Depression following myocardial infarction (MI) can be a first-ever episode for some, whereas for others, it may represent a recurrent episode or one that was present at the onset of the infarction. ...We investigated if there are differences in pre- and post-MI characteristics between these subtypes.
Four hundred sixty-eight patients admitted for an MI were assessed for the presence of an ICD-10 depressive disorder following MI. A comparison was made between first-ever and ongoing or recurrent depression on demographic and cardiac data, personality, and depression characteristics.
Depressive disorder during the first post-MI year was present in 25.4% of the MI patients (
n=119), and almost half were ongoing or recurrent (
n=53, 44.5%). Recurrent and ongoing depression was related to high neuroticism (
Z=2.77,
P<.01), whereas first-ever depression was associated with MI severity (poor left ventricular ejection fraction:
Z=1.64,
P=.05; PTCA or CABG during hospitalization:
Z=1.88,
P=.03; arrhythmic events:
Z=1.49,
P=.06).
Our results suggest that in the first-ever post-MI depression cases, depression may be triggered by the severity of the MI, whereas ongoing and recurrent depression is more related to personality. Future research should address the question whether these subtypes of depression differ in cardiovascular prognosis and response to psychiatric treatment.
A recent meta-analysis suggests that the impact of post-myocardial infarction (MI) depression on cardiac prognosis has decreased over the last decade. We tested whether depression still significantly ...affects prognosis in the present health care situation.
Four hundred ninety-four MI patients were screened for depression. Patients with depression were compared with patients without on cardiovascular events (fatal or nonfatal) during an average follow-up of 2.5 years. Demographic characteristics and cardiac risk factors were controlled for.
We found that depression was associated with the occurrence of cardiovascular events in both univariate hazard ratio (HR), 1.84; 95% confidence interval, 1.24–2.72 and multivariate analysis (HR, 1.56; 1.02–2.38).
Depression still has an independent impact on cardiac prognosis after MI, but this influence is smaller than found in early studies. Improvements in general care for MI and better recognition and treatment of post-MI depression may have decreased the impact of depression on prognosis.
Background: Depression treatment by General Practitioners (GPs) and patient outcomes improved significantly after a comprehensive 20-h training program of GPs. This study examines whether the effects ...on patient outcomes are caused by the improvements in the process of care.
Methods: Seventeen GPs participated in the training program. A pre-test–post-test design was used. A total of 174 patients (85 pre-test, 89 post-test) aged 18–65 met ICD-10 criteria for recent onset major depression. The main indicator of mediation was a drop in training effect size (
η
2) on patient outcome after adjustment for individual and combined process of care variables. We evaluated depression-specific (recognition, accurate diagnosis, prescription of antidepressant, adequate antidepressant treatment) and a non-specific process of care variable (communicative skillfulness of the GP) as well as the combination of adequate antidepressant treatment and communicative skillfulness. Patient outcomes were assessed at 3 months and consisted of change in severity of symptomatology, level of daily functioning and activity limitation days from baseline.
Results: Depression-specific interventions mediated up to one third of the observed improvement in patient outcome. ‘Adequate dosage and duration of an antidepressant’ explained 36% of the training effect on patient outcome (
η
2 from 0.044 to 0.028). ‘Communicative skillfulness of the GP’ only was a weak mediator (18% explained;
η
2 from 0.044 to 0.036). However, the combination of both, that is adequate antidepressant treatment by a communicative skillful GP, proved to be the strongest mediator of the observed training effect on patient outcomes (59% explained;
η
2 from 0.044 to 0.018).
Limitations: The training effects on patient outcomes in this sample were small. Hence, the scope for mediation was limited.
Conclusion: GP communication skills are important to enhance depression-specific interventions in bringing about improvements in patient outcomes and should be addressed in GP training programs for the treatment of depression.
To examine the care provided by general practitioners (GPs) for persistent depressive illness and its relationship to patient, illness and consultation characteristics.
Using the Composite ...International Diagnostic Interview-Primary Health Care Version (CIDI-PHC) a sample of 264 patients with ICD-10 depression was identified among consecutive primary care patients in the Netherlands. At 1-year follow-up 78 of these patients (30%) still fulfilled the criteria of an ICD-10 depression and were considered persistent cases. At baseline and follow-up the GPs specified their diagnosis and treatment. The extent of recognition as a mental health problem, accuracy of diagnosis as a depression and treatment in accordance with clinical guidelines for depression was examined. In addition it was examined whether these steps in adequate GP care for persistent depression were related to patient, illness and consultation characteristics.
Twenty percent of the persistent depression cases were not recognized at baseline or during follow-up, 28% was recognized but not accurately diagnosed, 17% was accurately diagnosed, but did not receive adequate treatment and 35% was treated adequately. Recognition was associated with psychological reason for encounter; accurate diagnosis with absence of activity limitation days; and adequate treatment with severity of depression and higher educational level.
Non-recognition, misdiagnosis and inadequate treatment are not limited to patients with a relatively mild and brief depression but are also prominent in patients with a persistent depression, who consulted their GP 8.2 times on average during the year their depression persisted.
Who is at risk of post-MI depressive symptoms? Spijkerman, Titia A.; van den Brink, Rob H.S.; Jansen, Jaap H.C. ...
