Significance of Comorbid Psychological Stress and Depression on Outcomes After Cardiac Rehabilitation

Background

Depression is associated with increased mortality in stable coronary heart disease. Cardiac rehabilitation and exercise training has been shown to decrease depression, psychological stress, and mortality after a coronary heart disease event. The presence of depression at completion of cardiac rehabilitation and exercise training is associated with increased mortality. However, it is unknown if depression with comorbid psychological risk factors such as anxiety or hostility confers an additional mortality disadvantage. We evaluated the mortality effect of anxiety and hostility on depression after cardiac rehabilitation and exercise training.

Patients and Methods

We studied 1150 patients with coronary heart disease following major coronary heart disease events who had completed formal cardiac rehabilitation and exercise training. Using Kellner questionnaires, stress levels were measured in 1 of 3 domains: anxiety, hostility, and depression (with an aggregated overall psychological stress score) and divided into 3 groups: nondepressed (n = 1072), depression alone (n = 18), and depression with anxiety or hostility (n = 60). Subjects were analyzed for all-cause mortality over 161 months of follow-up (mean 6.4 years) by National Death Index.

Results

Depression after cardiac rehabilitation was not common (6.8%; mortality 20.8%) but when present, frequently associated with either anxiety or hostility (77% of depressed patients; mortality 22.0%). After adjustment for age, sex, ejection fraction, and baseline peak oxygen consumption, depression alone (hazard ratio [HR] 1.73, P = .04), as well as depression with comorbid psychological stress, was associated with higher mortality (HR 1.98, P = .03). Furthermore, our data showed an increased mortality when both anxiety and hostility were present in addition to depression after cardiac rehabilitation (HR 2.41, P = .04).

Conclusions

After cardiac rehabilitation, depression, when present, is usually associated with other forms of psychological stress, which confers additional mortality. More measures are needed to address psychological stress after cardiac rehabilitation.     

心脏康复措施的现状及研究进展

目前,心脏康复的各种措施在不断完善,但仍相对滞后,尤其在我国呈现出临床医学发展迅速而康复医学相对落后的现象.然而,不论对社会还是个人而言,心脏康复带来的效益巨大而又长远.文章综述了心脏康复措施研究的现状及进展.     

心理干预对抑郁症患者康复效果的影响

目的探讨心理干预对抑郁症患者康复效果的影响。方法将60例抑郁症患者随机分为干预组和对照组,每组30例,对照组进行常规治疗与护理,干预组在此基础上进行心理干预治疗。6周后应用汉密顿抑郁量表(HAMD)及护士观察量表(NOSIE)进行评定。结果治疗6周后,干预组中社会能力、社会兴趣、个人清洁度等分值明显高于对照组(P0.05),差异有统计学意义。结论心理干预可以促进抑郁症患者的治愈及社会功能的恢复,对抑郁症患者的治愈有积极的临床意义。     

心脏康复与内皮祖细胞的关系

心脏康复是一个综合项目,其内容涵盖了病情评估、心血管疾病危险因素控制、药物治疗、心理干预、运动训练、疾病教育等。尽管心脏康复的获益已为大量研究所证实,但其具体机制迄今为止仍未完全阐明。目前,内皮祖细胞对心血管的保护作用已得到肯定,且已有研究证实了心脏康复可有效改善内皮祖细胞的功能及数量,这有望解释心脏康复的具体获益机制。因此,文章总结了心脏康复与内皮祖细胞的关系,旨在为探讨心脏康复的获益机制提供新的借鉴。     

国内外心脏康复发展模式及展望

本文首先讲解了心脏康复的定义,并且分析心脏康复的国内外模式,进一步分析了心脏康复的国内发展现状,以及国内不同地域的心脏康复发展现状,并且讲述了中医药在心脏康复中的优势,并对中国未来的心脏康复模式进行了展望。     

Current Trends in Reducing Cardiovascular Disease Risk Factors From Around the World: Focus on Cardiac Rehabilitation in Brazil

