Depression, anxiety and neuropsychological test scores of candidates for coronary artery bypass graft surgery

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1 Archives of Clinical Neuropsychology 20 (2005) Brief report Depression, anxiety and neuropsychological test scores of candidates for coronary artery bypass graft surgery Abstract William T. Tsushima a,, David B. Johnson b, Jeffrey D. Lee c, Jennifer M. Matsukawa d, Kathrine M.S. Fast d a Department of Psychiatry and Psychology, Straub Clinic and Hospital, Honolulu, HI 96813, USA b QMark, Honolulu, HI, USA c University of Hawaii School of Medicine, Honolulu, HI, USA d University of Hawaii, Honolulu, HI, USA Accepted 9 April 2005 The effect of depression and anxiety upon neuropsychological test scores of candidates for coronary artery bypass graft (CABG) surgery was examined. Sixty patients were administered the Beck Depression Inventory II and the State-Trait Anxiety Inventory, along with a battery of neuropsychological tests. Regression analyses were conducted in which the neuropsychological test scores were predicted using age, education, depression, anxiety, and combined depression-anxiety scores. While age and education were significant predictors of several neuropsychological test measures, no significant regression analysis results were obtained for the depression, anxiety and combined depression-anxiety scores. Similarities and discrepancies between this research and previous studies are discussed. It appears that low levels of preoperative depression and anxiety states do not affect neuropsychological functioning among CABG candidates National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved. Keywords: Depression; Anxiety; Neuropsychological performance; Coronary artery bypass graft surgery Neuropsychological impairment following coronary artery bypass graft (CABG) surgery is well known (Lee et al., 2003; Newman et al., 2001; Stygall et al., 2003; Van Dijk et al., 2002), but relatively less is known about the presurgical neuropsychological status of CABG candidates. Recent research shows presurgical deficits on a variety of neurocognitive tests (Browndyke et al., 2002; Keith et al., 2002; Millar, Asbury, & Murray, 2001), and one Corresponding author. Tel.: ; fax: address: wtsushima@straub.net (W.T. Tsushima) /$ see front matter 2005 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved. doi: /j.acn

2 668 W.T. Tsushima et al. / Archives of Clinical Neuropsychology 20 (2005) study showed presurgical cognitive deficits on nearly every neuropsychological test (Rankin, Kochamba, Boone, Petiti, & Buckwalter, 2003). Preoperative neuropsychological deficits might be from cardiovascular disease (McKhann, Goldsborough, et al., 1997; Vingerhoets et al., 1995) but might also relate to emotional factors, such as depression and anxiety (Haddock, Poston, & Taylor, 2003). Two studies employing patients before and after CABG found no relation between mood factors (depression and anxiety) and a series of cognitive tests (Andrew, Baker, Knweebone, & Knight, 2000; McKhann, Borowicz, Goldsborough, Enger, & Selnes, 1997), but such relations are found in studies of non-cardiac patients where depression was associated with significant impairments in memory (Burt, Zembar, & Niederehe, 1995), executive functioning (Lockwood, Alexopoulos, & van Gorp, 2002), and general cognitive functioning (King, Cox, Lyness, & Caine, 1995; Ravnkilde, Videbech, Clemmensen, Egander, Rasmussen, & Rosenberg, 2002). Some of this discrepancy may stem from differences in mediating factors, such as age and degree or type of depression (Kindermann & Brown, 1997; Kizilbash, Vanderploeg, & Curtiss, 2002). In the Andrew et al. (2000) study, the possible effect of age and education on neuropsychological test scores was not examined, while McKhann, Borowicz, et al. (1997), after controlling for age and education, found that non-depressed patients performed better than depressed patients on one out of eight preoperative cognitive areas (visuoconstruction). The above studies present inconsistent results pertaining to the effects of depression and anxiety on neurocognitive abilities. The role of emotional states such as depression and anxiety needs to be clarified when interpreting the preoperative cognitive deficits seen in CABG candidates, and the present study examined this very issue. 1. Method 1.1. Participants The participants were 60 consecutive patients who were undergoing first-time elective CABG surgery and had no significant renal dysfunction. Candidates for study inclusion were asked if they were interested in participating and signed an Informed Consent agreement at the time of their initial evaluation. Based on a modified National Institute of Health stroke scale (Cummins, 2003), six patients (10%) were identified by a neurologist as having a previous stroke. Four patients (7%) had a previous myocardial infarction. The mean age of the patients was years (S.D. = 10.22). The mean education was years (S.D. = 3.04). Forty-six (77%) patients were male, and 14 (23%) were female Procedure Participants underwent a broad 1 1 h neuropsychological evaluation prior to CABG surgery. 2 The following instruments were used Measures of mood and anxiety The Beck Depression Inventory II (BDI II; Beck, Steer, & Brown, 1996) is a 21-item measure of the symptoms of depression.

