Depression and acute coronary syndromes: gender-related differences

Abstracts

OBJETIVO: Investigar, em portadores de Síndromes Isquêmicas Miocárdicas Instáveis (SIMI) estratificados por sexo, se características sociodemográficas, diagnóstico clínico, tabagismo, consumo de álcool e ansiedade estão associados com depressão. MÉTODOS: Foram entrevistados 345 pacientes consecutivos com SIMI (206 com infarto agudo do miocárdio e 139 com angina instável). As entrevistas incluíram questões sobre características sociodemográficas, tabagismo, avaliação de depressão (Prime MD e BDI), de ansiedade traço e ansiedade estado (IDATE), e de consumo de álcool (AUDIT). RESULTADOS: O diagnóstico de depressão se correlacionou, significativamente, com sexo feminino, idade inferior a 50 anos e escores médios mais elevados de ansiedade traço e ansiedade estado. Os homens (245) com depressão eram freqüentemente mais jovens que 50 anos, fumantes, e apresentavam escore médio de ansiedade traço e ansiedade estado mais elevado que os não deprimidos. A análise multivariada aponta que, no sexo masculino, idade está negativamente associada (OR 0,9519, 95% IC 0,9261 - 0,9784) e escores mais altos de ansiedade traço estão positivamente associados (OR 1,0691 95% IC 1,0375 - 1,1017) com depressão. Na amostra feminina (100), mulheres com depressão diferenciam-se das sem depressão por apresentarem escore médio mais alto de ansiedade traço e de ansiedade estado. Na análise multivariada da amostra feminina, escore mais alto de ansiedade traço associou-se de forma independente à depressão (OR 1,1267 95% IC 1,0632-1,1940). CONCLUSÃO: Conclui-se que, em pacientes hospitalizados com SIMI, as mulheres, os homens com menos de 50 anos e os ansiosos têm mais chance de apresentarem depressão.

depressão; infarto do miocárdio; angina instável; ansiedade

ORIGINAL ARTICLE

Depression and acute coronary syndromes: gender-related differences

Glória Heloise Perez; José Carlos Nicolau; Bellkiss Wilma Romano; Ronaldo Laranjeira

Instituto do Coração do Hospital das Clínicas - FMUSP - São Paulo, SP - Brazil

^{Mailing address}

ABSTRACT

OBJECTIVE: Investigate whether social and demographic characteristics, clinical diagnosis, smoking status, alcohol consumption, and anxiety are associated with depression in patients with Acute Coronary Syndromes (ACS) stratified by gender.

METHODS: Three hundred forty-five consecutive patients with unstable myocardial ischemic syndrome (206 with myocardial infarction and 139 with unstable angina) were interviewed. The interviews included questions about sociodemographics, smoking status, screening for depression (Prime MD e BDI), trait and state anxiety, (IDATE), and alcohol consumption (AUDIT).

RESULTS: Diagnosis of depression has significantly correlated with female gender, age under 50 years, and higher average scores on trait anxiety and state anxiety. Depressed men (245) were usually younger than 50 years of age, smokers and had higher average score on trait anxiety and state anxiety than those non-depressed. The multivariate analysis highlights that age is negatively associated with depression (OR 0.9519 95% CI 0.9261 – 0.9784) and that higher scores on trait anxiety are positively associated (OR 1.0691 95% CI 1.0375 – 1.1017) with depression in the male gender. In the female sample (100), depressed women differ from non-depressed women in that they have a higher average score on trait anxiety and state anxiety. In the multivariate analysis of the female sample, a higher score on trait anxiety was independently associated with depression (OR 1.1267 95% CI 1.0632 - 1.1940).

CONCLUSION: It was concluded that, among hospitalized patients with ACS, women, as well as men under 50 years and who suffer from anxiety are more likely to experience depression.

Keywords: depression; myocardial infarction; unstable angina; anxiety

Coronary heart disease (CHD) and depression have great impact on health, since they are highly prevalent conditions that reflect both on mortality rates and quality of life of contemporary man.

Depression has a complex relationship with CHD. Evidence shows it is a risk factor,^1-4 as well as a contributing factor for morbidity,¹ mortality^3,5-7 and quality of life⁸ of the CHD patient.

