depression following acute myocardial infarction-a prospective relationship with ongoing health and...

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Psychosomatics 46:4, July-August 2005 http://psy.psychiatryonline.org 355

Depression Following Acute Myocardial Infarction: AProspective Relationship With Ongoing Health and Function

JAMES A. FAUERBACH, PH.D., DAVID E. BUSH, M.D.

BRETT D. THOMBS, PH.D., UNA D. MCCANN, M.D.

JOSHUA FOGEL, PH.D., ROY C. ZIEGELSTEIN, M.D.

The relationship between baseline depression and health-related quality of life were examined in

a cohort of patients after hospitalization due to acute myocardial infarction (N 196). Patients

were assessed for presence of mood disturbance, anxiety, and quality of life at the time of hospi-

talization and again 4 months later. Baseline assessment was used to assign subjects to a de-

pressed or a nondepressed group. Adjusting for preinfarction quality of life, in-hospital anxiety,

and demographic variables, depression was prospectively and independently related to reduced

global health at 4 months as well as reduced overall mental healthincluding vitality, psycho-

logical health, and social functionand increased role interference from psychological problems.

(Psychosomatics 2005; 46:355361)

Received Oct. 23, 2003; revision received Nov. 13, 2004; accepted Dec.

16, 2004. From the Department of Psychiatry & Behavioral Sciences,

Department of Physical Medicine & Rehabilitation, and Department of

Medicine, Division of Cardiology, The Johns Hopkins University School

of Medicine; and the Department of Economics, Brooklyn College of the

City University of New York, Brooklyn, N.Y. Address correspondence

and reprint requests to Dr. Fauerbach, c/o Baltimore Regional Burn Cen-

ter, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave. Balti-

more, MD 21224; [email protected] (e-mail).

Copyright 2005 The Academy of Psychosomatic Medicine.

Depressive symptoms during hospitalization for acutemyocardial infarction occur in as many as 45% ofpatients1 and significantly increase the short-term risk for

morbidity and mortality, even after established risk factors,

including left ventricular ejection fraction, Killip class, age,

and history of prior infarction,2,3 are controlled. Depression

following myocardial infarction also predicts long-term

mortality.4 Behavioral (especially nonadherence to risk-

reduction recommendations), neuroendocrine, and throm-

botic mechanisms have been proposed as pathways

through which depression affects health after myocardial

infarction.57 Depression has been associated with poor

treatment adherence in patients with8,9 and without10,11 car-

diac disease.Similarly, perceived quality of life has been related to

mortality and has been found to be a better predictor of

mortality than objective health indices (e.g., left ventricular

ejection fraction and exercise treadmill testing) among el-

derly patients with chronic diseases.12 Quality-of-life vari-

ables have also been found to be predictive of poor treat-

ment adherence among myocardial infarction patients,

even after adjustment for depression.13

Thus, both depression and quality of life have been

found to relate to health outcomes in myocardial infarction

patients. In addition, there appears to be a meaningful re-lationship between depression and quality of life. Depres-

sion has been found to relate to reduced quality of life to

a degree equal to or greater than that of other chronic health

problems (e.g., advanced coronary artery disease, angina)14

and traditional measures of cardiac function (e.g., ejection

fraction, ischemia).15 A 6-year, population-based, longitu-

dinal study of community-dwelling elderly adults found

baseline symptoms of depression to increase the likelihood

of becoming disabled, decrease the likelihood of recover-

ing from a disabling condition among those who developed

impairment, and decrease quality of life.16


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Depression and Health After Myocardial Infarction

356 http://psy.psychiatryonline.org Psychosomatics 46:4, July-August 2005

Among postmyocardial infarction patients, cross-sec-

tional results after 5 months show depression associated

with both physical and mental health domain scores of the

SF-36, a quality-of-life measure.17 Depression and anxiety

were both associated with quality of life 4 months after

myocardial infarction,18 and emotional distress predicted

poor SF-36 scores on all eight subscales 3 and 12 months

after myocardial infarction, while subthreshold distress did

not.19 At both 4 months20 and 12 months21 after myocardial

infarction, baseline depression was the best predictor of

quality of life. In addition to postmyocardial infarction pa-

tients, poor quality of life has been found to predict a

poorer long-term outcome among those with chronic car-

diac disease.22,23

These studies relating depression to subsequentquality

of life have important limitations. First, design and sam-

pling issues, as well as patient and treatment characteristics

particular to these studies, suggest the need for replication.