Cardiovascular diseases (CVD) are among the leading causes of morbidity and mortality in Brazil. Cardiac rehabilitation (CR) is a program composed of structured exercise training, comprehensive education and counseling to positively impact functional, psychological, social, and quality of life aspects in these patients. However, the delivery of formal CR programs is limited to major metropolitan centers in Brazil and does not exist in much of the national territory, specifically in the North and Northeast regions. Barriers to the inclusion of qualified patients are lack of referral by the health professionals, as well as transportation difficulties, low income, lack of insurance coverage, and low educational level. Government efforts to implement CR programs on a broader scale, to reach a larger portion of the CVD population, are imperative. Additional research must be focused on the assessment of CR referral and adherence patterns as well as the effectiveness of different CR delivery models.     

抗抑郁治疗对老年脑卒中后抑郁及康复的影响

目的　观察抗抑郁治疗对老年缺血性脑卒中后抑郁症状及神经功能康复的影响。　方法　老年脑卒中后抑郁患者 178例分为百忧解 (氟西汀 )治疗组 6 4例、阿米替林治疗组 5 8例及对照组 5 6例 ;3组均行常规脑血管病治疗 ,百忧解治疗组加用百忧解每天 1次晨服 ,剂量 2 0～ 80mg ;阿米替林治疗组加用阿米替林每天 2次 ,剂量 5 0～ 10 0mg。于治疗前 ,治疗后第 1、2、4、8周 ,3、6、12个月分别进行汉密尔顿抑郁量表 (HAMD)评分和神经功能缺损、日常生活能力 (ADL)评定。　结果　第 2周HAMD评分百忧解治疗组从 2 7 7± 6 9降至 17 3± 5 9,阿米替林组从 2 6 9± 6 9降至 15 7± 4 2 ,较治疗前和对照组明显降低 (P <0 0 5 ) ;第 12周神经功能缺损百忧解组降至 11 8± 5 7,阿米替林组降至 11 9± 6 1,较治疗前及对照组均明显降低 (P <0 0 5 ) ;3个月后日常生活能力指数百忧解组上升到 6 9 0± 5 1,阿米替林组上升到 6 7 0± 6 2 ,较治疗前及对照组亦明显改善 (P <0 0 5 ) ;而且治疗组并发症明显少于对照组 (P <0 0 1) ,脑卒中复发及死亡均低于对照组 (P <0 0 1)。百忧解与阿米替林疗效相近 ,但不良反应明显低于阿米替林。　结论　抗抑郁治疗能有效地控制老年脑卒中后抑郁症状 ,百忧解对老年卒中后     

米氮平治疗急性卒中后抑郁的疗效及其对康复的作用

目的观察米氮平治疗急性卒中后抑郁的疗效及其对卒中康复的影响。方法109例急性卒中后抑郁患者随机分为米氮平组（55例）和对照组（54例），两组患者均接受常规药物治疗，米氮平组同时加用米氮平治疗。治疗前后应用Hamilton抑郁量表（HRSD）评价抑郁状况，治疗前、治疗后4周末和12周末，采用简易智能状态量表（MMSE）、中国卒中量表（CSS）和Barthel指数（BI）评价患者的认知和神经功能状况。结果治疗后12周末，米氮平组患者痊愈35例（64％），总有效52例（95％）；对照组患者痊愈9例（17％），总有效31例（57％），两组比较差异有统计学意义（x^2=6．75、5．52，P〈0．05）。治疗后4周末和12周末时，米氮平组MMSE评分较对照组显著增加（t=2．93、3．12，P〈0．01）；治疗后4周末，两组CSS和BI评分均有改善，但差异无统计学意义；治疗后12周末，米氮平组CSS和B1评分均优于对照组（t=5．02、10．25，P〈0．01）。米氮平的主要不良反应为中枢神经系统和消化系统反应，但症状轻微。结论米氮平治疗卒中后抑郁安全有效，且能改善12周末时的认知功能和神经功能。     

The impact of depression medications on oral antidiabetic drug adherence in patients with diabetes and depression

Aims

To compare adherence and persistence to oral antidiabetic drugs (OAD) between patients who are new users of second generation antipsychotics (SGA) versus new users of other depression therapies in adults with type 2 diabetes mellitus (T2DM) and major depressive disorder (MDD).