In a meta-analysis study, which included data published between 1945 and 1985⁹, depression was associated with CHD and considered the highest psychological risk for heart disease. Regarding the association between CHD and depression, literature shows a prevalence ranging from 14 to 60%^1,5,7, with 15 and 44%^3,5,10,11 among patients with myocardial infarction or unstable angina.

Despite being an isolated risk factor for the development of CHD, depression is often associated with other risk markers. Studies conducted with non-cardiac populations point to an association with obesity (prevalence of depression in 51% of obese subjects with Binge Eating Disorder (BED) and in 14% of non-BED obese subjects)¹², diabetes (a three-fold higher prevalence of depressed subjects among diabetics than in the general population)¹³ and cigarette smoking (prevalence ranging from 18.5 to 60.6%)¹⁴.

Depression may also affect the development and course of CHD, as emphasized by Glassman and Shapiro², since in addition to the negative impact of the depressed mood in the management of heart disease, evidence shows that its physical concomitants have a direct effect on heart function. Discouragement, apathy, intolerance to frustrations and inflexible thinking, all typical of depressed mood, create unfavorable conditions that make the patient unmotivated to comply with drug therapy and change in lifestyle. Additionally, the physiological changes associated with depression, such as enhanced platelet aggregation, sympathoadrenal hyperactivity, reduction in heart rate variability and decrease in ventricular fibrillation threshold, directly affect the progression of CHD¹⁵. These pathophysiological mechanisms, together with failure to comply with treatment and changes in lifestyle, account for the higher risks of myocardial infarction (MI) recurrence and increased mortality rates among depressed patients.

It must be emphasized that depression tends to be poorly recognized by cardiologists in patients with CHD, because it is not always that it presents itself in its typical form, with symptoms of depressed mood, marked lack of interest or pleasure in usual activities, feelings of worthlessness or guilt, recurrent thoughts of death, and suicidal ideation. On the contrary, somatic symptoms, such as tiredness, lack of energy, psychomotor retardation, loss or increase of appetite, insomnia, and hypersomnia, are more common and can be mistaken for the heart disease symptomatology. It is also important to consider that depression might present itself in its atypical form, for example, with irritability, hyperphagia and hypersomnia, rather than loss of appetite and insomnia, respectively. All these characteristics of the depressive symptoms in CHD patients determine a tendency towards failure in diagnosis and treatment.

Studies conducted with non-cardiac patients also suggest that depressed patients find it more difficult to quit smoking¹⁶ and alcohol abuse¹⁷. Thus, the recognition and treatment of depression may significantly reduce failure in the management of heart disease.

Evidence regarding the broad, negative impact of depression on the development, course, severity, and treatment of CHD warns us of the benefits derived from further knowledge on the peculiarities of depression associated with CHD. Studies performed with foreign populations show that depression in patients with MI or unstable angina is associated to the same psychosocial factors observed in non-cardiac patients: women, unmarried, no close friends^3,18. Unlike non-cardiac patients, however, depression is not associated with cigarette smoking in CHD patients^3,19. As far as we know, no studies on the subject have been conducted among Brazilians with unstable myocardial ischemic syndrome.

Therefore, this study aimed at investigating whether sociodemographic characteristics, clinical diagnosis, smoking status, alcohol consumption, and anxiety are associated with depression in a population of patients with Acute Coronary Syndromes (ACS), comparing men and women.

METHODS

The study protocol was submitted to and approved by the Research Ethics Committee of the institution in which it was performed on May 10^th, 2000.

The study was performed with a sample of 345 consecutive patients diagnosed with ACS, 206 with myocardial infarction (MI) confirmed by clinical and electrocardiographic findings and/or biochemical markers of myocardial necrosis and 139 with unstable angina (UA). All patients were hospitalized and had been contacted while still in the Emergency Room or in the Intensive Coronary Care Unit between July 2000 and July 2001.

After informed consent was obtained, a research psychologist assistant conducted the interviews, always during the admission period, from the third day in case of MI or from the second day of onset in case of unstable angina. Patients with co-existent severe non-cardiac condition, cognitive deficit, use of antidepressant and older than 80 years were excluded from the study.

To prevent any possible bias from the psychological stress caused by examination, the interviews were not conducted in the same day of the hemodynamic study. They were conducted, on average, 4.15 + 1.56 days post MI. Patients with UA were interviewed, on average, within 2.94 + 1.30 days. This study includes partial data from an investigation into factors associated with and predictive of smoking maintenance in patients with ACS, and this explains a sample of 135 smokers, 109 ex-smokers and 104 non-smokers. Twenty-four patients refused to participate in the study.