Second, insufficient attention has been paid to identifying

specific functional domains that are negatively impacted

by the presence of depression. Third, while poor quality of

life predicts a poorer long-term outcome, to our knowl-

edge, no studies have addressed the possibility that poor

quality of life prior to the myocardial infarction may ac-

count for this relationship. The present study addresses

these gaps in the scientific literature. Specifically, the ob-

jectives of the study include 1) replicating the relationship

between depression following myocardial infarction and

quality of life, both at baseline and after 4 months and

2) examining the relationship between depression at the

time of the myocardial infarction and longitudinal quality

of life, with quality of life and anxiety before myocardial

infarction controlled.

METHOD

Participants

We conducted this study at a large metropolitan teach-

ing hospital from which we received institutional review

board approval. Over an 18-month period, 696 patientswere admitted to the hospital as a result of acute myocar-

dial infarction, defined by the presence of at least two of

the following: typical ischemic chest pain lasting20 min-

utes, presence of ECG changes typical of ischemia/infarc-

tion, peak creatine phosphokinase [CPK] 1.5 times nor-

mal, or a CPK-myocardial band index 10 ng/ml with a

simultaneous CPK exceeding the normal limits.

Of these 696 eligible patients admitted to the hospital

because of acute myocardial infarction, 285 patients were

interviewed. All patients were approached for consent ex-

cept those excluded because of 1) comorbid noncardiac

illness likely to lead to death within 6 months, 2) medical

conditions precluding reliable verbal communication,

3) nonadmission to the cardiology service, 4) in-hospital

death, 5) transfer to other facilities within the first 48 hours

of hospitalization (patients requiring early angioplasty or

cardiac surgery were immediately transferred to a different

site because these services were not available at this hos-

pital site) or 6) symptoms of dementia or delirium deter-

mined during clinical examination.

Analyses of available records of those excluded at

baseline showed that they did not differ significantly from

those who provided informed consent in terms of age, gen-

der, diabetes status, prior myocardial infarction, living

alone, cigarette use, Killip class, or peak CPK value. Rea-

sons for loss to follow-up (N 89) included death (N 18),

refusal to be reinterviewed (N 11), unreachable (N 43),

and partial completion of interview (N 17). Participants

at the follow-up evaluation tended to be more likely to have

a left ventricular ejection fraction of 35 or above and less

likely to be categorized in Killip classes IIIV than those

lost to follow-up. Otherwise, participants at the follow-up

evaluation did not differ on any demographic or health-

related variable from those not reinterviewed 4 months af-

ter myocardial infarction.

Procedure and Materials

Participants provided informed consent and during the

first 25 days following admission were assessed with the

mood disorders module of the Structured Clinical Inter-

view for DSM-III-R (SCID)24 to evaluate the presence of

mood disorder before hospital admission, and both the

Beck Depression Inventory25 and Beck Anxiety Inven-

tory26 to measure postmyocardial infarction symptoms of

depression and anxiety, respectively, present since admis-

sion. Quality of life was measured with the SF-36 Health

Survey27 at baseline by asking participants to rate their

quality of life before hospitalization. Quality of life wassubsequently reassessed at the 4-month follow-up evalua-

tion.

Demographic, medical, and treatment data were gath-

ered by reviewing hospital charts after discharge. Myocar-

dial infarction severity, comorbid conditions, and cardiac

risk factor status were evaluated using standard criteria by

one of two cardiologists (D.E.B., R.C.Z.) blind to the psy-

chiatric and psychosocial status of the subjects at the time


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Fauerbach et al.


TABLE 1. Demographic and Clinical Characteristics of 196 Patients With or Without Depression Following Hospitalization Due to Acute

Myocardial Infarction

Depressed (N 44)

