Depression Treatment and Health Status Outcomes in Young Patients With Acute Myocardial Infarction
2017; Lippincott Williams & Wilkins; Volume: 135; Issue: 18 Linguagem: Inglês
10.1161/circulationaha.116.027042
ISSN1524-4539
AutoresKim G. Smolderen, John A. Spertus, Kensey Gosch, Rachel P. Dreyer, Gail D’Onofrio, Judith H. Lichtman, Mary Geda, John F. Beltrame, Basmah Safdar, Héctor Bueno, Harlan M. Krumholz,
Tópico(s)Heart Failure Treatment and Management
ResumoHomeCirculationVol. 135, No. 18Depression Treatment and Health Status Outcomes in Young Patients With Acute Myocardial Infarction Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBDepression Treatment and Health Status Outcomes in Young Patients With Acute Myocardial InfarctionInsights From the VIRGO Study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) Kim G. Smolderen, PhD, John A. Spertus, MD, MPH, Kensey Gosch, MS, Rachel P. Dreyer, PhD, Gail D'Onofrio, MD, MS, Judith H. Lichtman, PhD, MPH, Mary Geda, MSN, John Beltrame, MD, Basmah Safdar, MD, MSc, Héctor Bueno, MD, PhD and Harlan M. Krumholz, MD, SM Kim G. SmolderenKim G. Smolderen From University of Missouri Kansas City (K.G.S., J.A.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (K.G.S., J.A.S., K.G.); Yale School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (R.P.D., J.H.L., M.G., H.M.K.); Yale University, Department of Emergency Medicine, New Haven, CT (G.D'O., B.S.); University of Adelaide, Queen Elizabeth Hospital, Australia (J.B.); Centro Nacional de Investigaciones Cardiovasculares (H.B.); Instituto de Investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre & Facultad de Medicina, Universidad Complutense de Madrid, Spain (H.B.); and Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine & Yale University School of Medicine; Department of Health Policy and Management, Yale-New Haven Hospital, CT (H.M.K.). , John A. SpertusJohn A. Spertus From University of Missouri Kansas City (K.G.S., J.A.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (K.G.S., J.A.S., K.G.); Yale School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (R.P.D., J.H.L., M.G., H.M.K.); Yale University, Department of Emergency Medicine, New Haven, CT (G.D'O., B.S.); University of Adelaide, Queen Elizabeth Hospital, Australia (J.B.); Centro Nacional de Investigaciones Cardiovasculares (H.B.); Instituto de Investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre & Facultad de Medicina, Universidad Complutense de Madrid, Spain (H.B.); and Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine & Yale University School of Medicine; Department of Health Policy and Management, Yale-New Haven Hospital, CT (H.M.K.). , Kensey GoschKensey Gosch From University of Missouri Kansas City (K.G.S., J.A.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (K.G.S., J.A.S., K.G.); Yale School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (R.P.D., J.H.L., M.G., H.M.K.); Yale University, Department of Emergency Medicine, New Haven, CT (G.D'O., B.S.); University of Adelaide, Queen Elizabeth Hospital, Australia (J.B.); Centro Nacional de Investigaciones Cardiovasculares (H.B.); Instituto de Investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre & Facultad de Medicina, Universidad Complutense de Madrid, Spain (H.B.); and Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine & Yale University School of Medicine; Department of Health Policy and Management, Yale-New Haven Hospital, CT (H.M.K.). , Rachel P. DreyerRachel P. Dreyer From University of Missouri Kansas City (K.G.S., J.A.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (K.G.S., J.A.S., K.G.); Yale School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (R.P.D., J.H.L., M.G., H.M.K.); Yale University, Department of Emergency Medicine, New Haven, CT (G.D'O., B.S.); University of Adelaide, Queen Elizabeth Hospital, Australia (J.B.); Centro Nacional de Investigaciones Cardiovasculares (H.B.); Instituto de Investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre & Facultad de Medicina, Universidad Complutense de Madrid, Spain (H.B.); and Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine & Yale University School of Medicine; Department of Health Policy and Management, Yale-New Haven Hospital, CT (H.M.K.). , Gail D'OnofrioGail D'Onofrio From University of Missouri Kansas City (K.G.S., J.A.