The interview included:

• A questionnaire designed to collect sociodemographic data and smoking history.

• Critério de Classificação Econômica Brasil CCEB (Brazilian Criterion of Economic Classification) for the evaluation of financial status¹⁶.

• Prime MD – Primary Care Evaluation of Mental Disorders (mood module),¹⁷ version translated into Portuguese by Fráguas Jr. e Henriques Jr., and a short scale (17 items) for diagnosing mood disorders, based on the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV), developed for primary care research.

• The Beck Depression Inventory (BDI)^18,19 scale to diagnose depression. This is a 21-item scale with scores ranging from 0 to 3 designed to assess the presence and severity of depressive symptoms, yet inappropriate to diagnose depression. The cut-off point used was: <10, for no or minimal depression; 10 to 18 for mild to moderate depression; 19 to 29 for moderate to severe depression; 30 to 63 for severe depression.

• IDATE state-trait anxiety inventory to measure trait anxiety and state anxiety²¹. This inventory consists of two scales, each one containing 20 items. One of the scales evaluates state anxiety, characterized by subjective feelings of tension and apprehension, followed by autonomic nervous system responses²² at a given moment. Trait anxiety, assessed by the other scale, refers to a relatively stable tendency to perceive situations as threatening and react anxiously to them. Given the difficulties faced by the studied population to deal with a five-point Likert-type scale, (such as IDATE), detected in a previous study²³, we have created cards depicting graphically all the alternatives.

• AUDIT - The Alcohol Use Disorder Identification Test²⁴, version translated by Figlie,²⁵ is a ten-item questionnaire with scores ranging from 0 to 40 that assess alcohol consumption, abuse and dependence.

The chi-square test was used in the univariate analysis to compare categorical variables: gender, age group, level of education, socioeconomic status, clinical diagnosis, smoking status, and BDI score. Student's t-test was used to compare mean values for age, AUDIT score (alcohol consumption), and IDATE score (trait anxiety and state anxiety). Equality of variances was checked by Levene's test, when necessary. A p-value < 0,05 was considered statistically significant.

Considering depression (Prime-MD) a dependent variable, the significant variables in the univariate analysis were evaluated in three logistic regression models: with the total sample, male sample and female sample. The Stepwise method was used, and the statistically nonsignificant variables were removed according to Wald test.

The significant variables for depression in the univariate analysis, considered as independent variables in the multivariate analysis of the total sample, were gender, age, state anxiety and trait anxiety. Age, smoking, state anxiety and trait anxiety were the independent variables included in the logistic regression model of the male sample; whereas trait anxiety and state anxiety were included in the female sample.

Statistical treatment was performed using SPSS for Windows 8.0.

RESULTS

The mean age of the population sample was 59.45 + 10.52 years, male predominance, 71% (n = 245); living with a partner, 69.2% (n = 240); with low education level, up to elementary and middle school (K-8) 55.9% (n = 193) and belonging mostly to C, 24.4% (n = 84) and B2, 24 % (n = 83) socioeconomic classes (table I)

Depression rate was 46.7% (n = 161). Patients diagnosed with depression had lower mean age (p = 0.003), were usually under 50 (p = 0.009), mostly female and had higher trait (p < 0.001) and state anxiety mean scores (p < 0.001) (table I)

BDI results demonstrate that women were more likely to have higher levels of depression than men (p < 0.0001) (table II).

Multivariate analysis shows that female gender (OR 2.4026, 95% CI 1.4424 4.0020), age below 50 years (OR 1.9722 95% CI 1.1055-3.5185), and higher scores on trait anxiety (OR 1.0825 95% CI 1.0541 1.1117) were significantly associated with depression.

Univariate analysis of the male sample shows that those with depression were often younger (p < 0.0001), below 50 years of age (p=0.001), smokers (p=0.018), and had mean trait anxiety scores (p<0.001) and higher state anxiety scores than those non-depressed (table III).

Multivariate analysis suggests that age is negatively associated with depression (OR 0.9519, 95% CI 0.9261 – 0.9784) and that higher scores on trait anxiety are positively associated (OR 1.0691 95% IC 1.0375 – 1.1017) with depression.

