5 Assessment and Management of Depression in Cardiac
Rehabilitation Patients
Krista A. Barbour, PhD
CONTENTS
Prevalence of Depression in Cardiac Patients 45
Prognostic Value of Depression in CHD 45
Definitions of Depression 46
Assessment of Depression in the Cardiac
Rehabilitation Setting 46
Managing Depression in CR 47
Treatment of Depression in Cardiac Patients 48
Summary and Future Directions 50
References 51
PREVALENCE OF DEPRESSION IN CARDIAC PATIENTS
The relationship between depression and coronary heart disease (CHD) is well documented (1). Relative to the primary care setting, in which the prevalence is 5–9%
(2), depression is highly prevalent in cardiac patients, with estimates ranging from 15 to more than 40% (3). Less is known about the prevalence of depression in patients enrolled in cardiac rehabilitation (CR) programs, but a recent study of patients entering a phase II program found that approximately 26% of patients met diagnostic criteria for a depressive disorder (4).
PROGNOSTIC VALUE OF DEPRESSION IN CHD
Significant evidence exists identifying depression as a powerful and independent risk factor for cardiac outcomes [for a review, see (3)], including cardiovascular events [e.g., recurrent myocardial infarction (MI)] (5) and mortality (6).
Given the association between depression and cardiac outcomes and the desire to improve the quality of life of depressed patients, assessment of psychological functioning is an essential part of CR programs. Indeed, routine screening for depression has been recommended by the Board of the American Association of Cardiovascular
From: Contemporary Cardiology: Cardiac Rehabilitation
Edited by: W. E. Kraus and S. J. Keteyian © Humana Press Inc., Totowa, NJ 45
and Pulmonary Rehabilitation (7). In the following sections, depression will be defined and commonly utilized methods for assessing depression will be described.
DEFINITIONS OF DEPRESSION
Definitions of “depression” vary from a patient’s endorsement of a few key symptoms (e.g., sadness and tearfulness) to that of a clinical diagnosis, such as major depressive disorder (MDD), which is based upon well-defined diagnostic criteria. The diagnostic criteria for MDD, taken from the Diagnostic and Statistical Manual of Mental Disorders-fourth edition (8), are summarized in Table 1.
Although CR patients who meet criteria for MDD merit particular attention by CR staff, it has been shown that even the presence of depressive symptoms that are sub- threshold for MDD also confers increased risk of mortality (6). Thus, it is important to screen all patients entering CR programs.
ASSESSMENT OF DEPRESSION IN THE CARDIAC REHABILITATION SETTING
The gold standard for assessment of mood disorders is a structured diagnostic interview administered by a trained mental health professional. The result of such an interview would be a determination of whether MDD is present. However, such an assessment in most CR settings is impractical and probably not necessary, given the importance of sub-threshold depressive symptoms in relation to patients’ quality of life and cardiovascular prognosis. Thus, CR staff need tools designed to quickly screen for degree of depressive symptoms. On the basis of the results of such depression measures, staff can then make decisions about intervention and, if necessary, referral to the appropriate mental health professional.
Table 1
Summary of DSM-IV Diagnostic Criteria for Major Depressive Episode Five (or more) of the following symptoms are present during the same 2-week period and represent a change from previous functioning [note: at least one of the symptoms has to be either (1) or (2) below]
1 Depressed mood most of the day, nearly every day 2 Diminished interest or pleasure in all or most activities 3 Significant change in weight or appetite
4 Insomnia or hypersomnia
5 Psychomotor agitation or retardation 6 Fatigue or loss of energy
7 Feelings of worthlessness or guilt
8 Diminished ability to think or concentrate 9 Recurrent thoughts of death or suicide
The symptoms cause clinically significant distress or impairment, are not due to the effects of a substance or general medical condition, and are not better accounted for by bereavement or other psychi- atric disorder.
Many self-report measures are available to assess the severity of depressive symptoms. These questionnaires generally consist of a series of written questions with multiple-choice responses that patients complete on their own. Widely used examples include the Beck Depression Inventory (BDI) (9), the Center for Epidemiological Studies Depression Scale (CES-D) (10), and the Hospital Depression and Anxiety Scale (HADS) (11). These measures, administered when patients begin participation in CR, provide a picture of the type and severity of depressive symptoms. Staff should pay special attention to responses to items that inquire about suicidal ideation and hopelessness. Patients who endorse such items should be carefully monitored and the appropriate care provider consulted (e.g., the patient’s cardiologist or primary care provider).
It is important to remember that self-report questionnaires are not designed to allow for the identification of MDD and are not a substitute for diagnostic clinical interviews. Instead, these screening questionnaires allow CR staff to triage each case and develop a plan at the time of enrollment (i.e., one patient’s depressive symptoms may be mild enough to manage within the CR setting, whereas another patient may benefit from referral to a mental health provider for further evaluation of mood).
