Around one in five heart patients in cardiac rehabilitation are depressed, anxious or stressed, according to a new study published in the European Journal of Preventive Cardiology.
It’s well-established that comorbid depression and anxiety can have a negative impact on a person’s prognosis after a cardiac event, Angela Rao, a PhD candidate at the University of Technology Sydney, and colleagues wrote in their paper. Concomitant depression on its own increases a patient’s odds of death by more than twofold and predicts poor adherence to rehab programs and drug regimens.
Mental health also takes a hefty financial toll on patients and healthcare systems at large, Rao et al. wrote, costing the global economy around $1 trillion in U.S. currency each year. It’s a high price considering the fact that CVD—the world’s most prolific killer—also racks up some $863 billion in global healthcare expenditures annually.
Milder forms of depression affect an estimated 30% of patients after an acute CV event, but Rao and her co-authors stressed that conditions like depression and anxiety are transient in nature and can worsen over time.
“Depression and anxiety are under-recognized and undertreated in heart disease patients, particularly in women,” Rao and co-authors said. “Misdiagnosis commonly occurs during hospitalization due to the protective function of denial, and accounts for the persistence of symptoms after discharge and on entry into cardiac rehabilitation programs.”
The team launched a retrospective cohort study of 5,908 patients who entered cardiac rehab programs sometime between 2006 and 2017 at one of two metropolitan teaching hospitals in Sydney. They considered participants’ demographics, diagnoses, CV risk factors, medication use and rate of participation in rehab, as well as health status (determined by Medical Outcomes Study Short Form-36) and psychological health status (determined by Depression Anxiety Stress Scales).
Rao and colleagues found that moderate depression, anxiety or stress symptoms were evident in 18%, 28% and 13% of adults entering cardiac rehabilitation, respectively. Patients with moderate symptoms were far less likely than their normal-to-mild-symptom peers to adhere to rehab (13% vs. 24%, respectively, for depressive patients; 23% vs. 32%, respectively, for anxious patients; 10% vs. 18%, respectively, for stressed patients).
Anxiety and stress were the strongest predictors of depression in the study, raising participants’ odds of the condition by 4.3-fold and 4.5-fold, respectively. Depression and stress increased the risk of anxiety on entry by more than three times, beating out CV risk factors, sociodemographic risk factors, diagnoses and quality of life as the most accurate predictors.
The authors noted that, in addition to their troubling statistic that one in five adults in cardiac rehab present to those programs with “extremely severe psychological health symptoms,” half of adults with moderate depression and anxiety who do complete cardiac rehab don’t exhibit significant improvements in their psychological symptoms.
“The impact of moderate anxiety and stress on moderate depression has been underestimated, and the effect is bi-directional,” Rao et al. wrote. “These findings confirm depression as a strong predictor of anxiety over and above CAD severity, antidepressant use or clinical characteristics.”
The team suggested comprehensive screening for and treatment of comorbid depression and anxiety after a cardiac event is “essential” for identifying patients at a greater risk of CV mortality. It also gives physicians a chance to address patients’ underlying mental stress, which could vastly improve their prognosis.
“Monitoring depression and anxiety symptoms on entry and during cardiac rehabilitation can assist to improve adherence and may identify the need for additional psychological health support,” the authors wrote. “Exploring the relevance and use of adjunct psychological support strategies within cardiac rehabilitation programs is warranted.”
After graduating from Indiana University-Bloomington with a bachelor’s in journalism, Anicka joined TriMed’s Chicago team in 2017 covering cardiology. Close to her heart is long-form journalism, Pilot G-2 pens, dark chocolate and her dog Harper Lee.