Nondepressed

(N 152) Analysis

Factor N % N % v2 p

Age 2.12 0.15

65 19 43.2 84 55.6

65 25 56.8 67 44.4

Gender 4.52 0.03

Female 25 56.8 59 38.8

Male 19 43.2 93 61.2

Race 4.56a 0.03

White 43 97.7 131 86.2

Non-white 1 2.3 21 13.8

Living situation 0.37 0.54

Lives alone 9 20.9 25 16.9

Lives with someone 34 79.1 123 83.1

Hypertension 0.56 0.45

Present 30 68.2 93 62.0

Absent 14 31.8 57 38.0

Hyperlipidemia 0.82 0.37Present 30 68.2 91 60.7

Absent 14 31.8 59 39.3

Diabetes 0.01 0.93

Present 14 31.8 47 31.1

Absent 30 68.2 104 68.9

History of myocardial infarction 1.79 0.18

Present 14 31.8 33 22.0

Absent 30 68.2 117 78.0

Family history of myocardial infarction 0.01 0.93

Present 17 38.6 59 39.3

Absent 27 61.4 91 60.7

Ejection fraction 0.17 0.68

35% 10 26.3 34 23.1

35% 28 73.7 113 76.9

Killip class 0.10 0.75I 29 65.9 95 63.3

II-IV 15 34.1 55 36.7

Myocardial infarction location 0.00 0.99

Anterior 10 22.7 34 22.8

Other 34 77.3 115 77.2

Myocardial infarction type 0.11 0.75

Q-Wave 14 31.8 51 34.5

Non Q-wave 30 68.2 97 65.5

Peak CPK 0.01 0.93

500 24 54.5 83 55.3

500 20 45.5 67 44.7

Current smoker 0.97 0.32

Yes 15 34.1 40 26.5

No 29 65.9 111 73.5

COPD 1.16 0.28

Present 8 18.2 18 11.9

Absent 36 81.8 133 88.1

Intubation 0.85a 0.69

Yes 1 2.4 9 6.1

No 40 97.6 139 93.9

Renal failure/insufficiency 3.74a 0.09

Present 8 19.5 13 8.8

Absent 33 80.5 135 91.2


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TABLE 1. Continued

Current depression

SCID 103.6 0.01

Present 26 59.1 0 0.0

Absent 18 40.9 152 100.0

Beck

10 137.1

0.01Present 33 75.0 0 0.0

Absent 11 25.0 152 100.0

ap value for Fishers exact test since table includes an expected cell count 5.

of the chart review. Cardiac risk factors examined included

hypertension (defined as systolic blood pressure 140 mm

Hg or diastolic blood pressure 90 mm Hg, history of

hypertension, or receiving antihypertensive medications),

hyperlipidemia (total cholesterol 240 mg/dl, history of

increased cholesterol, or receiving lipid-lowering medica-tion at the time of admission), previous myocardial infarc-

tion (determined by a review of patient history or from

electrocardiographic evidence), left ventricular ejection

fraction (35% versus 35%), and tobacco use (self-re-

ported current status). Demographic variables were col-

lected and then dichotomized as follows: age (65 versus

65 years), race (white versus non-white), living alone

versus living with someone, and gender. Comorbid con-

ditions examined included renal insufficiency or failure,

chronic obstructive pulmonary disease (COPD), and dia-

betes mellitus. At the 4-month follow-up evaluation, 196

individuals were interviewed.

Statistical Analyses

The depressed group comprised individuals with

SCID-diagnosed mood disorder or Beck Depression In-

ventory scores 10 at baseline on the basis of previous

work in this area.2,3 Analyses comparing the depressed and

nondepressed groups with regard to anxiety, demographics,

coronary disease risk factors, and indices of myocardial

infarction severity and cardiac function are presented in

Table 1. Significance of differences between the groups on

these variables was evaluated with chi-square tests for di-chotomized variables (Fishers exact test where appropri-

ate) and t tests for continuous variables. The relationship

between depression status and quality of life was evaluated

with t tests of group differences. Analysis of covariance

(ANCOVA) was applied to assess for an association be-

tween depression at baseline and quality of life at 4 months

after we controlled for quality of life before myocardial

infarction.

RESULTS

Patient Characteristics

The characteristics of participants in the depressed and

nondepressed groups who were followed at both baseline

and 4 months are described in Table 1. Of the depressed

group (N 44), 26 had a DSM-III-R mood disorder at the

time of the myocardial infarction, and 33 had a Beck De-

pression Inventory score of 10 or greater within 5 days of

hospitalization. Individuals scoring below 10 on the Beck

Depression Inventory and not meeting criteria for a current

mood disorder comprised the nondepressed group

(N 152). Participants in the depressed group, relative to

the nondepressed group, were more likely to be white and

female. The depressed group also scored significantly

higher than the nondepressed group on measures of base-

line anxiety (mean 36.5 [SD 11.5] versus 30.2[SD 10.1], respectively; t 4.45, df 194, p0.01).

There were no significant differences on any other demo-

graphic variables, coronary disease risk factors, or indices

of myocardial infarction severity or cardiac function. Gen-

der, race, and anxiety at baseline were used as control vari-

ables in the subsequent evaluation of the relationship be-

tween depression at baseline and quality of life at 4 months.

