Recognition and Treatment of Depression and Anxiety in Patients With Acute Myocardial Infarction

Transcription

1 Recognition and Treatment of Depression and Anxiety in Patients With Acute Myocardial Infarction Jeff C. Huffman, MD a,c, *, Felicia A. Smith, MD a,c, Mark A. Blais, PsyD a,c, Marguerite E. Beiser, BA d, James L. Januzzi, MD b,c, and Gregory L. Fricchione, MD a,c The objective of this study was to determine the ability of providers (medical residents and nurse practitioners) on inpatient cardiac units to recognize and appropriately treat patients with clinically significant depression and anxiety among a cohort admitted with acute myocardial infarction. Patients within 72 hours of acute myocardial infarction underwent screening with the Standardized Clinical Instrument for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition module for major depressive disorder (MDD), the Beck Depression Inventory (BDI-II), and the Beck Anxiety Inventory (BAI). In addition, the study psychiatrist and a treatment team clinician independently assessed whether they believed that patients had clinically significant depression or anxiety. Prescription of antidepressants and benzodiazepines during hospitalization was recorded by chart review. Assessments were completed for 74 patients. Providers identified <15% of patients with current MDD or with a BDI score >10; 11% of patients with current MDD had appropriate treatment with antidepressants. There was no significant correlation of providers assessment of depression with current MDD, BDI scores, or psychiatrists clinical assessment of depression. In contrast, providers identified 31% of patients with a BAI score >10 and 50% of patients who were assessed by psychiatrists as anxious; >80% of patients with high anxiety received benzodiazepines. Providers assessments of anxiety were significantly correlated with BAI scores and with psychiatrists clinical assessments. In conclusion, medical residents and nurse practitioners routinely under-recognize and undertreat depression among patients with acute myocardial infarction on inpatient cardiac units. Recognition and treatment of anxiety is substantially better, up to 50% of patients who are found to be anxious by psychiatrists after acute myocardial infarction remain unrecognized Elsevier Inc. All rights reserved. (Am J Cardiol 2006;98: ) The Departments of a Psychiatry and b Cardiology, Massachusetts General Hospital, and c Harvard Medical School, Boston, Massachusetts; and the d School of Nursing, Columbia University, New York, New York. Manuscript received November 28, 2005; revised manuscript received and accepted February 9, This study was supported by the Kaplen Fellowship Award Grant and the Livingston Fellowship Award Grant through Harvard Medical School, Boston, Massachusetts. * Corresponding author: Tel: ; fax: address: jhuffman@partners.org (J.C. Huffman). Psychiatric symptoms in the period after acute myocardial infarction appear to negatively affect cardiac outcomes. Depression after acute myocardial infarction has been associated with increased rates of cardiac and all-cause mortality, increased risk of cardiac complications, and greater impairment of quality of life. 1 3 Patients with anxiety after acute myocardial infarction have been found to have higher rates of in-hospital complications (ischemia, infarction, and ventricular arrhythmia) 4 and higher rates of recurrent cardiac events after acute hospitalization. 5,6 Although there are effective treatments for these syndromes after acute myocardial infarction, studies of depression recognition in the acute period after acute myocardial infarction and of anxiety recognition in the year after acute myocardial infarction have confirmed that identification of these symptoms is significantly limited. 3,6,7 To our knowledge, no study has assessed the ability of providers to recognize in-hospital depression and anxiety among patients who are admitted for an acute myocardial infarction. The present study determined providers ability to recognize these psychiatric symptoms among patients on cardiac units within 72 hours of acute myocardial infarction. In addition, we examined rates of antidepressant and anxiolytic prescriptions to patients with high levels of depression and anxiety. Methods Design: This was a prospective study that examined the ability of clinicians (medical residents and nurse practitioners) on inpatient cardiac units to recognize patients with clinically significant depression and anxiety as measured by standardized research instruments and psychiatrists clinical assessment and to appropriately treat patients with antidepressant and anxiolytic medications when indicated /06/$ see front matter 2006 Elsevier Inc. All rights reserved. doi: /j.amjcard