3 W.T. Tsushima et al. / Archives of Clinical Neuropsychology 20 (2005) The State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, & Luchens, 1970) was used to assess anxiety and to differentiate between the temporary condition of state anxiety and the more long-standing trait anxiety Neurocognitive measures Neuropsychological tests measured motor speed, visual-motor coordination, visual memory, verbal memory, and vocabulary, using the Finger Tapping Test (Halstead, 1947), Grooved Pegboard Test (Kl ve, 1963), Trail Making Test, Parts A and B (Reitan, 1958), Digit Symbol subtest of the Wechsler Adult Intelligence Scale Third Edition (WAIS III; Wechsler, 1997), Benton Visual Retention Test (Sivan, 1991), Rey Auditory Verbal Learning Test (Schmidt, 1996), and the Vocabulary subtest of the WAIS III (Wechsler, 1997). This battery of tests is based on the 1994 Conference on CNS Dysfunction after Cardiac Surgery (Murkin, Martzke, Buchan, Bentley, & Wong, 1995; Murkin, Newman, Stump, & Blumenthal, 1995), with some additional assessment instruments included for this study. The tests were selected because of their reliability and validity, brevity, sensitivity to relevant neuropsychological domains, and use in prior studies (Andrew et al., 2000; Van Dijk et al., 2002) 1.5. Data analysis Analyses were performed with SPSS (Chicago, IL, USA) using a two-tailed alpha of P.05 and Bonferroni s correction for multiple comparisons. Separate regression analyses were performed for each of the neuropsychological raw score measures using age, education, depression, anxiety, and combined depression-anxiety raw test scores as predictors that were entered as a set in each of the regression analyses. 2. Results Table 1 reveals the mean raw scores of the psychological test measures of the CABG candidates. The large majority (88%) of patients reported depression in the minimal or normal range (Beck, Steer, & Brown, 1996); in contrast, 54% admitted to having substantial anxiety symptomatology (Koivula, Paunonen-Ilmonen, Tarkka, Tarkka, & Laippala, 2001). The degree and distribution of depression and anxiety states appear to be consistent with previous investigators (Vingerhoets, Van Nooten, & Jannes, 1997). While age and education correlated significantly with several of the neuropsychological tests (range = ), correlations between the depression and anxiety scores with the neuropsychological test scores were negligible (range = ). In the regression analyses, age was a significant predictor of the Finger Tapping Dominant Hand score, the Benton Correct score, and the RAVL Total and Recognition score. Education was a significant predictor of the Vocabulary score. Both age and education predicted the Benton Error score, Trail Making A and B, and the Digit Symbol score. No significant regression analysis results were obtained for the depression, anxiety or combined depression-anxiety