Journal of psychosomatic research,
05/2005, Letnik:
58, Številka:
5
Journal Article
Recenzirano
The aim of this study was to identify cardiologic, psychologic, and demographic risk factors in two groups of patients with post-myocardial infarction (MI) depressive symptoms (in-hospital and during ...the postdischarge year).
Patients admitted for MI were assessed for depressive symptoms with the Beck Depression Inventory (BDI) during hospitalization and 3, 6, and 12 months post-MI. We contrasted both groups with nondepressed patients.
Pre-MI vital exhaustion, living alone, history of depressive disorder, history of MI, poor performance on exercise tolerance testing, and female gender were significantly and independently associated with in-hospital depressive symptoms. Pre-MI vital exhaustion, history of depressive disorder, female gender, poor ejection fraction, and longer hospital stay were independent predictors of the development of postdischarge depressive symptoms.
Post-MI depressive symptoms seem largely driven by the psychological and social consequences of the MI in patients vulnerable to depression, as indexed by a history of depression and vital exhaustion.
In outpatient forensic psychiatry, assessment of re-offending risk and treatment needs by case managers may be hampered by an incomplete view of client functioning. The client's appreciation of his ...own problem behaviour is not systematically used for these purposes. The current study tests whether using a new client self-appraisal risk assessment instrument, based on the Short Term Assessment of Risk and Treatability (START), improves the assessment of re-offending risk and can support shared decision making in care planning.
In a sample of 201 outpatient forensic psychiatric clients, feasibility of client risk assessment, concordance with clinician assessment, and predictive validity of both assessments for violent or criminal behaviour were studied.
Almost all clients (98 %) were able to fill in the instrument. Agreement between client and case manager on the key risk and protective factors of the client was poor (mean kappa for selection as key factor was 0.15 and 0.09, respectively, and mean correlation on scoring -0.18 and 0.20). The optimal prediction model for violent or criminal behaviour consisted of the case manager's structured professional risk estimate for violence in combination with the client's self-appraisal on key risk and protective factors (AUC = 0.70; 95%CI: 0.60-0.80).
In outpatient forensic psychiatry, self-assessment of risk by the client is feasible and improves the prediction of re-offending. Clients and their case managers differ in their appraisal of key risk and protective factors. These differences should be addressed in shared care planning. The new Client Self-Appraisal based on START (CSA) risk assessment instrument can be a useful tool to facilitate such shared care planning in forensic psychiatry.
A prognosis serves important functions for the management of common mental disorders in primary care.
To establish the accuracy of the general practitioner's (GP) prognosis.
The agreement between GP ...prognosis and observed course was determined for 138 cases of ICD-10 depression and 65 of generalised anxiety disorder, identified among consecutive attenders of 18 GPs.
Modest agreement between GP prognosis and course was found, both for depression (kappa=0.21) and generalised anxiety (kappa=0.11). Better agreement (kappa=0.45 for depression, and kappa=0.33 for generalised anxiety) was observed between the course and predictions from a statistical model based on information potentially available to the GP at the time the prognosis was made. This model assesses attainable performance for GPs.
General practitioners do a fair job in predicting the 1-year course of depression and generalised anxiety. Even so, their performance falls significantly short of attainable performance.
Several predictors of the course of depression and generalized anxiety have been identified. Whether these predictors provide a solid basis for primary care physicians (PCPs) to give an accurate ...prognosis remains unclear. A parallel study showed modest agreement between PCP prognosis and observed course (κ≤0.21). It is the aim of the present study to establish the extent to which the one-year course of depression and generalized anxiety in primary care is in fact predictable. Predictability is operationalized as the combined predictive power of major prognostic factors identified in the literature. We identified 269 cases of ICD-10 depression and 134 of generalized anxiety among consecutive PCP attenders. For these patients a statistical model was built that provided optimal predictions of the one-year course of the disorder, based on the prognostic factors discerned. The predictions were compared with the actual course observed. Reasonable agreement (κ=0.37 for depression, κ=0.35 for anxiety) and good association (γ=0.66 for depression, γ=0.67 for anxiety) were found between predicted and observed course. Nevertheless, the combined predictive power of the prognostic factors remains limited. A realistic evaluation of the accuracy of the PCP prognosis should take this limited predictability into account.
The purpose of this pretest-posttest study was to evaluate effects of a training program designed to improve primary care physicians’ (PCPs) ability to recognize mental health problems (MHP) and to ...diagnose and manage depression according to clinical guidelines. The primary care settings were in the northern part of The Netherlands. There were eight intensive, hands-on training sessions of 2.5 hours, each of which three were targeting depression (7.5 hours). In the pretraining phase we screened 1778 consecutive patients of 17 PCPs with the 12-item General Health Questionnaire (GHQ-12) and interviewed a stratified sample of 518 patients about presence of current depression with the Primary Health Care version of the Composite International Diagnostic Interview (CIDI-PHC). PCPs registered patient’s mental health (status, severity, diagnosis) and treatment prescribed. Then we trained the PCPs. In the posttraining phase, we screened a new group of 1724 consecutive patients of the same PCPs and a new stratified sample of 498 patients went through the same interview and rating procedures as patients in the pretraining phase. Knowledge about depression was assessed pre- and posttraining. PCPs’ knowledge of depression improved significantly. Recognition of MHP and accuracy of depression diagnosis improved, but was not statistically significant. The proportion of patients receiving treatment according to the clinical guidelines increased significantly. It was observed that training PCPs improves the management of depression.
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