Psychiatry Research 208 (2013) 288–290

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Brief report

Baseline physical health-related quality of life and subsequentdepression outcomes in cardiac patients

Gillian L. Sowden a,e, Carol A. Mastromauro b, Rita C. Seabrook c, Christopher M. Celano a,b,Bruce L. Rollman d, Jeff C. Huffman a,b,n

a Harvard Medical School, Boston, MA, United Statesb Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United Statesc Department of Psychology, University of Michigan, Ann Arbor, MI, United Statesd Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, United Statese Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA, United States

a r t i c l e i n f o

Article history:Received 11 October 2012Received in revised form15 May 2013Accepted 19 May 2013

Keywords:Health-related quality of lifeCollaborative careCardiovascular disease

81/$ - see front matter & 2013 Elsevier Irelanx.doi.org/10.1016/j.psychres.2013.05.019

espondence to: Massachusetts General HospMA 02114, United States. Tel.: +1 617 724 291ail address: jhuffman@partners.org (J.C. Huffm

a b s t r a c t

Among 137 depressed cardiac patients, lower baseline physical health-related quality of life (HRQoL) wasindependently associated with greater depression persistence at 6 months among patients randomizedto collaborative care, but not usual care. Low physical HRQoL may impact collaborative care effectivenessand indicate a need for alternate depression treatment.

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1. Introduction

Depression in cardiac patients is common, persistent, andindependently associated with recurrent cardiac events and mor-tality (Celano and Huffman, 2011), and depression that persistsdespite treatment appears to be even more strongly linked tomortality (Carney and Freedland, 2009). Depression and impairedphysical health-related quality of life (PHRQoL) have been linked(McKnight and Kashdan, 2009), and low PHRQoL has beenassociated with decreased survival in cardiac patients (Rumsfeldet al., 1999), suggesting a potential mediating effect of PHRQoL ondepression-associated mortality. Collaborative care (CC) depres-sion programs that use a non-physician care manager to identifydepression and coordinate depression treatment among patients,primary medical providers, and mental health specialists, canimprove depression outcomes in persons with cardiovasculardisease (Katon et al., 2010).

Few studies have evaluated factors predicting the effectivenessof CC, and none have evaluated the impact of PHRQoL on depres-sion response among patients in CC programs. To investigate this,we performed a secondary analysis of a randomized CC trial of

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depressed cardiac patients (Huffman et al., 2011a). We investi-gated the relationship of baseline PHRQoL with depression persis-tence and change in depression severity over a 6-month period.Based on a prior study showing that pain limits the effectivenessof CC, but not usual care (UC) (Thielke et al., 2007), we hypothe-sized that low baseline PHRQoL would be associated with depres-sion persistence in CC patients.

2. Methods

The parent trial (Huffman et al., 2011a) studied patients who were admitted toinpatient cardiac units for acute coronary syndrome, heart failure, or arrhythmia,and were diagnosed with depression on interview based on a Patient HealthQuestionnaire-9 (PHQ-9) (Kroenke et al., 2001) score of 10 or more, with five ormore symptoms, including depressed mood and/or anhedonia, more than half thedays in the prior 2 weeks (see Huffman et al., 2011b, for more detail on studymethods). Subjects were randomized to a 12-week, phone-based CC interventionthat used a social work care manager to monitor and coordinate depressiontreatment, or to UC (letters to treating physicians). Study outcomes, assessed at6 weeks, 12 weeks and 6 months, included measures of depression severity, mentalHRQoL, PHRQoL, and anxiety. Depression persistence was defined, per prior trials(Katon et al., 2010), as less than 50% reduction of PHQ-9 scores from baseline.Overall, CC patients had significantly greater improvement in depression than UCpatients at 6 and 12 weeks; this effect somewhat waned by 6 months (Supple-mentary Table 1).

We compared baseline sociodemographic, psychiatric, and medical character-istics, and baseline study measures, between UC and CC groups using chi-squareanalysis for dichotomous variables and t tests for continuous variables. Weperformed multivariate logistic and linear regression, respectively, to assess the

Table 1Multivariate logistic regression assessing variables associated with depression persistencea at 6 months.

Variable Usual care n¼65 Collaborative care n¼72.

Odds ratio SE p 95% CI Odds ratio SE p 95% CI

Physical HRQoL (initial SF-12 PCS) 1.01 0.03 0.73 0.96–1.07 0.93 0.03 0.01 0.88–0.98Anxiety (initial HADS-A) 1.07 0.07 0.31 0.94–1.23 1.15 0.09 0.06 1.00–1.34Admission diagnosis 0.88 0.29 0.71 0.46–1.69 1.15 0.40 0.70 0.58–2.29Depression severity(initial PHQ-9) 1.10 0.10 0.25 0.93–1.31 1.02 0.08 0.80 0.88–1.18Prior diagnosis of depression 1.39 0.96 0.64 0.36–5.37 0.94 0.51 0.92 0.33–2.73Adjusted R2 for model 0.04 0.14

CI¼Confidence interval; HADS-A¼Hospital Anxiety and Depression Scale-Anxiety Subscale; HRQoL¼health-related quality of life; PHQ-9¼Patient Health Questionnaire-9;SF-12 PCS¼Medical Outcomes Study 12-item Short-Form Physical Component Score.

a Depression persistence was defined as a reduction of depression symptoms (PHQ-9 score) from baseline of less than 50%.