4 670 W.T. Tsushima et al. / Archives of Clinical Neuropsychology 20 (2005) Table 1 Preoperative psychological test scores Tests Mean S.D. Beck Depression Inventory II State-Trait Anxiety Inventory State Trait Finger Tapping Dominant Hand Non-dominant Hand Grooved Pegboard Dominant Hand Non-dominant Hand Trail Making A B Digit Symbol Benton Visual Retention Correct Error Rey Auditory Verbal Learning Total Recognition Vocabulary scores. In sum, emotional states had no significant effect on neuropsychological functioning among the CABG candidates. 3. Discussion The present findings are in accordance with previous research of CABG candidates (Andrew et al., 2000; McKhann, Borowicz, et al., 1997) in demonstrating that preoperative levels of depression and anxiety were not related to preoperative neuropsychological test performance. Unlike McKhann, Borowicz, et al. (1997) who, after controlling for age and education, found that non-depressed patients performed better than depressed patients on one of eight cognitive areas, this study revealed no relation between depression and a variety of neurocognitive tests. Further, the results of this research suggest that, even when depression and anxiety coexist, there is no significant impact upon neuropsychological functioning. This finding is contrary to those of Kizilbash et al. (2002) who reported that depression compounded by anxiety led to adverse effects on memory performance. The conflicting evidence may be attributed to differences in research participants (cardiac patients vs. military veterans), in measures

5 W.T. Tsushima et al. / Archives of Clinical Neuropsychology 20 (2005) of emotional states (BDI II and STAI vs. MMPI), and/or in cognitive measures (battery vs. California Verbal Learning Test). The present findings support the position that preoperative neuropsychological assessments of cardiac patients are valid measures of cognitive abilities and are not contaminated by low level mood and anxiety factors, as measured by self-report inventories. The results also imply that patients complaints of cognitive symptoms before surgery should not be dismissed as a consequence of emotional factors. Although mild depression and anxiety do not seem to affect preoperative neuropsychological functioning in this study, the results do not imply that assessment of presurgical emotional states is superfluous. There appears to be a significant relationship between preoperative emotional states and surgical outcomes (Connerney, Shapiro, Mclaughlin, Bagiella, & Sloan) as well as postoperative psychological complications (Pignay-Demaria, Lesperance, Demaria, Frasure- Smith, & Perrault, 2003), so that the evaluation of a patient s depression and anxiety before surgery remains valuable. Several limitations of the present study are noteworthy. In particular, the data are based on a relatively small sample of elective CABG patients who were slightly older (mean age = years) than those in other large scale studies (Newman et al., 2001; Stygall et al., 2003; Van Dijk et al., 2002). Thus, the findings of this study may not be representative of the larger population of CABG candidates who may not present the confounding dementia associated with aging and who may display a broader range of mood states. There was no control group with which to compare the depression, anxiety and neuropsychological test scores. Furthermore, there were no postoperative comparisons that would have provided further analyses of the relationship between emotional factors and neuropsychological functioning. It should be noted that depression and anxiety were measured by self-report inventories rather than a clinical examination. Thus, these findings may not generalize to patients meeting the diagnostic criteria for depression and anxiety in a clinical examination. Moreover, the level of depression and anxiety was relatively mild. Although the low levels of depression and anxiety seemed unrelated to neuropsychological test performance, we cannot conclude that moderate depression and anxiety do not have any impact on cognitive functioning among CABG candidates. Nonetheless, the results of this study contribute to the existing literature, suggesting that preoperative depression and anxiety states do not influence neuropsychological test performance among CABG candidates. References Andrew, M. J., Baker, R. A., Kneebone, A. C., & Knight, J. L. (2000). Mood state as a predictor of neuropsychological deficits following cardiac surgery. Journal of Psychosomatic Research, 48, Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory-II. New York: Psychological Corporation. Browndyke, J. N., Moser, D. J., Cohen, R. A., O Brien, D. J., Algina, J. J., Haynes, W. G., et al. (2002). Acute neuropsychological functioning cardiovascular interventions associated with the production of intraoperative cerebral microemboli. The Clinical Neuropsychologist, 16,

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