Relationship Between Depression and Quality of Life at

the Time of Hospitalization and After 4 Months

The aggregate SF-36 mental and physical domainscores for the depressed and nondepressed groups differed

significantly at both baseline and 4 months. At baseline,

the mean SF-36 mental domain score for the depressed

group was 42.7 (SD 11.0), which was significantly lower

than that of the nondepressed group (mean 51.8,

SD 6.2) (t 7.0, df 194, p0.01). The baseline score

for the SF-36 physical domain was also lower for the de-

pressed group (mean 37.4, SD 10.4) relative to the non-


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Fauerbach et al.


depressed group (mean 40.9, SD 9.6) (t 2.1, df 194,

p 0.04). At the 4-month follow-up evaluation, the de-

pressed group again had lower scores than the nonde-

pressed group in both mental domain functioning and

physical domain functioning (Table 2). There was no sig-

nificant change in physical domain scores across time for

depressed patients (baseline: mean 37.4 [SD 10.4]; 4

months: mean 36.9 [SD 12.8]) and nondepressed pa-

tients (baseline: mean 40.9 [SD 9.6]; 4 months:

mean 42.1 [SD 12.0]), although physical functioning

tended to decline slightly for the depressed group and

improve slightly for the nondepressed group. Mental do-

main scores improved significantly for both the depressed

patients (baseline: mean 42.7, SD 11.0; 4 months:

mean 49.8, SD 13.5 [t 3.1, df 43, p0.01]) and

nondepressed patients (baseline: mean 51.8, SD 6.2;

4 months: mean 58.7, SD 7.4 [t 10.4, df 151, p

0.01]).

Quality of Life 4 Months After Discharge in the

Depressed and Nondepressed Groups, With

Premyocardial Infarction Quality of Life Controlled

ANCOVA was used to test the hypothesis that 4-month

postmyocardial infarction aggregate SF-36 mental and

physical domain scores and the eight component subscales

would differ between depressed and nondepressed groups

at the 4-month follow-up evaluation after the influence of

baseline (premyocardial infarction) SF-36 subscale scores,

anxiety, gender and race (i.e., the univariate correlates of

baseline depression status) was controlled. Table 2 presents

both unadjusted and adjusted SF-36 subscale means and

95% confidence intervals for the depressed and nonde-

pressed groups at the follow-up evaluation. After removing

the effect of the covariates, there remained a significant

multivariate effect of depression on postmyocardial infarc-

tion quality of life in the aggregate mental domain

(F 8.06, df 5, 195, p0.01). There was not a significant

adjusted effect of depression on aggregate physical domain

score (F 0.11, df 5, 195, p 0.57). Comparisons of ad-

justed means of the eight SF-36 subscales at 4 months in-

dicated that patients who were depressed at the time ofbaseline assessment scored significantly lower than those

in the nondepressed group at 4 months on measures of

global health (F 7.45, df 5, 195, p0.01), mental health

(F 6.53, df 5, 195, p 0.01), role interference by emo-

tional problems (F 7.27, df 5, 195, p0.01), vitality

(F 9.83, df 5, 195, p0.01), and social functioning

(F 7.99, df 5, 195, p0.01). Significant differences be-

tween groups on adjusted means were evaluated usingT

ABLE2.QualityofLifeA

fter4Monthsin196PatientsWithandWithoutDepressionFollowingHospitalizationfo

rAcuteMyocardialInfarction

Nondepressed(N

152

)

Dep

ressed(N

44)