2 320 The American Journal of Cardiology ( Subject selection: The study was approved by the institutional review board of Massachusetts General Hospital (Boston, Massachusetts). Patients who were admitted to the Massachusetts General Hospital Coronary Care Unit or Cardiac Step-Down Unit between October 2003 and July 2005 with a primary diagnosis of myocardial infarction were recruited for entrance into the study within 72 hours of symptom onset. Inclusion and exclusion criteria were similar to those of similar studies of psychiatric syndromes after acute myocardial infarction. 3,8 Specifically, eligible patients met 2 of 3 World Health Organization criteria for an acute myocardial infarction (typical chest pain, increased cardiac enzymes [troponin T level 0.10 ng/ml or creatine phosphokinase-mb isoenzyme level 1.5 times the upper limit of the normal range], and electrocardiographic changes consistent with acute myocardial infarction). Exclusion criteria included patients with periprocedural acute myocardial infarctions (i.e., in the context of coronary artery bypass surgery, percutaneous coronary angioplasty, or coronary catheterization). Patients with cognitive difficulties that interfered with their ability to provide informed consent or to complete a baseline interview or those who were not medically stable enough to complete the baseline evaluation were also excluded. We excluded patients with substance abuse or dependence (identified by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition 9 [DSM-IV]) to decrease the possibility of substance withdrawal as a cause of anxiety symptoms. Patients were identified by contact with their primary treatment teams; for patients meeting inclusion criteria into the study, willing participants were then contacted by a physician investigator (JCH or FAS) to discuss the study and provide informed consent. Initial evaluation: Research psychiatrists (JCH and FAS) performed an initial screening battery for each subject. This battery included the Beck Depression Inventory-II (BDI-II), 10 the Beck Anxiety Inventory 11 (BAI; modified to identify symptoms since onset of acute myocardial infarction symptoms), and the Structured Clinical Interview for the DSM-IV 9 (current and lifetime) module for major depressive disorder (MDD). When the BAI was administered, the total BAI score was recorded, as was the total subscore on the 7 psychological items ( unable to relax, fear of worst happening, terrified or afraid, nervous, fear of losing control, fear of dying, and scared ), denoted as BAI-P. In addition, at the time of subject recruitment, the primary treatment team member (medical resident or nurse practitioner) was asked 2 questions: Does this patient have clinically significant depression? Does this patient have abnormally high and clinically significant anxiety? After completion of the screening battery, the physician investigator also completed a separate form with the same 2 questions. Chart review: At the end of the hospitalization, a subject s medical record was reviewed by research staff to obtain demographic, medical, and medication-related variables. Specifically, information obtained included demographic variables (age, gender, marital status, and employment status), medical variables (peak creatine phosphokinase-mb fraction and troponin levels as a correlate of acute myocardial infarction severity, left ventricular ejection fraction, and cardiac risk factors, such as diabetes mellitus, hypercholesterolemia, hypertension, and current smoking), and medication-related variables (prescriptions, including total daily doses of benzodiazepines, antidepressants, blockers, angiotensin-converting enzyme inhibitors, and lipid-lowering agents). Diagnoses of depression and anxiety: Three different measurements of depression were used when evaluating subjects for depression. (1) MDD was diagnosed according to the DSM-IV 12 by interview with study staff. (2) BDI scores were used as a continuous variable and a categorical variable, with a cut-off score 10 (signifying mild to moderate depression). This value was chosen because multiple studies have reported that a score 10 on the original BDI 13 predicts negative cardiac outcomes. 2,14,15 (3) Psychiatrist researchers diagnosis of clinically significant depression was also used. MDD of the DSM-IV was considered the most important of these. Three different measurements of clinically significant anxiety were also used: (1) BAI scores as a continuous and a categorical variable using a traditional cut-off score 10 (as used in other studies of this population), 16 (2) BAI-P scores (sum of the 7 psychological items) as a continuous variable, and (3) psychiatrist researchers diagnosis of clinically significant depression; no category from the DSM-IV adequately characterized free-floating anxiety after acute myocardial infarction. Statistical analysis: Data analysis was performed with SPSS for Windows (SPSS, Inc., Chicago, Illinois). Categorical data were analyzed with chi-square tests and phi correlations. Dimensional data were analyzed with independent t tests and Pearson s correlations. Sensitivity and specificity of providers assessments (using MDD from the DSM-IV as the standard criterion) were calculated according to standard formulas. 17 Effect sizes (reported as Cohen s d values) were calculated to further compare differences in mean BAI/BDI scores of patients who were or were not assessed by providers as anxious/ depressed. 18