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (K.G.S., J.A.S., K.G.); Yale School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (R.P.D., J.H.L., M.G., H.M.K.); Yale University, Department of Emergency Medicine, New Haven, CT (G.D'O., B.S.); University of Adelaide, Queen Elizabeth Hospital, Australia (J.B.); Centro Nacional de Investigaciones Cardiovasculares (H.B.); Instituto de Investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre & Facultad de Medicina, Universidad Complutense de Madrid, Spain (H.B.); and Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine & Yale University School of Medicine; Department of Health Policy and Management, Yale-New Haven Hospital, CT (H.M.K.). , Judith H. LichtmanJudith H. Lichtman From University of Missouri Kansas City (K.G.S., J.A.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (K.G.S., J.A.S., K.G.); Yale School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (R.P.D., J.H.L., M.G., H.M.K.); Yale University, Department of Emergency Medicine, New Haven, CT (G.D'O., B.S.); University of Adelaide, Queen Elizabeth Hospital, Australia (J.B.); Centro Nacional de Investigaciones Cardiovasculares (H.B.); Instituto de Investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre & Facultad de Medicina, Universidad Complutense de Madrid, Spain (H.B.); and Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine & Yale University School of Medicine; Department of Health Policy and Management, Yale-New Haven Hospital, CT (H.M.K.). , Mary GedaMary Geda From University of Missouri Kansas City (K.G.S., J.A.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (K.G.S., J.A.S., K.G.); Yale School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (R.P.D., J.H.L., M.G., H.M.K.); Yale University, Department of Emergency Medicine, New Haven, CT (G.D'O., B.S.); University of Adelaide, Queen Elizabeth Hospital, Australia (J.B.); Centro Nacional de Investigaciones Cardiovasculares (H.B.); Instituto de Investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre & Facultad de Medicina, Universidad Complutense de Madrid, Spain (H.B.); and Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine & Yale University School of Medicine; Department of Health Policy and Management, Yale-New Haven Hospital, CT (H.M.K.). , John BeltrameJohn Beltrame From University of Missouri Kansas City (K.G.S., J.A.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (K.G.S., J.A.S., K.G.); Yale School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (R.P.D., J.H.L., M.G., H.M.K.); Yale University, Department of Emergency Medicine, New Haven, CT (G.D'O., B.S.); University of Adelaide, Queen Elizabeth Hospital, Australia (J.B.); Centro Nacional de Investigaciones Cardiovasculares (H.B.); Instituto de Investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre & Facultad de Medicina, Universidad Complutense de Madrid, Spain (H.B.); and Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine & Yale University School of Medicine; Department of Health Policy and Management, Yale-New Haven Hospital, CT (H.M.K.). , Basmah SafdarBasmah Safdar From University of Missouri Kansas City (K.G.S., J.A.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (K.G.S., J.A.S., K.G.); Yale School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (R.P.D., J.H.L., M.G., H.M.K.); Yale University, Department of Emergency Medicine, New Haven, CT (G.D'O., B.S.); University of Adelaide, Queen Elizabeth Hospital, Australia (J.B.); Centro Nacional de Investigaciones Cardiovasculares (H.B.); Instituto de Investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre & Facultad de Medicina, Universidad Complutense de Madrid, Spain (H.B.); and Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine & Yale University School of Medicine; Department of Health Policy and Management, Yale-New Haven Hospital, CT (H.M.K.). , Héctor BuenoHéctor Bueno From University of Missouri Kansas City (K.G.S., J.A.