The psychological impact of permanent cardiac pacemakers on pediatric patients and their parents: A case control study

BackgroundThis study assessed anxiety and depression in children with permanent pacemakers (PPM) and quality of life of their parents.MethodsNinety children (63.3% males and 36.6% females) and their parents were included in the study and were divided into three groups. The control group (Group 1) included 30 normal healthy children (57% males and 43% females), the PPM group (Group 2) included 30 age-matched children (70% males and 30% females) with PPM and structurally normal heart, while the Group 3 included 30 children (63% males and 37% females) with PPM and congenital heart disease (PPM + CHD). Psychological assessment of children and their parents was carried out using an interview-based questionnaires.ResultsPsychiatric disorders were more prevalent in PPM + CHD group including depression (P = 0.04), anxiety (P = 0.02) and lower parents’ QoL (P = 0.01). The PPM group had higher depression and lower parents’ QoL than the control group. Family income was independent factor for depression (r2 = −6.3, with P < 0.05). Sex of the child and CCU admission were independent factors for anxiety (r2 = −9.5, P < 0.05 & r2 = 10.5, P = 0.001) in PPM group.ConclusionChildren with pacemakers have higher psychiatric disorders and their parents have lower QoL.     

心脏康复促进冠状动脉搭桥术后患者体能恢复及不良情绪改善

目的观察心脏康复治疗对冠状动脉搭桥术后患者运动功能及不良情绪的改善作用。方法心脏外科拟行冠状动脉搭桥手术患者52例,将其随机分为康复组及对照组。两组患者均接受常规治疗,康复组在上述基础同时给予运动训练及心理干预。于术前、术后15天对入选患者进行6 min步行实验(6MWT)、左心室射血分数、汉密尔顿焦虑量表(HAMA)和汉密尔顿抑郁量表(HAMD)评定。结果与对照组比较,术后15天康复组患者6MWT明显提高(298.15±59.24 m比220.80±54.25 m,P<0.01),HAMA及HAMD评分显著降低(2.07±2.45分比5.48±3.32分及2.26±2.31分比6.36±3.81分,P<0.01)。与术前比较,康复组术后左心室射血分数也有改善(P<0.01);进一步分析发现,患者手术前后6MWT差值与手术前后HAMA及HAMD评分差值具有负相关性(r=-0.53,P<0.01;r=-0.60,P<0.01)。结论心理干预联合运动训练对冠状动脉搭桥术后患者不良情绪改善及运动能力恢复均有促进作用,值得临床推广应用。     

抑郁症与抑郁/焦虑共病患者的人格特征及社会支持对比研究

目的 探讨抑郁症与抑郁/焦虑共病患者的人格特征及社会支持的特点及与正常人的差异.方法 对同时符合美国精神疾病和统计手册第四版(DSM-IV)抑郁障碍和焦虑障碍诊断标准的36例患者(共病组)与33例仅符合抑郁障碍诊断者(抑郁症组)分别进行艾森克个性问卷(EPQ)和社会支持评定量表(SSRS)评定,并与30名正常人(正常组)对照,然后进行对比分析.结果 共病组和抑郁症组的EPQ-N、L因子分均高于正常组,EPQ-E因子分低于正常组,差异有显著性(P《0.05或P《0.01),SSRS总分及主观支持和对支持利用度两个因子分均低于正常组(P《0.05或P《0.01).共病组与抑郁症组的EPQ和SSRS总分及因子分组间差异无显著性(P》0.05).结论 抑郁症与抑郁/焦虑共病患者均具有神经质、内向和过度掩饰的个性特征,需要更多的社会支持.     