3 Coronary Artery Disease/Post-MI Psychiatric Recognition and Treatment 321 Table 1 Baseline and in-hospital characteristics of study subjects Psychosocial characteristics Age (yrs) Men 58 (78%) Marital status (married) 47 (64%) Employment status (employed) 47 (64%) Living alone 21 (28%) Medical and psychiatric history Hypertension 41 (56%) Hyperlipidemia 47 (64%) Diabetes Mellitus 15 (20%) Current smoker 18 (24%) Previous AMI 15 (20%) Previous major depressive episode 16 (22%) In-hospital values ST-elevation AMI 52 (70%) Peak CPK (U/L) ( ) Peak CPK-MB (ng/ml) ( ) Peak troponin T (ng/dl) 2.50 ( ) Left ventricular ejection fraction Medications received during hospitalization Blockers 73 (99%) Angiotensin-converting enzyme inhibitors 61 (82%) Lipid-lowering agents 73 (99%) Antidepressants 8 (11%) Benzodiazepines 46 (62%) Values are presented as mean SD, number of patients (percentage), or median (25th to 75th percentile). AMI acute myocardial infarction; CPK creatine phosphokinase; CPK-MB creatine phosphokinase-mb fraction. Results Medical and psychosocial characteristics: In total, 74 eligible patients with acute myocardial infarction were enrolled in this portion of the study. Overall, characteristics of this population were similar to those of related studies; medical, psychosocial, and medication-related variables are listed in Table 1. Eight of 74 patients (11%) received antidepressants (2 of the 8 received new prescriptions of antidepressants or an increase in antidepressant dose; the remaining patients entered the hospital taking antidepressants and dose was not adjusted), whereas 46 of 74 patients (62%) received benzodiazepines at some point during hospitalization. Psychiatric outcomes: With respect to depression, 9 of the 74 subjects (12%) met DSM-IV criteria for current MDD. BDI scores ranged from 0 to 44; the mean score on the BDI was 9.6, with 21 patients (28%) having a BDI score 10, indicating at least mild to moderate depression. With respect to anxiety, BAI scores (modified to measure anxiety symptoms after acute myocardial infarction) ranged from 0 to 42; the mean BAI score was 7.9, with 19 subjects (26%) having a BAI score 10, indicating at least mild to moderate anxiety. BAI-P scores (sum of the 7 psychological items on the BAI) ranged from 0 to 20, with a mean score of 4.3. Table 2 Correlations among measurements of depression employed in the study DSM-IV MDD BDI Total Score BDI Score 10 Research Treatment DSM-IV MDD 1.00 BDI total score 0.76* 1.00 BDI score * 0.83* 1.00 Research team 0.77* 0.77* 0.66* 1.00 Treatment team * Correlations are significant at a p value Providers and researchers assessments of depression and anxiety: Correlations for all measures of depression are listed in Table 2. MDD from the DSM-IV, BDI score 10, continuous BDI scores, and psychiatrists clinical assessments of depression were significantly correlated with 1 another. In contrast, provider-identified depression was not correlated with any of these measurements of depression. Twenty-one of 74 subjects (28%) subjects had a BDI score 10, and 9 of 74 (12%) met DSM-IV criteria for MDD. Providers identified 3 of 74 subjects (4.1%) as having clinically significant depression compared with 11 subjects (14.9%) so identified by research staff (psychiatrist researchers). Of the 3 provider-identified subjects, 1 of 3 (33%) met criteria for MDD and 2 of 3 had a BDI score 10; these subjects identified as depressed by clinicians had a mean BDI score of 17.3 compared with a mean BDI score of 9.3 for those assessed as nondepressed; this difference did not reach significance (independent t test, t , p 0.15) despite yielding a large effect size (d 0.89). By using each measurement of clinical depression, treating clinicians identified 1 of 9 subjects (11.1%) with current MDD, 2 of 21 (9.5%) with a BDI score 10, and 2 of 11 (18%) assessed by research staff as depressed. Chi-square analysis showed that providers clinical diagnoses of depression were not significantly related to any measurement of depression. Specifically, clinicians assessments of depression were not significantly related to MDD as diagnosed by the Structured Clinical Interview (chi-square 1.312, degree of freedom 1, p NS), a BDI score 10 (chi-square 2.255, degree of freedom 1, p NS), BDI scores (continuous; correlation 0.169, p NS), or researchers clinical diagnosis of depression (chisquare 0.843, degree of freedom 1, p NS). When using a Structured Clinical Interview diagnosis of MDD as the standard criterion, the sensitivity and specificity of providers assessments of depression were 33.3% and 96.9%, respectively. Correlations for all measurements of anxiety are presented in Table 3. All measurements of anxiety (BAI score 10, continuous BAI scores, BAI-P scores, research psychiatrists assessments, and providers clinical assessment of anxiety) were significantly correlated with