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (K.G.S., J.A.S., K.G.); Yale School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (R.P.D., J.H.L., M.G., H.M.K.); Yale University, Department of Emergency Medicine, New Haven, CT (G.D'O., B.S.); University of Adelaide, Queen Elizabeth Hospital, Australia (J.B.); Centro Nacional de Investigaciones Cardiovasculares (H.B.); Instituto de Investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre & Facultad de Medicina, Universidad Complutense de Madrid, Spain (H.B.); and Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine & Yale University School of Medicine; Department of Health Policy and Management, Yale-New Haven Hospital, CT (H.M.K.). and Harlan M. KrumholzHarlan M. Krumholz From University of Missouri Kansas City (K.G.S., J.A.S.); Saint Luke's Mid America Heart Institute, Kansas City, MO (K.G.S., J.A.S., K.G.); Yale School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (R.P.D., J.H.L., M.G., H.M.K.); Yale University, Department of Emergency Medicine, New Haven, CT (G.D'O., B.S.); University of Adelaide, Queen Elizabeth Hospital, Australia (J.B.); Centro Nacional de Investigaciones Cardiovasculares (H.B.); Instituto de Investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre & Facultad de Medicina, Universidad Complutense de Madrid, Spain (H.B.); and Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine & Yale University School of Medicine; Department of Health Policy and Management, Yale-New Haven Hospital, CT (H.M.K.). Originally published2 May 2017https://doi.org/10.1161/CIRCULATIONAHA.116.027042Circulation. 2017;135:1762–1764Article, see p 1681; Editorial, see p 1690Depression is common among patients with acute myocardial infarction (AMI) and associated with adverse outcomes. Because depression disproportionately affects women, we examined sex differences in depression treatment rates in young patients with depressive symptoms following AMI admission and evaluated 1-year depressive symptom and health status outcomes by sex and depression treatment status. We evaluated these by using the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients), a multicenter, international, prospective cohort study that enrolled patients aged 18 to 55 years (66.8% women).1 VIRGO was approved by Yale's Institutional Review Board and all patients in the study provided informed consent. We abstracted medical records and conducted in-person interviews to record patient characteristics and used the 9-item Patient Health Questionnaire (PHQ-9)2 to assess depressive symptoms during or shortly after the AMI admission and 1 and 12 months later. Depression treatment was assessed among those with baseline PHQ-9 scores ≥10. Receiving depression treatment was defined as new or continued antidepressant medications or depression counseling at discharge or within at 1 month of discharge.To compare outcomes as a function of depression treatment, we quantified outcomes in those with (1) no significant depressive symptoms (baseline PHQ-9<10); (2) treated depressive symptoms (baseline PHQ-9≥10 and receiving treatment); (3) untreated transient depressive symptoms (baseline PHQ-9≥10 and untreated, but PHQ-9<10 at 1 month); (4) untreated persistent depressive symptoms (baseline PHQ-9≥10 and untreated, and PHQ remained ≥10 at 1 month). The clinical logic for further categorizing untreated depressive symptoms into transient and persistent was to describe the greater benefit of treating those with sustained depressive symptoms rather than transient, self-resolving symptoms. Disease-specific and generic Health Status outcomes were quantified with the Seattle Angina Questionnaire and the EQ-5D visual analogue scale, respectively, up to 1 year.3,4Depression treatment rates were calculated and compared by sex using χ2 tests. The independent association between sex and lack of depression treatment was evaluated among those who had PHQ-9 scores ≥10 at baseline by using a hierarchical logistic regression model with a random effect for site and adjusting for age, race, marital status, education, insurance status, prior peripheral arterial disease, diabetes mellitus, prior AMI, prior percutaneous coronary intervention, prior coronary artery bypass grafting, current smoking, ST-segment–elevation myocardial infarction, ejection fraction, heart failure, renal disease, chronic lung disease, cancer, body mass index, PHQ-9 baseline score, and somatic versus cognitive depressive