The univariate analysis of the female sample revealed that the only difference between depressed women and non-depressed women is that the former have higher mean score on trait anxiety (p < 0,0001) and state anxiety (p = 0,001) (table IV).

In the multivariate analysis, a higher score on trait anxiety was significantly associated with depression (OR 1.1267, 95% CI 1.0632-1.1940).

DISCUSSION

A high prevalence of depression (46.7%) was observed in the population studied, higher than the one found in other studies conducted with ACS patients, whose results ranged from 15 to 44%^3,5,14,15. This difference cannot be explained by the age factor, since it was very similar to that of other studies^3,5. Rather, it may be justified by the use of different instruments or evaluation criteria or the large number of male smokers (who tend to be more depressed than non-smokers) included in the sample. On the other hand, it may be a distinguishing trait of Brazilian samples; yet, we cannot corroborate this hypothesis due to the lack of previous studies on the subject.

While for some variables, such as education level, marital status, financial status, clinical diagnosis, alcohol consumption, trait anxiety and state anxiety, the relationship with depression for both genders has the same pattern, relevant differences were detected in some aspects. For example, women are more likely to experience depression, and in higher levels, than men.

The higher prevalence of depressive disorders among women is in keeping with literature data, which evaluated foreign populations^6,19,21,28. It is also suggested that this might be associated to the higher in-hospital mortality of female gender ^31,33.

Possible explanations for the higher prevalence of depressive disorders in women range from statistical artifacts, since they are more inclined to seek help and feel more at ease to report emotional aspects (thus contributing to the diagnosis), to biological and psychosocial aspects. Among the biological aspects, the importance of hormonal factors, genetic inheritance and differences in brain structure and function is postulated³³. Psychosocial factors refer to different lifestyle and psychological mechanisms, as well as the family and social roles of women in view of the changing social environment and growing professional demands³⁴.

Depression is associated with age in the male gender, but not in the female gender. Men under 50 with ACS are more likely to get depressed than older men. The emotional impact of a serious condition such as MI or UA in a productive age can account for the increased rate of depression among younger men. The psychological impact caused by an MI or UA episode on younger men, such as loss of the healthy status and of the productive capacity and, ultimately, the fear of dying, may be higher than on older men, depression being a manifestation of this impact. On the other hand, it may be considered that younger men, due to cultural issues related to the male stereotype, find it less difficult to perceive and express their feelings of fragility (thus reporting a depressive symptoms) than older men, for whom the internalized concept of masculinity is associated with the non-manifestation of emotions³⁵.

Another point to be considered, to justify the association between depression and younger ages, is the possible impact of a depressive disorder that might have been installed before the patient's cardiac condition became unstable. In this case, being depression a risk factor for CHD, the earlier onset of ACS in depressed patients compared to those non-depressed could be explained. Nevertheless, since history of depression was not investigated in this protocol, this hypothesis cannot be confirmed. Considering the differences of our results with those obtained with foreign populations, an association with age, ^18,19 rather than with lack of a partner, was observed^18,19.

In this study, depression is associated with trait anxiety for women and men alike. This association is understood by the fact that trait anxiety is a characteristic of mental function, including the relatively constant subjective perception of feelings of tension and apprehension, and the revealing sign of lack of psychological resources and limited ability to cope with adverse situations, thus determining a higher predisposition to depression.

Our data reinforce the importance of screening for depressive symptoms in patients admitted with ACS, especially women as well as men under 50 and who suffer from anxiety. Preventing failure in diagnosis and management of depression may be important to a more favorable outcome for patients with CHD, reducing the risks of noncompliance with treatment, recurrence and mortality from ACS.

Besides allowing a richer discussion of our data, the inclusion of depression history and onset of the current condition into the investigation might confirm some of the hypothesis raised.

It was concluded that, in patients admitted with ACS, women, as well as men under 50 years who suffer from anxiety, are more likely to experience depression.

REFERENCES

19. www.anep.org.br/codigosguias/CCEB.pdf

Received on 11/03/04

Accepted on 04/04/05

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Publication Dates

• Publication in this collection
  05 Dec 2005
• Date of issue
  Nov 2005

History

• Received
  03 Nov 2004
• Accepted
  13 Apr 2005