiovascular conditions and identifies patients at heightened risk of short- and long-term adverse cardiovascular events, excess health care expenditures, and adverse quality of life. Screening for depression utilizing standardized and guideline-supported simple questionnaires can be efficiently integrated into cardiovascular practices and should be routinely considered in patients with CVD. Although SSRIs are considered safe and effective first-line treatment for depression in most patients with CVD, nonpharmacological approaches may be more appropriate for patients with heart failure where the superiority of SSRIs is not well established. Clinicians should be mindful of polypharmacy, treatment adherence challenges, and potential for adverse drug-drug interactions in patients with depression and CVD. While studies of antidepressant treatments so far have focused on measures of depressive symptom severity or adverse cardiovascular events, future studies should also evaluate patient-centered outcomes such as quality of life and functional improvement. Future randomized clinical trials comparing different pharmacological and nonpharmacological approaches may further our understanding of personalized care plans for individual patients with CVD and depression. Cardiologists represent an important node of patient entry and identification in the multidisciplinary care model (involving primary care physicians, mental health clinicians, therapists, social workers, pharmacists, and care coordinators) in the comprehensive management of patients with depression. Similar to other chronic cardiometabolic conditions, depression has emerged as a prevalent, clinically important, and potentially modifiable risk factor of CVD.
|
|
| |
| |
|
|
|
