Depression Vulnerabilities in Patients with Different Levels of Depressive Symptoms after Acute Coronary Syndromes

Abstract

Background: Cognitive, behavioral, and interpersonal vulnerabilities have been studied in patients fulfilling diagnostic criteria for major depression and dysthymia. The extent to which these vulnerabilities are present in cardiac patients with mild to moderate depressive symptoms – a risk factor for mortality – is unknown. Moreover, few studies have examined interrelations among depression vulnerabilities. Methods: A consecutive cohort of 314 patients with acute coronary syndrome completed the Beck Depression Inventory (BDI) and measures of cognitive, behavioral, and interpersonal vulnerabilities (Dysfunctional Attitudes Scale, Pleasant Events Schedule for the Elderly, Dyadic Adjustment Scale, and an inventory of role transitions) within 1 week of hospital admission. Of the patients, 166 were classified as nondepressed (BDI score, 0–4), 91 as mildly depressed (BDI score, 10–16), and 57 as moderately to severely depressed (BDI score, >16). Results: Compared with nondepressed patients, both mildly depressed and moderately to severely depressed patients exhibited higher mean levels of all vulnerabilities as well as a higher prevalence of more than one elevated vulnerability, defined by threshold scores. Vulnerabilities were only minimally interrelated (r = 0.01–0.25), and they were independently associated with mild and moderate depressive symptom status. Conclusions: This is the first study to show that cognitive, behavioral, and interpersonal depression vulnerabilities are uniquelyassociated with concurrent depressive symptoms. There appeared to be only modest overlap between vulnerabilities, supporting the idea that depression in medically ill patients is a multifaceted phenomenon, even in the presence of minimally elevated depressive symptoms. Longitudinal studies are required before causality and treatment implications can be addressed.

Challenges in reducing depression-related mortality in cardiac populations: cognition, emotion, fatigue or personality?

“…Furthermore, aetiological studies have established an association between depressive symptoms and incident CHD in initially healthy individuals, as demonstrated in systematic reviews (Rugulies, 2002;Wulsin & Singal, 2003). The findings of Rieckmann et al (2006) outlined above, which show that depressed ACS patients exhibit the theoretical vulnerabilities to depression, also indicate that depression is present prior to the cardiac event in a substantial number of patients. As these vulnerabilities would have been present prior to the ACS event, and they are theoretically unrelated to CHD, one could therefore argue that these patients are depressed independently of CHD severity.…”

“…Cognitive models of depression have been investigated in cardiac patients (Berkman et al, 2003;Carney et al, 2004;de Jonge, Ormel, et al, 2006;Dijkstra et al, 2002;Rieckmann et al, 2006;Roberts, 1989;Shnek, Irvine, Stewart, & Abbey, 2001). Rieckmann et al (2006) demonstrated that mildly to moderately/severely depressed patients with ACS had significantly higher levels of dysfunctional attitudes compared to non-depressed ACS patients.…”

“…Cognitive models of depression have been investigated in cardiac patients (Berkman et al, 2003;Carney et al, 2004;de Jonge, Ormel, et al, 2006;Dijkstra et al, 2002;Rieckmann et al, 2006;Roberts, 1989;Shnek, Irvine, Stewart, & Abbey, 2001). Rieckmann et al (2006) demonstrated that mildly to moderately/severely depressed patients with ACS had significantly higher levels of dysfunctional attitudes compared to non-depressed ACS patients. Although depression has been associated with morbidity and mortality following CHD, subsequent research questioned whether cognitive symptoms of depression were associated with mortality, or whether only somatic symptoms predicted outcomes (Table 1) (de Jonge, Ormel, et al, 2006;Doyle et al, 2006).…”

“…Furthermore, since major depressive disorder is a heterogeneous disease, it may be that only a proportion of the treatment group benefited from improved cardiovascular outcomes (i.e., a sub-group for whom CBT was most appropriate, other sub-groups may have benefited from interpersonal therapy or operant therapy) (Davidson et al, 2004). Indeed, Rieckmann et al (2006) demonstrated that depressed ACS patients exhibited cognitive, interpersonal and behavioural vulnerabilities to depression, and that these vulnerabilities were independently associated with depression. Therefore, the trial would not have been powered to find the difference in the sub-group for which it was most suited.…”

“…To our knowledge, only one study has demonstrated that several theoretical vulnerabilities to depression are present in the depressed cardiac population. Rieckmann et al (2006) assessed 314 ACS patients with the BDI within one week of hospital admission and reported that both mildly and moderately/severely depressed patients showed higher levels of cognitive, interpersonal and behavioural vulnerabilities. These vulnerabilities independently contributed to depressive symptoms (although the presence of more than one vulnerability increased the odds of being depressed).…”