Analysis

SF-36HealthSurveyMeasure

Unadjusted

Mean

95%CI

Adjust

ed

Mean

a

95%CI

Unadjusted

Mean

95%

CI

Adjusted

Meana

95%CI

p

Partial

EtaSquared

Aggregatephysicaldomain

42.1

40.244.0

41.2

39.542.9

36.9

33.0

40.8

40.1

36.843.4

0.57

0.0

02

Physicalfunctioning

68.9

64.673.3

65.4

62.168.8

54.5

45.4

63.7

66.6

60.073.2

0.77

0.0

01

Role-physical

58.9

53.064.8

56.2

50.362.0

42.6

30.4

54.8

52.0

40.563.5

0.54

0.0

02

Bodilypain

43.0

41.144.9

42.6

40.744.5

42.3

38.7

45.9

43.6

39.847.3

0.67

0.0

01

Generalhealth

74.4

71.677.2

73.2

70.476.0

60.2

54.7

65.7

64.4

58.969.9

0.01

b

0.0

51

Aggregatementaldomain

57.7

56.558.8

56.9

55.458.3

49.2

45.1

53.3

52.0

49.155.0

0.01

b

0.0

38

Vitality

62.4

59.165.6

60.6

57.263.9

41.8

34.7

48.9

48.0

41.254.8

0.01

b

0.0

49

Socialfunction

89.5

85.693.4

88.6

84.193.1

71.0

59.6

82.4

74.1

65.382.8

0.01

b

0.0

40

Role-emotional

92.8

89.196.4

91.6

87.395.9

73.5

62.2

84.8

77.5

68.886.3

0.01

b

0.0

37

Mentalhealth

84.6

82.686.5

82.8

80.684.9

69.9

64.0

75.8

76.1

71.680.5

0.01

b

0.0

33

aPrehospitalizationSF-36scores,gender,race,andbaselineanxietyentered

ascovariatesintotheanalysis.

bSignificantbetween-groupd

ifferencesinadjustedmeansevaluatedbyusingHochbergsSequentialMethod28

formultiplemeancomparisonstomaintainthefamily-wiseerrorrateatp0.0

5.


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Hochbergs Sequential Method28 for multiple mean com-

parisons to maintain the family-wise error rate at p0.05.

Partial eta squared values are also provided in Table 2.

Following Cohens guidelines,29 the estimates of effect

sizes for the mental domain and significant subscale do-

main effects were in the small to medium range.

DISCUSSION

Patients depressed at the time of hospitalization following

acute myocardial infarction reported significantly poorer ag-

gregated physical and psychological health at baseline and

at a 4-month follow-up evaluation. Even after we controlled

for baseline quality of life, anxiety, and demographic vari-

ables, depression at baseline was significantly associated

with reduced global health, psychological health, vitality,

social function, and psychological problems interfering with

function 4 months later. Aggregated mental domain scores

of both groups improved significantly over the follow-up

period. While significant changes in the aggregated physical

domain scores were not evident, physical function tended to

decline slightly for the depressed group and improve slightly

for the nondepressed group.

These results replicate and extend previous work in

several areas. For example, whereas previous studies have

focused on global measures, using the SF-36 Health Sur-

vey in the current study permitted the identification of spe-

cific areas of function affected by postmyocardial infarc-

tion depression. Also, previous work has shown that

patients with depression who underwent elective cardiac

catheterization experienced poorer 12-month physical

functioning outcomes relative to those who were not de-

pressed, and that both anxiety and baseline health status

predicted 6-month physical and social quality of life.22,23

The current investigation detected the same pattern of

poorer perceived global health and psychological and so-

cial outcomes at an earlier time point, with potentially con-

founding baseline anxiety and preinfarction quality of life

controlled. This suggests that the biopsychosocial link be-

tween depression and poor outcome from myocardial in-

farction is influential within a few months after myocardial

infarction, and that specific aspects of depression deter-

mine this relation, as opposed to a causal role being attrib-

uted to general negative affectivity per se.30

Several limitations of the present study should be ad-

dressed. This prospective cohort study can only establish

correlations and not definitive causal relationships. How-

ever, the major known physical (e.g., left ventricular ejec-

tion fraction, age, diabetes mellitus, prior history of myo-

cardial infarction) and psychosocial (e.g., living alone)

determinants of postmyocardial infarction outcome were

examined directly or statistically controlled where indi-

cated, and therefore were unlikely to confound the ob-

served relationships between depression and various post-

myocardial outcome measures. It is also possible that

results were affected by differential recruitment, since the

consenting subjects had a higher rate of prior myocardial

infarction than the total population of myocardial infarction

admissions in the hospital, and it is possible that similar

findings would not have been seen in patients following

their first myocardial infarction. Study attrition might have

influenced findings, since participants at the follow-up

evaluation tended to be more likely to have a left ventric-

ular ejection fraction of 35 or above and less likely to be

categorized in Killip classes IIIV.

In conclusion, the present results underscore the im-

portant relationship between depression and perceived

poor quality of life, and the negative impact of both of these

factors in long-term health following myocardial infarc-

tion. These results, when considered with previous find-

ings, underscore the importance of early identification and

treatment of depression among patients following acute

myocardial infarction to minimize long-term morbidity and

disability.

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