4 322 The American Journal of Cardiology ( Table 3 Correlations among measurements of anxiety employed in the study BAI Total Score BAI Score 10 BAI-P Research Treatment BAI total score 1.00 BAI score * 1.00 BAI-P 0.89* 0.69* 1.00 Research 0.58* 0.37* 0.60* 1.00 Treatment 0.48* 0.39* 0.46* 0.66* 1.00 * Correlations are significant at a p value another. On interview, clinicians assessed 8 of 74 subjects (10.8%) as having clinically significant anxiety compared with 16 of 74 (21.6%) assessed as anxious by researchers; 6 of 8 provider-identified patients (75%) had a BAI score 10. Mean BAI and BAI-P scores for provider-identified anxious patients were 18.5 and 10.4, respectively, compared with 6.6 and 3.5 for nonanxious patients. Independent t tests showed these differences to be significant (t , p for BAI; t , p for BAI-P) and effect sizes to be large (d 1.69 for BAI, 1.64 for BAI-P). By using each measurement of anxiety, providers identified 6 of 19 subjects (31.6%) with a BAI score 10 as anxious and recognized 8 of 16 researcher-identified anxious subjects (50%) as such. Providers diagnoses of clinical anxiety were significantly related to researchers assessment of clinically significant anxiety (chi-square , degree of freedom 1, p 0.001) and to a BAI score 10 (chi-square , degree of freedom 1, p 0.003). Treatment of depression and anxiety: One of 9 subjects (11.1%) who met DSM-IV criteria for MDD received appropriate treatment with antidepressants at some point during hospitalization (i.e., had a new prescription of an antidepressant or, for subjects already on antidepressants but with ongoing MDD, had a switch or dose increase of antidepressant). One other subject was admitted on an antidepressant but continued to meet criteria for current MDD and did not have the dose adjusted; 7 of 9 subjects with current MDD did not receive an antidepressant during hospitalization. Those subjects with current MDD were not significantly more likely to receive antidepressants than other patients (chi-square 1.384, degree of freedom 1, p NS). Of the 3 subjects who were diagnosed by the treating clinicians as depressed, 1 was placed on an antidepressant. In contrast, the number of patients who received anxiolytic medication was much larger. Subjects who were diagnosed as anxious by providers received benzodiazepines in 7 of 8 cases (87.5%), and subjects diagnosed as anxious by researchers received benzodiazepines in 13 of 16 cases (81.2%). Benzodiazepine prescription was significantly related to BAI total score (r 0.31, p 0.05) and BAI-P score (r 0.36 p 0.01), and patients with a BAI score 10 trended toward being significantly more likely to receive benzodiazepines (r 20, p 0.08). However, benzodiazepine use was not significantly related to providers diagnosis of anxiety (chi-square 2.44, degree of freedom 1, p 0.117). No subjects received antidepressant medications to treat anxiety. Discussion The first major result of this study is that, in the absence of systematic screening, treating providers in busy inpatient cardiac units significantly underdiagnosed and undertreated depression among patients with acute myocardial infarction in an academic teaching hospital. Providers diagnoses of depression did not significantly match psychiatrist researchers clinical diagnoses of depression, DSM-IV diagnoses of MDD, or higher BDI scores. Further, only 1 subject with MDD was started on an antidepressant during hospitalization, and only 1 of the 3 patients identified by providers as depressed received an antidepressant. These findings agree with several studies that have reported low rates of depression recognition and treatment in depressed outpatients in medical settings. 