Transcript Cardiovascular disease in a large cohort of depressed and

Cardiovascular disease in persons with
anxiety or depressive disorders
Nicole Vogelzangs1,2, Adrie Seldenrijk1,2, Aartjan TF Beekman1,2,
Hein PJ van Hout1,3, Peter de Jonge4, Brenda WJH Penninx1,2
Journal of Affective Disorders, Epub
EMGO Institute and Department of 2 Psychiatry, 3General Practice,
VU University Medical Center, Amsterdam, The Netherlands
4 Department of Psychiatry, University Medical Center Groningen, The Netherlands
1
Burden of disease in Western countries
2030
1
2
3
4
5
6
7
8
9
10
Disease
Depression
Heart disease
Alzheimer, dementia
Alcohol problems
Diabetes
Stroke
Hearing problems
Cancer
Arthritis
Lung disease
* DALYs = disability-adjusted life years =
lost life years + lost quality of life
% DALYs*
9.6%
5.9%
5.8%
4.7%
4.5%
4.5%
4.1%
3.0%
2.9%
2.5%
WHO: Mathers et al.
Plos Medicine 2006
Depression as risk factor for CVD
General population
Proof from systematic reviews
Review
#
studies
#
persons
RR
Rugulies, 2002
11
36 549
1.64
Wulsin, 2003
10
28 737
1.64
Nicholson, 2006
21
124 509
1.81
Van der Kooy, 2007
28
±80 000
1.60
Rugulies Am J Prev Med 2002
Wulsin & Singal Psychosom Med 2003
Nicholson et al. Eur Heart J 2006
Van der Kooy et al. Int J Geriatr Psychiatry 2007
Depression and CVD prognosis
CVD patients
Proof from systematic reviews
Review
#
studies
#
persons
RR
Barth, 2004
20
11 018
2.24
Van Melle, 2004
16
6 367
2.59
Nicholson, 2006
34
17 842
1.80
Barth et al. Psychosom Med 2004
Van Melle et al. Psychosom Med 2004
Nicholson et al. Eur Heart J 2006
Relatively unknown

Prevalence of CVD in population of
depressed and anxious persons

Association anxiety disorders and CVD

Which characteristics of depression and
anxiety are linked with CVD
Netherlands Study of Depression and Anxiety
www.nesda.nl
funded through the mental health program of the Netherlands
Organization for Health Research (ZonMW)
and matching funds from participating institutes
Design & Sample NESDA
Design
Naturalistic cohort study
 Baseline assessment and follow-up assessments
after 1, 2, 4, 6, 8 years

Sample

Depressed and/or anxious persons (18-65 years) from
community, primary care, and outpatient
psychiatric clinics (n=2329) and healthy controls (n=652)

2981 persons; 1979 women
(66%),
1002 men
(34%)
Sample selection

Exclusion of
– persons with depressive or anxiety symptoms
but no diagnosis (subthreshold symptoms;
n=158)
– Persons with self-reported CVD without heart
medication (n=16)
=> 2807
Psychopathology
CIDI psychiatric interview (DSM-IV)

Presence (& subtype),
current (1 year) or remitted:
– Depressive disorder (dysthymia, major depressive
disorder [MDD; single, recurrent])
– Anxiety disorder (generalized anxiety disorder, social
phobia, panic disorder and/or agoraphobia)

Additional subtype specifiers
– Late age of onset (≥ 30 years)
– Atypical symptoms (based on IDS)
– Melancholic symptoms (based on IDS)
Clinical characteristics

Duration:
– % of time affected of past 48 months, life chart

Severity:
– Inventory of Depressive Symptoms (IDS), 0-84
– Beck Anxiety Inventory (BAI), 0-63

Psychoactive medication:
–
–
–
–
Selective serotonin reuptake inhibitor (SSRI)
Tricyclic antidepressant (TCA)
Other antidepressant
Benzodiazepine
Cardiovascular disease

Stroke and/or coronary heart disease (CHD):
– self-report of stroke supported by use of
anticoagulant, antiplatelet, antihypertensive or lipid
modifying agent;
– self-report of myocardial infarction or angina pectoris
(symptoms) supported by use of beta blocker, nitrate
vasodilator, calcium channel blocker, anticoagulant or
antiplatelet agent;
– self-report of coronary angioplasty or bypass surgery.
Baseline characteristics
No CVD
Age (years)
Women (%)
Education (years)
Smoking status
never smoker (%)
former smoker (%)
current smoker (%)
Alcohol intake
< 1 drink/week (%)
1-14 drinks/week (%)
> 14 drinks/week (%)
Physical activity (MET-min/wk)
BMI
(n=2651)
CVD
(n=156)
p
41.1 (12.9)
67.7
12.2 (3.3)
54.1 (7.8)
45.5
11.0 (3.2)
<.001
<.001
<.001
28.4
32.3
39.3
18.6
46.2
35.3
.001
32.2
52.1
15.7
3720 (3046)
25.4 (5.0)
37.8
42.3
19.9
3423 (3198)
28.6 (4.8)
.05
.24
<.001
Adjusted OR for CVD
No depression
Remitted depression
Current depression
N
847
693
1267
No anxiety
Remitted anxiety
Current anxiety
1046
408
1353
No depression/anxiety
Remitted depression/anxiety
Current depression only
Current anxiety only
Current depression + anxiety
492
544
418
504
849
OR*
1.50
1.59
95% CI
REF
0.93-2.40
1.02-2.47
p
.10
.04
1.31
2.18
REF
0.74-2.30
1.45-3.28
.35
<.001
1.27
0.93
1.96
2.35
REF
0.68-2.37
0.44-1.96
1.06-3.64
1.33-4.20
.45
.85
.03
.004
* Adjusted for age, sex, education, smoking, alcohol use, physical activity and BMI
Adjusted OR for stroke and CHD
Stroke
No dep/anx
Remitted dep/anx
Current dep only
Current anx only
Current dep+anx
OR*
95%CI
0.73
0.53
1.02
1.37
REF
0.24-2.19
0.13-2.18
0.34-3.11
0.49-3.86
CHD
p
.57
.38
.97
.55
OR*
1.65
1.41
2.70
3.54
95% CI
p
REF
0.79-3.43 .18
0.61-3.23 .42
1.31-5.56 .007
1.79-6.98 <.001
* Adjusted for age, sex, education, smoking, alcohol use, physical activity and BMI
OR* for CHD in persons with a
current depressive and/or anxiety disorder
OR
5
4
3
2.40
2
1.77
1
0
Current
depressive disorder
N = 418
Current
anxiety disorder
N = 504
* Adjusted for age, sex, education
Current depressive
and anxiety disorder
N = 848
Depression and anxiety
characteristics and CHD
N = 1770
OR*
95% CI
p
Type of depressive disorder
-
-
-
Type of anxiety disorder
-
-
-
Chronicity
-
-
-
1.32
1.36
1.05-1.65
1.11-1.66
.02
.003
-
-
-
Severity
Depressive symptoms score (IDS)
Anxiety symptoms score (BAI)
Psychoactive medication
* Per SD increase, adjusted for age, sex, education
Conclusions

Coronary heart disease is more prevalent among
depressed and particularly anxious persons

The association of depression with CHD was
largely owing to comorbidity with anxiety

The highest CHD prevalence was found among
those with the most severe anxiety and
depressive symptoms
Discussion

Cross-sectional design
– No effects of symptom duration on CHD risk
– CHD also increased among those with disorder onset
before 30 years

Anxiety (alone or comorbid to depression) as
risk indicator for CHD deserves more attention in
research as well as clinical care