symptoms.One-year health status change scores were compared by the 4 depression treatment groups (analysis of variance and Wilcoxon tests). Hierarchical, multivariable linear regression models with a random effect for site were constructed to evaluate the association between depression treatment status following AMI and 1-year changes in depressive symptoms and health status scores. In addition to the covariates used in the depression treatment model, baseline health status scores and PHQ-9 scores were also included as appropriate. Interaction terms with sex and depression treatment status were examined but excluded from the final models because they were not significant. All analyses were performed using SAS 9.3 (SAS Institute Inc).Our analytic cohort consisted of 3324 patients, of whom 1031 (31%) had PHQ-9 scores ≥10: 36.6% (n=813) of women and 19.7% (n=218) of men had PHQ-9 scores ≥10 (P<0.0001). Among patients with significant depressive symptoms, 57.8% (596 of 1031) were not treated for depression. For women, this rate was 54.2% and for men this rate was 71.1% (P<0.0001). In the untreated depressive symptoms group, symptoms resolved on their own by 1-month follow-up in 407 of 596 cases (68.3%), whereas in 189 cases (31.7%) the symptoms persisted.Among patients with a PHQ-9 score ≥10, male sex (odds ratio, 1.86; 95% confidence interval, 1.30–2.66) was independently associated with untreated depressive symptoms. Overall, the lowest levels of improvements in depressive symptoms, angina, physical limitations, and disease-specific and generic quality of life were noted among patients whose depressive symptoms persisted at 1 month and who were untreated by their providers. One-year Seattle Angina Questionnaire angina, physical limitations, and quality of life scores and EQ-5D visual analogue scores were lowest for the group with untreated persisting depressive symptoms (P values for unadjusted comparisons baseline, 1-year, and 1-year change scores across groups all <0.001, except for Seattle Angina Questionnaire quality of life 1-year change score [P=0.046] and EQ-5D visual analogue scale 1-year change score [P=0.25]; results are available on request). In adjusted models, patients with untreated persistent depressive symptoms had significantly smaller improvements in angina frequency and angina-specific quality of life (Table).Table. Overview of Adjusted Linear Regression Results for the Association Between Depression Treatment Groups and 1-Year Depression and Health Status Change ScoresModels1-Year PHQ-9 Change Scores*1-Year SAQ Angina Frequency Change Scores1-Year SAQ Physical Limitations Change Scores1-Year SAQ Quality-of-Life Change Scores1-Year EQ-5D Visual Analogue Change Scale ScoresAdjusted Standardized β (95% CI)P ValueAdjusted Standardized β (95% CI)P ValueAdjusted Standardized β (95% CI)P ValueAdjusted Standardized β (95% CI)P ValueAdjusted Standardized β (95% CI)P ValueTreated depressive symptomsReferenceReference0.39 (–2.50 to –3.29)0.79–0.23 (–3.46 to 3.00)0.88–0.96 (–4.78 to 2.85)0.62–0.42 (–3.96 to 3.11)0.81Untreated transient depressive symptoms–2.33 (–3.27 to –1.38)<0.00010.34 (–2.25 to 2.94)0.802.26 (–0.62 to 5.14)0.122.06 (–1.39 to 5.51)0.243.99 (0.79 to 7.19)0.0145Untreated persistent depressive symptoms0.85 (–0.31 to 2.01)0.15–4.21 (–7.66 to –0.77)0.017–1.75 (–5.62 to 2.11)0.37–7.30 (–11.89 to –2.71)0.0018–0.56 (–4.79 to 3.67)0.79No significant depressive symptomsReferenceReferenceReferenceReferenceThree groups were compared for model 1: (1) treated depressive symptoms (reference); (2) untreated transient depressive symptoms; and (3) untreated persistent depressive symptoms. Four groups were compared for models 2 to 4: patients with (1) no significant depressive symptoms (reference); (2) treated depressive symptoms; (3) untreated transient depressive symptoms; and (4) untreated persistent depressive symptoms. Adjusted standardized betas and corresponding 95% confidence intervals (CIs), and P values are presented. The interaction term for sex by depression treatment status was not significant in these models and was left out of the final models. PHQ-9 indicates 9-item Patient Health Questionnaire; and SAQ, Seattle Angina Questionnaire.