19,20 Further, our findings match those of a similar study of 60 patients with acute myocardial infarction by Ziegelstein et al. 7 In this study, the investigators found that clinicians (nurses, residents, and attending cardiologists) under-recognized depression (when using a BDI score 10 as a cutoff) in a similar inpatient academic setting, with little correlation between provider assessments of depression and BDI scores. Of note, residents and nurses (the subject of our study) performed more poorly than attending cardiologists. Our findings concerning the low rates of antidepressant treatment are also consistent with the findings of Frasure- Smith et al 21 in their landmark study of depression after acute myocardial infarction. In that study, the investigators found that 10% of the 35 patients with depression after acute myocardial infarction received treatment with antidepressants during the index admission. The low rates of depression treatment may be affected by clinicians reluctance to initiate antidepressant treatment in the days immediately after acute myocardial infarction, because most larger studies of depression after acute myocardial infarction were performed weeks after the acute event. However, under-recognition of depression (rather than a carefully considered decision to hold antidepressants for a brief interval after acute myocardial infarction) appears to be a much more likely cause for the low rates of treatment. The second major finding of this report is that providers are much more able to recognize anxiety after acute myocardial infarction. In contrast to the findings for depression, providers reports of clinically significant anxiety were significantly related to researcher psychiatrists clinical diag-

5 Coronary Artery Disease/Post-MI Psychiatric Recognition and Treatment 323 noses, BAI total scores, and BAI-P scores (sum of psychological items). In addition, a clinician diagnosis of anxiety was significantly associated with a prescription of benzodiazepines, with the majority of patients assessed as clinically anxious receiving benzodiazepines at some point during their hospitalization. Providers still appeared to underdiagnose anxiety, because clinicians identified only 50% of the patients considered to be clinically anxious by the psychiatrist researchers and identified only 33% of patients with BAI scores 10. Further, anxiety has historically been undertreated in this and other settings, 22,23 and dose and scheduling of benzodiazepines may still have been ineffective even in the presence of identification. This report is somewhat in contrast to a previous study of anxiety recognition after acute myocardial infarction by O Brien et al. 24 In this study, 110 patients with acute myocardial infarction completed a standardized anxiety instrument (Spielberger State Anxiety Index), 25 and their anxiety ratings were compared with anxiety reported in the medical record by physicians and nurses. The investigators found no association between patients self-assessments and their clinicians assessments of anxiety. The somewhat different designs of the 2 studies may have accounted for the somewhat different findings, because our study included direct questioning of clinicians rather than medical record review and included information about anxiolytic medication prescription. In addition, we used a different measurement of anxiety, choosing the BAI rather than the Spielberger State Anxiety Index, because of the latter instrument s high overlap with depression. 26 However, providers rates of anxiety recognition in our study (50% using clinician ratings, 31% using BAI scores) were similar to those in a longitudinal study concerning the period after acute myocardial infarction by Grace et al. 6 In this study, 38% of patients with persistently high anxiety after acute myocardial infarction reported being asked about such symptoms by their treaters in the year after their acute myocardial infarction. One limitation of this study is that providers were polled within 72 hours of symptom onset; although the providers were members of the primary treatment team, they may not have had sufficient time to serially assess patients during this relatively early point in hospitalization. In addition, providers were asked a single yes/no question about depression and anxiety, and a more continuous scale may have allowed more identification of possible depression/anxiety cases. The relatively small numbers of patients (74), numbers of cardiac units (2), and treatment centers (1) may mean that the results are not generalizable to all patients with acute myocardial infarction in all settings, although the characteristics of the patient population were similar to those of other studies of this population. Although we were able to identify and use several clear diagnostic standards for depression (with MDD diagnosed from the DSM-IV as the gold standard among these), there is no clear diagnostic gold standard for free-floating anxiety, and we used BAI scores, BAI psychological item subscores (essentially an endorsement of nervousness/fear), and psychiatrists clinical assessment as our best characterization. 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