Cardiovascular disease in a large cohort of depressed and/or anxious

patientsResults of the

Netherlands Study of Depression and Anxiety

N Vogelzangs1, A Seldenrijk1, HPJ van Hout2, HWJ van Marwijk2, M Diamant3, BWJH Penninx1

EMGO Institute and Department of 1Psychiatry, 2General Practice, 3Endocrinology,

VU University Medical Center, Amsterdam, The Netherlands

2030 Disease % DALYs*1 Depression 9.6%2 Heart disease 5.9%3 Alzheimer,

dementia5.8%

4 Alcohol problems 4.7%5 Diabetes 4.5%6 Stroke 4.5%7 Hearing problems 4.1%8 Cancer 3.0%9 Arthritis 2.9%

10 Lung disease 2.5%

Burden of disease in Western countries

* DALYs = disability-adjusted life years = lost life years + lost quality of life

WHO: Mathers et al. Plos Medicine 2006

First studies in heart patients

End ’80 – start ’90: first studies show a high prevalence of depression among heart patients

1993: Frasure-Smith: first study to show that MI patients with depression have a greater risk of dying

“Depression Following Myocardial Infarction”

Frasure-Smith et al. JAMA 1993

HR = 5.74 (4.61-6.87)

After adjustment for severity of CVD:HR = 4.29 (3.14-5.44)

Depression as risk factor for CVDGeneral 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 2002Wulsin & Singal Psychosom Med 2003Nicholson et al. Eur Heart J 2006Van der Kooy et al. Int J Geriatr Psychiatry 2007

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 2004Van Melle et al. Psychosom Med 2004Nicholson et al. Eur Heart J 2006

Depression and CVD prognosisCVD patients

Proof from systematic reviews

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 Naturalistic cohort study Baseline assessment and follow-up assessments after 1, 2, 4, 6, 8 years

Sample Depressed and/or anxious patients recruited from community, primary care, and outpatient psychiatric clinics, and healthy controls 2,981 persons; 1979 women (66%), 1002 men (34%)

Design & Sample NESDA

Psychopathology

CIDI psychiatric interview (DSM-IV):

Presence & subtype– Major depressive disorder (MDD; single, recurrent) – Anxiety disorder (generalized anxiety disorder,

social phobia, panic disorder and/or agoraphobia)

Recency: – Current: within last year– Remitted: lifetime, not current

Psychopathology

Chronicity: – affected ≥ 50% of past 48 months, life chart

Severity: – Inventory of Depressive Symptoms (IDS), 0-84– Beck Anxiety Inventory (BAI), 0-63

Subthreshold: – Depression: no MDD + IDS ≥ 14– Anxiety: no anxiety disorder + BAI ≥ 10

Cardiovascular disease

Coronary heart disease and/or stroke based on:

Self-report of myocardial infarction or angina pectoris supported by use of beta blockers or vasodilators (nitrates or calcium channel blockers) (n=129)

Self-report of coronary angioplasty or coronary artery bypass surgery (n=70)

Self-report of cerebrovascular disease (n=56)

=> Total N=184

Baseline characteristics No CVD (n=2746) CVD (n=184)

p

Age (years) Women Education (years) No MDD (n=650)

Subthreshold depression Remitted MDD (n=680)

Current MDD (n=1204)

No anxiety (n=907)

Subthreshold anxiety Remitted anxiety (n=403)

Current anxiety (n=1333)

IDS BAI

41.2 (13.0)67.9

12.3 (3.2)22.813.323.040.831.89.6

13.844.8

21.1 (14.0)11.8 (10.5)

53.1 (8.9) 48.4

10.8 (3.1)12.516.3 26.145.117.913.012.5 56.5

26.4 (14.3)16.4 (11.2)

<.001<.001<.001 .01

<.001

<.001<.001

(n=396)

(n=287)

Adjusted OR for CVD

OR* 95% CI p MDD and anxiety in separate models

No MDD Subthreshold depression Remitted MDD Current MDD

1.931.842.21

REF1.07-3.491.07-3.141.33-3.67

.03

.03 .002

No anxiety Subthreshold anxiety Remitted anxiety Current anxiety

2.111.422.42

REF1.18-3.780.80-2.521.58-3.72

.01

.23<.001

* Adjusted for age, sex, education, smoking, alcohol use, and BMI

Depression and anxiety characteristics

In multivariable regression analyses:

Chronicity of depression or anxiety was not associated with CVD prevalence

Subtype of depression (single/recurrent) or anxiety (social phobia, GAD, panic) was not associated with CVD prevalence

0

2

4

6

8

10

12

Normal< 14

1027

Mild14-25

813

V. severe≥ 49

114

Severe39-49

273

Moderate26-38

703

IDS:

N=

%withCVD

p <.001

3.6

7.66.4

9.9

11.4

CVD prevalence and severity of depression and anxiety symptoms

0

2

4

6

8

10

12

BAI:

N=

Normal< 10

1472

Mild10-18

757

Severe≥ 30

215

Moderate19-29

486

p <.001

3.8

7.5

9.910.7%

withCVD

Depression severity Anxiety severity

OR* 95% CI p MDD and anxiety in separate models

No MDD Subthreshold depression Remitted MDD Current MDD

1.931.842.21

REF1.07-3.491.07-3.141.33-3.67

.03

.03 .002

No anxiety Subthreshold anxiety Remitted anxiety Current anxiety

2.111.422.42

REF1.18-3.780.80-2.521.58-3.72

.01

.23<.001

* Adjusted for age, sex, education, smoking, alcohol use, and BMI

Depression or anxiety?Adjusted OR for CVD

Depression or anxiety?Adjusted OR for CVD

OR* 95% CI p MDD and anxiety in one model

No MDD Subthreshold depression Remitted MDD Current MDD

No anxiety Subthreshold anxiety Remitted anxiety Current anxiety

1.291.361.35

1.831.282.11

REF0.67-2.490.75-2.460.74-2.48

REF0.96-3.490.70-2.331.27-3.50

.46

.31

.33

.07

.43 .004

* Adjusted for age, sex, education, smoking, alcohol use, and BMI

Conclusions

Cardiovascular disease is more prevalent among depressed and/or anxious patients

This association was most strong for current anxiety

The highest CVD prevalence was found among those with the most severe anxiety and depressive symptoms

Discussion

CVD was largely based on self-report

Link between anxiety and cardiovascular disease needs more attention