Often, it is not practical for a mental health specialist to assist in the interpretation of these questionnaires; so, specific screening questions have been developed for use by primary care physicians. For example, the Primary Care Evaluation of Mental Disorders (PRIME-MD) is an assessment procedure intended to detect psychiatric disorders in primary care patients (12). Two specific questions from the PRIME-MD may be especially useful in identifying patients who may need to be further evaluated for MDD (13) and are included in the Feature Box.
PRIME-MD Depression Screening Questions
During the past month, have you been bothered by
• little interest or pleasure in doing things,
• feeling down, depressed, or hopeless?
Note: A positive screen is indicated if either question is answered with “yes.”
MANAGING DEPRESSION IN CR
For depressed patients who are considered appropriate to enter CR (e.g., they are not suicidal, and their depression is not so severe as to prevent active participation), the question arises as to how to manage depressive symptoms that may affect the course of CR participation and adherence. Some common symptoms of depression, such as fatigue and loss of interest in people and activities, may interfere with adherence to CR. In fact, depression is related to lack of adherence to treatment regimens in general (14) and CR specifically. For example, results of several studies of depressed patients enrolled in CR programs have demonstrated that depression at program entry is predictive of number of sessions attended as well as drop out (15,16). Thus, identifying and monitoring patients with depression is crucial in the CR setting. These patients may require continued efforts by staff to keep them engaged in the program (see Table 2 for a list of strategies to promote adherence in patients enrolled in exercise programs).
Table 2
Strategies for Enhancing Exercise Adherence in Cardiac Rehabilitation
• Most important, work to establish good rapport with patients. Positive feedback and attention from rehabilitation staff can go a long way toward promoting adherence.
(This may be especially true for patients who are depressed.)
• As part of the orientation to cardiac rehabilitation, review with patients their personal barriers to participation (e.g., child care responsibilities and transportation issues).
Once barriers have been identified, staff may problem solve with patients about ways to overcome or minimize these obstacles.
• Educate patients about the health and mood benefits of exercise. Elicit from and remind patients of their personal reasons for exercising.
• Many patients benefit from the social support that comes with being involved in cardiac rehabilitation. Interaction with other individuals who are experiencing similar health problems can help to keep patients motivated.
• Patients are more likely to adhere to exercise training if the experience is an enjoyable one. Work with patients to increase their satisfaction with the program (e.g., switching equipment used and increased interaction with other patients).
• Assist patients in the development of realistic exercise goals (e.g., gradual increase in exercise time).
• Encourage patients to reward themselves for participation in exercise. Positive reinforcement for exercise is very important. Even simple rewards (e.g., purchasing a new book or CD) can be powerful motivators.
• Re-establish contact with patients as soon as possible following a cardiac event or hospitalization. Early intervention is crucial in getting patients back on track.
• As much as possible, engage patients’ family members. They are often a valuable resource in offering encouragement for patients’ participation in exercise.
• Remember that untreated depression is likely to reduce adherence to exercise.
Encourage patients to seek treatment for depression if relevant.
TREATMENT OF DEPRESSION IN CARDIAC PATIENTS
In their recent review of psychosocial risk factors in CHD, Rozanski and colleagues (17) recommend a stepped care plan of intervention when managing psychologically distressed patients in clinical practice. In this approach, the level of intervention depends on the severity of distress. For example, a patient experiencing a moderate degree of depression may be monitored more closely by staff (e.g., more frequent telephone contact and efforts to enhance motivation and adherence), whereas a patient with more severe depression would be referred to a mental health professional.
Sometimes, a patient’s level of depressive symptoms appears to interfere with his/her participation in CR, and it is felt that referral for more intensive intervention is needed.
The following section reviews treatments that have been demonstrated to improve depression in cardiac patients.
Pharmacological
One large randomized clinical trial (RCT) (18) has been conducted to evaluate the safety and efficacy of the antidepressant medication sertraline in depressed patients with MI or unstable angina. In this trial, 369 patients were randomized to receive
either sertraline or placebo for 24 weeks. It was found that sertraline was safe for use in this population, but the medication resulted in only modest improvement in depression. Despite this small effect in the overall study sample, analyses including only those patients with recurrent MDD or severe MDD demonstrated that sertraline was consistently superior to placebo. Thus, it appears that this medication may be a viable treatment option for this subset of depressed cardiac patients.
Evidence-Based Psychological Treatments
Several empirically supported psychological interventions exist for treatment of depression in noncardiac samples. However, only one of these, cognitive behavioral therapy (CBT), has been tested in an RCT of CHD patients diagnosed with MDD (19). In this multi-center trial, 2481 post-MI patients with depression and/or low social support were randomized to the CBT intervention or usual care. CBT was delivered in both individual and group format and was focused on teaching patients about the relationships among thoughts, behavior, and emotion (with the rationale that the modification of thoughts and behaviors can result in an improvement in depression), as well as training in assertive communication. Results indicated that patients in the CBT intervention experienced a significant improvement in depression relative to the usual care group.
