Cardiovascular disease in a large cohort of depressed and/or anxious patients
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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Discussion
CVD was largely based on self-report
Link between anxiety and cardiovascular disease needs more attention