Interpersonal Conflict & Role Transitions Predict Poor Adherence to Aspirin after Acute Coronary Syndromes Ian M. Kronish, MD, MPH 1, Nina Rieckmann, PhD 2, Matthew M. Burg, PhD 1,3, Carmela Alcantara, PhD 1, Karina W. Davidson, PhD 1 1 Center for Behavioral Cardiovascular Health, Columbia University Medical Center 2 Berlin School of Public Health, Charité Universitätsmedizin 3 Section of Cardiovascular Medicine, Yale University School of Medicine
Funded by NHLBI Disclosures
Background Depression after acute coronary syndromes (ACS) is associated with 2X risk of recurrent MI or mortality 1,2 Depression also associated with poor medication adherence 3 Poor medication adherence may mediate the association between depression and poor prognosis after ACS 4 1 Van Melle, Psychosom Med, 2004; 2 Whang, Am J Cardiol, 2010; Rieckmann, JACC, 2006; Rieckmann, Psycother Psychosom 2011
Background Despite improving depressive symptoms, enhanced depression care for depressed cardiac patients has not resulted in improved medication adherence 1,2 Need to better understand reasons for association between depression and adherence 1 Kronish, Am Heart J, 2012; Katon, N Engl J Med, 2010
Background Depression is a multifactorial condition that arises under conditions of stress in patients with underlying psychosocial vulnerabilities Interpersonal, cognitive, and behavioral vulnerabilities have been associated with depression in post-acs patiens 1 Rieckmann, Psychosom Med, 2004; Rieckmann, Psychother Psychosom, 2006
Study Aim Determine the association between psychosocial vulnerabilities for depression and medication adherence after ACS DEPRESSION VULNERABILITIES Interpersonal Cognitive ADHERENCE Behavioral
Study Design Prospective observational cohort of patients hospitalized with ACS from May 2003 to April 2005 3 Sites: Mount Sinai Hospital, NY Yale-New Haven Hospital, CT Hospital of St. Raphael, CT
Inclusions: Study Design hospitalized ACS in last 7 days agreed to take aspirin from electronic pill bottle Exclusions: severe mental illness or substance abuse cognitive impairment Beck Depression Inventory (BDI) score 5-9 used a pillbox
Outcome Measure Adherence to aspirin Objectively measured using MEMS for 3 months after ACS Defined as % days took correct number of doses Good adherence: 80% Poor adherence: <80%
Predictor Measures Vulnerability Assessment Interpersonal conflict 15 items from Dyadic Adjustment Scale 1 Asked to name person closest to them and then rate extent they disagree on important issues Increased role transitions Adapted from Interpersonal Problem Area Rating 2 Geographic move, graduation/new job, retirement/job loss, separation/divorce, marriage/cohabitation, health problems, other 1 Spanier, J Marriage Fam 1976; 2 Markowitz, J Psychother Pract Res 2009
Predictor Measures Vulnerability Dysfunctional cognitive attitudes and beliefs Behavioral deactivation Assessment Dyadic Adjustment Scale (15 items) 1 Sample item: if others dislike you, you can t be happy Pleasant Events Schedule for Elderly-20 item 2 Measures infrequency of engaging in 20 pleasant events in prior month 1 Power, J Res Pers 1994; 2 Teri, J Consult Clin Psychol 1982
Other Measures Depressive symptoms Beck Depression Inventory measured within 1 week of admission for ACS Potential Covariates age, gender, ethnicity, partner status Charlson comorbidity index
Analysis Plan Chi-squared, t-tests, or Mann-Whitney test for non-normally distributed variables to compare vulnerabilities according to aspirin adherence status Logistic regression models to determine if vulnerabilities predict poor adherence, adjusting for demographics, comorbidity, depressive symptoms Explored interaction with gender and partner status
Results Patient Characteristics (N=172) Characteristic Age, mean 59 yrs Female 45% White 87% Has partner 65% Depressed (BDI>=10)
Results Prevalence of Major Role Transitions in Year Prior to ACS 30% 25% 24.4% 20% 18.5% 15% 10% 10.1% 9.5% 9.5% 5% 0% Other Health problem Move New job/graduation 3.0% 2.4% Job loss Marriage Divorce
Results Vulnerability Poor Adherer (<80%; N=39) Good Adherer ( 80%; N=133) P- Value # Role Transitions 1.3 (1.2) 0.7 (0.9) 0.009 Dyadic Disagreement 2.5 (1.1) 2.1 (0.7) 0.06 Dysfunctional Attitudes (>94 = high) 75.7 (18.4) 78.8 (21.9) 0.42 Lack of Pleasant Events 0.3 (0.3) 0.3 (0.2) 0.43
Results % Poorly Adherent 70 60 50 40 30 20 10 0 Association between Role Transitions and Poor Adherence to Aspirin 17.1 17.6 34.8 58.3 0 1 2 3+ Number of Role Transitions
Results Characteristic Model 1 P- Model 2 P- (Nagelkerke R 2 =0.10) value (Nagelkerke R 2 =0.22) Value Odds Ratio (95% CI) Odds Ratio (95% CI) Depression (BDI 10) 2.50 (1.15 to 5.56) 0.02 2.38 (0.96 to 5.88) Number of role transitions - 1.72 (1.18 to 2.50) Dyadic disagreement - 1.49 (1.01 to 2.22) Dysfunctional attitudes - 0.68 (0.44 to 1.24) Lack of pleasant events - 1.01 (0.65 to 1.58) 0.06 0.005 0.05 0.08 0.95 Models additionally adjusted for age, gender, race, partner status, Charlson; none of these covariates was significant at P<0.05
Results Interaction between gender and dyadic disagreement (P=0.02) In gender stratified analyses, dyadic disagreements strongly predicted poor adherence in men (2.94, 95%CI 1.25 to 7.14; P=0.01) but not women (1.01, 95%CI 0.49 to 2.08; P=0.97)
Limitations Small sample size Generalizability Only measured adherence to aspirin
Conclusions Interpersonal psychosocial vulnerabilities predicted poor adherence to aspirin independent from depression Men with increased interpersonal conflict with their close relations are at especially high risk for poor adherence after ACS
Implications Clinicians should assess the social context of ACS patients and be mindful that recent major role transitions other than the ACS and/or interpersonal conflict may put patients at risk for poor adherence Psychotherapies directed at interpersonal problems may provide a useful approach to improving medication adherence in cardiac patients
Acknowledgments Center for Behavioral Cardiovascular Health Columbia University COPES Research Staff
Questions