The impact of incident depression on medication adherence in patients with type 2 diabetes

BackgroundDepression has been correlated with suboptimal adherence to antidiabetic drugs (ADs). Most studies on this topic were cross-sectional; thus, the directionality of this relationship could not be established. The objective of this study was to measure the association between incident depression and AD nonadherence among newly treated patients with diabetes.MethodsWe performed a population-based cohort study among new AD users using the Quebec public health insurance data. To avoid immortal time bias, we carried out depression diagnosis-time distribution matching by assigning a date of depression diagnosis to individuals without depression. Nonadherence (i.e., < 90% of days covered by ≥ 1 AD) during the year following depression diagnosis (real or assigned date) was the outcome. Multivariate logistic regression analyses that adjusted for baseline adherence and other confounders were used to estimate the adjusted effect of depression on AD nonadherence.ResultsBetween 2000 and 2006, we identified 3,106 new AD users with a subsequent diagnosis of depression and 70,633 without depression, of which 52% and 49% became non-adherent to AD treatment, respectively. Among patients with depression, 52.0% were considered AD non-adherent in the year after depression diagnosis compared with 49.0% of matched patients without depression. Depression was associated with AD nonadherence after accounting for baseline adherence and other confounders with an adjusted odds ratio of 1.24 (95% confidence interval: 1.13–1.37).ConclusionsThe results suggest that depression is an independent risk factor for AD nonadherence. Patients with type 2 diabetes and depression might benefit from adherence-enhancing interventions.     

心理干预结合盐酸帕罗西汀对冠脉介入治疗后患者焦虑、抑郁的影响

目的评价心理干预结合盐酸帕罗西汀对冠脉介入治疗后患者焦虑、抑郁的疗效。方法将首次接受PCI治疗后的合并焦虑、抑郁的冠心病患者随机分为两组，接受HAMA和HAMD评分。实验组除常规冠心病二级预防外，还给予心理干预，同时结合盐酸帕罗西汀（赛乐特，）20mg／d治疗。对照组仅给予常规冠心病二级预防。1个月以后，随访患者再次接受HAMA和HAMD评分。比较两组患者治疗后以胸部不适为主要临床症状的缓解率，以及两组患者治疗前后汉密尔顿焦虑量表（HAMA）、抑郁量表（HAMD）评分变化。结果处理组胸痛缓解率为80．43％（37／46），显著高于对照组45．24％（19／42）（P〈0．05）。治疗1个月以后，处理组HAMA、HAMD评分分别为7．8±2．1和6．7±1．3均显著低于对照组16．3±2．7和17．1±1．9（P〈0．05），且与治疗前差异存在统计学意义（P〈0．05）。结论心理干预同时结合盐酸帕罗西汀对冠脉介入治疗后患者焦虑、抑郁有较好的疗效。     

The effects of social support on the relationship of functional limitations and pain to depression

Objective . This study assessed the effects of social support on the relationship of functional impairments and pain to depression. Methods . Fifty-nine persons with end-stage joint disease (27 men and 32 women with an average age of 65 years) were interviewed. The Arthritis Impact Measurement Scales (AIMS) was used to assess functional impairment and depression. The modified Inventory of Socially Supportive Behaviors was used to assess 4 types of social support (emotional, informational, tangible, and integrative). Results . Contrary to the moderator model of social support, only low tangible support attenuated the adverse effects of functional impairments on depression, while other levels of this type and 3 other types of support either had no effect or enhanced the deleterious effects of functional impairments. Social support did not attenuate the relationship between pain and depression. Discussion . The findings suggest that certain types and levels of social support may reduce the effects of functional limitation and pain on depression, while other types and levels may increase their adverse effects.     

