Association of depression symptoms with quality of life and chronic artery vasculopathy: A cross-sectional study in heart transplant patients,☆☆

https://doi.org/10.1016/j.jpsychores.2014.06.007Get rights and content

Highlights

  • Depression symptoms are prevalent in patients long-term after heart transplantation.

  • Depression symptoms are associated with decreased quality of life.

  • Chronic artery vasculopathy (CAV) was not related to depression symptoms.

  • Overweight, longer time since transplant, and older age were associated with (CAV).

Abstract

Objective

Depression represents a relevant co-morbidity in patients with chronic heart disease and may diminish the overall success for long-term survival after heart transplantation (HTx). This study aimed to assess the prevalence of depression symptoms in long-term HTx survivors, and to compare depressive patients to those without depression with respect to chronic artery vasculopathy (CAV).

Methods

A sample of 203 HTx patients, median 11.5 (IQR 7–17) years after transplant, provided detailed data of depression symptoms, and other psychosocial symptoms including anxiety, family support, professional re-integration, and health-related quality of life (HRQoL). Data were analyzed for an association with CAV.

Results

Overall, 14.8% patients (95% CI: 10.2–20.4) showed relevant depression symptoms. No significant differences were seen between non-depressed vs. depressed patients with respect to demographics, clinical variables, and cardiovascular risk factors. Anxiety was prevalent in 9.0% (95% CI: 5.4–13.9) of the sample. Depression symptoms showed impaired HRQoL in the SF-36 physical (P = .012) and psychosocial (P = .0001) components. CAV was prevalent in 34.0% (95% CI: 27.5–41.0), and depression symptoms and CAV were not significantly associated. CAV-patients did not report their physical HRQoL being lower relative to those without CAV (P = .40). Multivariate analysis revealed overweight BMI (OR = 2.20; P = .04), longer time since transplant (OR = 1.10; P = .001), and older age (OR = 1.04; P = .01) being associated with CAV.

Conclusion

Depression symptoms are prevalent in long-term survivors after HTx, and psychological impairments decrease patients' perceptions of HRQoL. More research seems necessary to identify the inter-relationship between depression symptoms and CAV, in order to develop targeted interventions to overcome this problem.

Introduction

Depression holds the potential to diminish the overall success after heart transplantation (HTx) [1], [2], [3], [4], [5], [6], [7], [8]. Prevalence rates for depression in HTx recipients range between 9 and 37% [2], [3], [4], [5], thus representing a significant risk factor for morbidity and mortality [3], [5], [6], and impaired quality of life outcomes [9], [10], [11], [12]. Patients with depression show lower physical activity levels, and lower adherence rates to medication intake, and to other aspects of the treatment regimen following transplantation [13]. These factors, in addition to poor adherence in the areas of diet, exercise, and weight control may contribute to the development and progression of coronary artery vasculopathy (CAV) representing one of the major limiting factors for the overall survival after HTx [1], [4].

However, drawing firm conclusions from the literature is limited due to differing or missing definitions of depression, different study designs and sampling strategies used, small case series, diversity of samples with respect to factors potentially impacting depression, and instruments used to detect depression symptoms. More precisely, Dew et al. [2] defined depression according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV14), classifying their patients for ‘major depression disorders’. In contrast, other studies [3], [11], [15], [16] used several clinical screening instruments to assess prevalence rates of depressive symptoms not covering the full range for DSM-IV depressive disorders [17]. These rates do not qualify as ‘major depression disorders’. However, the term ‘depression’ is often used interchangeably for ‘major depression disorders’ assessed according to the DSM-IV, and ‘depression symptoms’ based on clinical screening. This may or may not have impacted the range of prevalence rates available to date. In line with the research question for this study the authors refer to ‘depression symptoms’ for this study.

In an early study by Dew et al. [1] persistent depression did elevate the risk of incident CAV in 145 US-American HTx recipients. In a more recent Norwegian study, the impact of depression on all-cause mortality after HTx showed an increased mortality risk for those with elevated depression levels [5]. Apart from these two studies, there is no evidence on the inter-relationship of these important outcome parameters available. Generalizability is limited by differing cultural backgrounds of these two patient populations. Our study aimed first, to assess the prevalence of symptoms of depression in a sample of HTx recipients, and second, to compare depressive patients with those without symptoms of depression with respect to the presence or absence of CAV.

Section snippets

Design and setting

Using a cross-sectional study design, a detailed assessment of symptoms of depression and other psychosocial symptoms including anxiety, social support, professional re-integration, and health-related quality of life (HRQoL) has been performed. Data were analyzed for their association with the presence or absence of CAV.

Potential study subjects were informed verbally and by a written informed consent form about the purposes of this study. Those consenting received a coded battery of

Patient characteristics

Median age of the overall sample was 63 years, ranging between 20 and 82 years. The majority were male (80.3%). CAV was diagnosed in 34.0% (n = 69) of the sample (95% CI: 27.5–41.0). Of these, 27 study subjects needed CAV interventional therapy, either coronary angiography with (n = 23) or without stent (n = 1), and coronary bypass surgery (n = 3) due to CAV. Patient characteristics include relevant demographic and clinical variables, and cardiovascular risk factors (Table 1). Recently, five patients had

Discussion

In this study, the overall prevalence for depression symptoms was 14.8%; and 9.0% for anxiety symptoms in patients after HTx. Psychological impairments were strongly associated with decreased perceptions of patients' HRQoL in the physical and psychosocial domain. Psychological assessment was based on psychometrically sound PRO instruments. Patient-related and clinical variables did not influence the presence or absence of depression symptoms. Although CAV was prevalent in 34.0% of patients, no

Conflict of interest statement

The funding sources had no influence on the design or conduct of the study; collection, management, and analysis or interpretation of the data; or the preparation, review, or approval of the manuscript. The authors have no competing interests to report.

Acknowledgments

This study was supported by grants from the Nursing and Social Sciences Research Grant 2011 by the International Society for Heart and Lung Transplantation and the German Federal Ministry of Education and Research (01EO0802).

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    Hannover Thoracic Transplant Program.

    ☆☆

    Work conducted at: Hannover Thoracic Transplant Program.

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