G.L. Sowden et al. / Psychiatry Research 208 (2013) 288–290 289

independent association of baseline PHRQoL with depression persistence anddepression severity at 6 months. Baseline PHRQoL was measured using the MedicalOutcomes Study 12-item Short-Form physical component score (SF-12 PCS), whichassesses physical function, self-rated health, pain, energy, social functioning, andrelated constructs; lower scores correspond to lower PHRQoL.

Separate analyses were performed for those randomized to CC and UC based onour hypothesis that PHRQoL would be associated with depression persistence in CC,but not UC, patients. Variables in the regression models included baselinedepression severity, baseline anxiety, cardiac admission diagnosis, prior depression,and baseline PHRQoL (see Table 1 for details on study measures). These variableswere included in the model because they have been associated with depressionpersistence (Kornstein and Schneider, 2001). Only subjects with complete baselineand 6-month data were included. Analyses were performed using Stata 11.0(StataCorp, College Station, TX), and p values were two-tailed with α¼0.05.

3. Results

Overall, 175 participants enrolled in the parent study and 157survived until the 6-month assessment (83 in CC, 74 in UC); ofthese, 89.7% (72 CC, 65 UC) completed the 6-month evaluation.There were no significant differences between those completingthe 6-month interview and those who did not, and there were nosignificant differences between UC and CC recipients on anybaseline characteristic or baseline study measures, except forhigher rates of prior depression in UC (81.5% vs. 63.9%; p¼0.021;Supplementary Table 2).

CC, but not UC, patients with depression persistence at6 months had a significantly lower baseline SF-12 PCS score thanthose without (CC: mean SF-12 PCS¼29.41 vs. 36.48, t¼2.91;d.f.¼70; p¼0.005; UC: 31.50 vs. 31.13, t¼−0.16; d.f.¼63, p¼0.87).Baseline SF-12 PCS score was independently associated withdepression persistence (odds ratio [OR]¼0.93, 95% confidenceinterval¼0.88–0.98, p¼0.01, Table 1) and less improvement indepression severity (β¼−0.15, p¼0.046, Supplementary Table 3) at6 months among patients receiving CC. In contrast, no variableswere significantly associated with depression persistence orchange in depression severity at 6 months in UC.

4. Discussion

Among patients admitted for acute heart disease, lower base-line PHRQoL was independently associated with greater depres-sion persistence and less improvement in depression severity at6-month follow-up among patients receiving CC, but not inpatients receiving UC. Our findings suggest that patients withpoor PHRQoL might be less likely to respond to a CC depressionprogram, especially this phone-based and brief (12-week)program.

Our results are consistent with prior findings that poor PHRQoLis a risk factor for ongoing depression (McKnight and Kashdan,2009). The impact of poor PHRQoL on the effectiveness of

depression outcomes among CC patients may stem from decreasedadherence to CC interventions. Indeed, post-ACS patients with lowPHRQoL have decreased adherence to medical treatment (Fogelet al., 2004). In contrast, this construct appears to have had littleimpact on spontaneous recovery from depression, given that UCsubjects with low PHRQoL did not have higher rates of depressionpersistence.

This work has several limitations. Patients were predominantlyCaucasian, and only subjects who completed follow-up assess-ments at 6 months (90%) were included. The sample size limitedthe number of covariates that could be tested without overfittingthe statistical model, and we did not have a specific measure ofbaseline cardiac disease severity. Finally, we did not have all itemscores from all PHQ-9 assessments, limiting our ability to drawconclusions about the relationship between specific depressivesymptoms and response. One possibility is that patients withlower baseline PHRQoL who received CC treatment had higherrates of residual somatic symptoms related to their physical illness,whereas untreated UC patients may have had a broader range ofdepressive symptoms.

Our preliminary findings could have meaningful implications.CC programs are being increasingly implemented but must beright-sized for individuals and populations. Some CC programsmay provide less aggressive treatment and contact with specialiststhan other care models, and our results suggest that patients withpoor PHRQoL may require a different and more intensive modalityof treatment, such as cardiac rehabilitation or regular visits withan outpatient psychiatrist.

Acknowledgments

Funding source: American Heart Association Scientist Devel-opment Grant 0735530T (Huffman)

Clinical Trial Registration: Unique Identifier: NCT00847132.

Appendix A. Supplementary materials

Supplementary data associated with this article can be found inthe online version at http://dx.doi.org/10.1016/j.psychres.2013.05.019.

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