XSL型心电信号记录仪的临床初步应用及价值

目的 探讨一种新型便携式心电信号记录仪的记录效果及临床价值.方法 选择2005年11月至2006年1月的随机门诊患者30例,给予普通12导心电图检查的同时,采用XSL记录仪同部位同时间记录心电信号.回放记录仪的心电信号,与普通心电图机图形进行比较.结果 30例全部记录出心电图,成功率100%,其中窦速2例、室性期前收缩2例、完全性左束支及右束支传导阻滞各1例、左房肥大1例、正常心电图23例.XSL记录仪对异常和正常心电图的诊断敏感性、特异性、诊断符合率为100%.结论 XSL型心电信号记录仪可以真实记录回放心电信号,其记录的真实性、长期性及超前性可以应用于临床中短暂的、一过性的心肌缺血及心律失常的诊断.     

Psychological treatment of cardiac patients: a meta-analysis.

Previous reports of the effectiveness of psychological treatments (PTs) for cardiac patients reveal inconsistent results. We determined overall effects and gender differences. Eligible studies were randomized controlled trials, containing a PT arm. The authors identified 43 relevant randomized trials; 23 reported mortality data for 9856 patients. The odds-ratio (OR) for all-cause mortality at follow-up of 2 years or less, comparing PT plus usual care vs. usual care only, was OR 0.72 [95% confidence interval (CI) 0.56-0.94], but weakened with longer follow-up (OR 0.89; 95% CI 0.80-1.10). Mortality benefits only applied to men (OR 0.73, 95% CI 0.57-1.00; OR 1.01; 95% CI 0.87-1.72 for women). Trials initiating treatment at least 2 months after a cardiac event showed greater mortality benefits than those initiating treatment right after the event (OR 0.28; 95% CI 0.11-0.70 vs. OR 0.87; 95% CI 0.86-1.15, respectively). Mortality benefits due to PT were achieved despite small concomitant changes in negative affect. PT of cardiac patients reduces mortality and event recurrence. The mortality benefits appeared only in men even after controlling for age differences. The timing for the initiation of PT may be a critical mediating variable for mortality outcomes.     

心理护理干预应用在老年糖尿病患者康复治疗中的干预效果观察

目的观察心理护理干预应用在老年糖尿病患者康复治疗中的干预效果分析。方法将在该院2017年1月—2018年12月期间收治的老年糖尿病患者总计314例,随机数字法分成对照组(157例)与心理组(157例),其中对照组患者采取常规护理干预,而心理组患者采取心理护理干预。对照两组护理干预前、后负性情绪评价(SAS、SDS)、空腹血糖、糖化血红蛋白及干预后对治疗的依从性。结果护理后两组老年患者负性心理评分均明显减少,空腹血糖及糖化血红蛋白水平明显下降,其中心理组老年患者负性心理状态评分明显少于对照组,空腹血糖及糖化血红蛋白水平明显低于对照组,心理组老年患者依从性优良率为99.36%,对照组为92.99%,差异有统计学意义(P<0.05)。结论在老年糖尿病患者康复治疗中,采取心理护理干预,可明显减轻患者负性情绪,提高对治疗的依从性,进而降低血糖水平保持稳定,效果理想。     

The impact of concomitant depression on quality of life and health service utilisation in patients with osteoarthritis

To assess the impact of concomitant depression on quality of life (QoL) and health service utilisation of patients with osteoarthritis (OA). Data were collected from 75 primary care practices in Germany. Totally, 1,250 patients were consecutively approached; 1,021 (81.7%) questionnaires were returned and analysed. Measures included sociodemographic data, the Arthritis Impact Measurement Scale (AIMS2-SF) and the Patient Health Questionnaire (PHQ-9) to assess depression. A PHQ-9 score ≥ 15 was defined as reflecting depression. Patients with a depressive disorder achieved significantly (all P < 0.001) higher scores in all AIMS2-SF dimensions. They had more contacts to general practitioners (P < 0.01), orthopaedics (P < 0.01) and to providers of Complementary Alternative Medicine offered e.g. by healers. Concomitant depression aggravates the burden of OA significantly. This results in increased health service utilisation. Appropriate treatment of depression would appear not only to increase QoL but also to lower costs by decreasing health service utilisation.