*Model 1 was run among those who had PHQ-9 scores ≥10 only. Covariates in the models included age, sex, race, marital status, education, insurance status, prior peripheral arterial disease, diabetes mellitus, prior myocardial infarction, prior percutaneous coronary intervention, prior coronary artery bypass grafting, current smoking, ST-segment–elevation myocardial infarction, ejection fraction, heart failure, renal disease, lung disease, cancer, body mass index, PHQ-9 baseline score, somatic versus cognitive symptoms of depression, and baseline depressive symptoms and health status scores as appropriate.Depression rates among young AMI survivors were highest in women, but men were significantly less likely to be treated. Among patients with persistent depressive symptoms, those who were not treated had significantly more angina and worse disease-specific quality of life. This study provides the first available evidence that being treated for depression in the context of an AMI admission is associated with better AMI recovery in both women and men. It confirms that depression remains common in AMI patients and is frequently untreated. Improving depression recognition and treatment may offer an opportunity to improve care and outcomes in patients recovering from an AMI.Kim G. Smolderen, PhDJohn A. Spertus, MD, MPHKensey Gosch, MSRachel P. Dreyer, PhDGail D'Onofrio, MD, MSJudith H. Lichtman, PhD, MPHMary Geda, MSNJohn Beltrame, MDBasmah Safdar, MD, MScHéctor Bueno, MD, PhDHarlan M. Krumholz, MD, SMSources of FundingThe VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) was supported by the National Heart, Lung, and Blood Institute (Bethesda, MD; 5R01HL081153). Infarto de miocardio en la Mujer JOVEN (VIRGO in Spain) was supported by grant PI 081614 from the Fondo del Instituto de Investigaciones Sanitarias del Instituto Carlos III, Ministry of Science and Technology, and additional funds from the Centro Nacional de Investigaciones Cardiovasculares in Spain. Dr Smolderen was supported by the Patient-Centered Outcomes Research Institute (Washington, DC; CE-1304–6677).DisclosuresDr Bueno reports having received consulting fees from Abbott, Astra-Zeneca, Bayer, BMS, Novartis and Pfizer; speaking fees from Astra-Zeneca, Bayer, BMS-Pfizer, Ferrer, Novartis, Servier and MEDSCAPE-the heart.og; and fees for research activities from Astra-Zeneca, BMS, Janssen, Novartis. Dr Krumholz is a recipient of research agreements from Medtronic and from Johnson & Johnson (Janssen), through Yale University, to develop methods of clinical trial data sharing; is the recipient of a grant from the Food and Drug Administration and Medtronic to develop methods for postmarket surveillance of medical devices; chairs a cardiac scientific advisory board for UnitedHealth; is a participant/participant representative of the IBM Watson Health Life Sciences Board; and is the founder of Hugo, a personal health information platform.FootnotesCirculation is available at http://circ.ahajournals.org.Correspondence to: Kim G. Smolderen, PhD, UMKC School of Medicine, Biomedical and Health Informatics, 1000 E 24th Street, 5th Floor, Kansas City, MO 64108. E-mail [email protected]References1. Lichtman JH, Lorenze NP, D'Onofrio G, Spertus JA, Lindau ST, Morgan TM, Herrin J, Bueno H, Mattera JA, Ridker PM, Krumholz HM. Variation in recovery: Role of gender on outcomes of young AMI patients (VIRGO) study design.Circ Cardiovasc Qual Outcomes. 2010; 3:684–693. doi: 10.1161/CIRCOUTCOMES.109.928713.LinkGoogle Scholar2. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure.J Gen Intern Med. 2001; 16:606–613.CrossrefMedlineGoogle Scholar3. Spertus JA, Winder JA, Dewhurst TA, Deyo RA, Prodzinski J, McDonell M, Fihn SD. Development and evaluation of the Seattle Angina Questionnaire: a new functional status measure for coronary artery disease.J Am Coll Cardiol. 1995; 25:333–341.CrossrefMedlineGoogle Scholar4. Brooks R. EuroQol: the current state of play.Health Policy. 1996; 37:53–72.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By L.J. Visseren F, Mach F, M. Smulders Y, Carballo D, C. Koskinas K, Bäck M, Benetos A, Biffi A, Manuel Boavida J, Capodanno D, Cosyns B, Crawford C, H. Davos C, Desormais I, Di Angelantonio E, H. 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