Other psychosocial interventions (e.g., stress management) targeting depressive symptoms (not documented MDD) in CHD patients have had mixed results in terms of symptom reduction (20). In sum, evidence suggests that psychological treatment is effective in improving depression in CHD patients.
Several studies have also assessed the degree to which psychological treatments for depression affect health outcomes (e.g., recurrent cardiac events and mortality). The data are mixed in terms of the benefit of these interventions for cardiac outcomes.
For example, in the trial of CBT for CHD patients described above, the intervention group did not differ from the usual care group in cardiac outcomes (19). It has been suggested that the failure to affect cardiac prognosis in some studies is due to the modest improvement demonstrated in (or failure to modify) depression scores (21).
Additional well-designed RCTs are needed to determine the effect of well-conducted and effective psychological treatment interventions on cardiac outcomes.
Exercise
Exercise training is an integral part of CR programs. In addition to the cardiovascular benefits of aerobic exercise, there has been a growing literature on the psychological benefits of regular exercise. Specifically, evidence exists supporting the value of exercise in reducing depressive symptoms in both healthy and clinical populations (22).
In a community sample of noncardiac patients, exercise was compared to antide- pressant medication in the treatment of MDD (23). Patients were randomized to super- vised exercise, an antidepressant medication (sertraline), or a combination of exercise and medication. The 16-week exercise treatment consisted of three weekly sessions of aerobic activity. By the end of the treatment period, each of the three treatment groups experienced a significant reduction in depression. The treatments did not differ signif- icantly from one another in efficacy. At 6 months post-treatment (24), it was found that patients assigned to exercise alone endorsed lower rates of depression than did
those receiving medication or a combination of exercise and medication. In addition, only 9% of remitted participants in the exercise group relapsed compared with more than 30% of participants in the medication and combination groups. It was also found that 64% of participants who received the exercise treatment continued to exercise following completion of the program. Self-reported exercise among all participants was associated with a 50% reduction in risk of depression 6 months after study completion.
These results suggest that aerobic exercise may be a viable alternative to medication in the treatment of MDD.
Several studies have examined the effect of exercise training on depression in cardiac populations. In general, results of these studies indicate significant improvements in depressive symptoms upon completion of exercise training (22). For example, in a sample of over 300 patients enrolled in CR after suffering a cardiac event, 20% of patients reported elevated depressive symptoms. At the end of the 3-month aerobic exercise training period, two-thirds of the initially depressed patients reported resolution of their depressive symptoms. Additionally, the depressed group demonstrated signif- icant improvements in other quality-of-life variables (25). However, it is not clear how much of this improvement can be specifically attributable to the exercise component of the program. Taken together, these results suggest that exercise training ameliorates depressive symptoms in both noncardiac and cardiac populations.
SUMMARY AND FUTURE DIRECTIONS
In sum, depression is quite common in patients with CHD and is a significant risk factor for cardiac outcomes. Patients should be screened for depression at entry to CR programs, using either a few verbal screening questions or a standardized depression questionnaire. Depressed patients enrolled in CR programs will require more attention to insure continued adherence and close monitoring to rapidly intervene should depressive symptoms worsen. Several treatments have shown some success in treating depression in cardiac patients, including antidepressant medication (sertraline), psychological interventions (such as CBT), and exercise training. Patients who endorse significant depressive symptoms should be approached in an empathic manner and encouraged to seek treatment to improve quality of life and cardiac outcomes. (It is often helpful to normalize the experience and treatment of depression when speaking with CHD patients. Patients can be educated regarding the prevalence of depressive symptoms in CHD patients as well as the association between mood and cardiac outcomes.)
Depression in CR
• Important to screen for depression, using an interview or survey tool.
• There are several potential treatment options for individuals who endorse depressed mood.
CBT under the guidance of a trained professional.
Antidepressant medications.
Exercise therapy as a part of CR.
• Extra efforts to monitor and maintain involvement of such patients is optimal.
In future research, more attention should be paid to uncovering the mechanisms of the depression-cardiac outcome relationship. For example, as described earlier, depression also is a predictor of nonadherence, and it is possible that nonadherence accounts for the observed relationship. In addition, many of the studies that have examined treatment of depression in cardiac patients have methodological flaws (e.g., small sample sizes and no control group). Thus, more well-designed depression intervention trials with cardiac patients are needed.
Finally, most of what is known about the relationship between depression and cardiac prognosis has been largely derived from studies in men only (6). It will be important for future clinical trials to focus on women as well as ethnic minorities, who also have been underrepresented in this research. Such studies will inform treatments for depression that are tailored to subgroups of CHD patients.
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