Dr Barbara Murphy1
Prof Fiona Judd2
Prof John Humphreys3
Dr John Edington4
Dr Anthony Jackson4
1 Heart Research Centre
2 Royal Women’s Hospital
3 Monash University
4 Bendigo Health
Beyond Blue Victorian Centre of Excellence
Project completion year
Previous research demonstrates that many patients with coronary heart disease (CHD) experience depressive symptoms during or after hospitalisation for an acute coronary event. Patients with depression tend to recover more slowly and have other complications after their cardiac event. Depressed cardiac patients also have high rates of smoking and tend to have more difficulty with positive behaviour change after their event. For these reasons, depressed cardiac patients require intensive support to adjust after their cardiac event.
For patients living in regional and rural areas, the barriers to accessing appropriate services and supports are exacerbated.
Relatively little is known about the experiences and service needs of cardiac patients with depression living in regional and rural parts of Victoria. This study was designed to explore the experiences and needs of this important patient group. The study involved a consecutive series of patients admitted to either Bendigo Health or St John of God Bendigo for either an acute myocardial infarction (AMI) or acute coronary syndrome (ACS), or for transferal to a metropolitan hospital to undergo coronary artery bypass graft surgery (CABGS) or percutaneous coronary intervention (PCI). Patients were assessed during hospitalisation to determine their level of depressive symptoms and to undergo a brief interview. The baseline interview also investigated the rates of current depressive symptoms, history of depression and previous diagnoses of depression.
From the 219 patients identified as potentially eligible for this study, 160 patients were included in the baseline sample, representing a 73 per cent participation rate. All 160 patients were screened for depressive symptoms at the time of hospitalisation, using the HADS-D, and completed a brief baseline interview. Of the 160 patients included at baseline, 142 were re-interviewed at two months post-discharge, and 140 were re-interviewed at six months post-discharge. All participating patients completed brief quantitative interviews at the two and six month time points.
Based on in-hospital HADS-Depression scores of ≥4, 80 patients were identified as having some depressive symptoms and were thus eligible for inclusion in the qualitative interview component of the study. Of these 80, a total of 70 (88 per cent) patients participated in an extensive qualitative interview.
Of the 219 eligible patients, 59 (27 per cent) were excluded due to unavailability for interview in hospital prior to inter-hospital transfer or discharge (n=23); unavailability for follow-up interview post discharge (n=2); inability to provide informed consent due to acute medical condition or concurrent physical impairment (n=24), and declining to participate (n=10). Exclusions were slightly higher than anticipated. Over the course of the study, 13 (8 per cent) patients died after participating in the in-hospital interview. This occurred in the period between recruitment in hospital and subsequent contact for the home-based interview, or prior to other occasions that patients were to be re-contacted for re-interview.
Around a third of patients reported some previous mental health problems and/or use of mental health services and a substantial proportions of patients were above recommended risk factor targets based on National Heart Foundation guidelines. Almost a third had a body mass index above 30 indicating obesity (29%) and, of those for whom waist girth data were available (n=50), a large proportion (72%) were above the recommended targets (≤95 cm for men; ≤80 cm for women). Substantial proportions of patients were above the recommended levels for systolic blood pressure (<130 mm Hg; 61%) and total cholesterol (<4.0 mmol/l; 68%).
Around a third were above the recommended diastolic blood pressure level (<80 mm Hg; 35 per cent). Over half were below the recommended level for HDL cholesterol (>1.0 mmol/l; 57 per cent), more commonly males. Males were also more likely than females to smoke, with current smoking rates of 20 per cent amongst males and 8 per cent amongst females.
Half the patients were found to have some depressive symptoms in hospital, somewhat higher than the 35-40 per cent evidenced in comparable metropolitan cardiac cohorts.
Of the full sample, around a third of patients had a history of depression, had been diagnosed with depression, and/or had used services or medication for mental health problems. Again, this suggests relatively high rates of mental health problems for this regional cardiac cohort.
Patients with ‘moderate to severe’ depressive symptoms in hospital were identified as being significantly younger than non-depressed patients, and having an increased likelihood of a history of depression. They tended to be more likely to smoke and to be obese.
There was a strong expressed desire for information about what to expect emotionally after a cardiac event. Patients preferred to receive this information either verbally from a health professional or in pamphlet format or, for some patients, both formats. The preferred timing for the information was at hospital discharge. Despite the expressed need for this information, two thirds of patients had not received any information, either written or verbal, about the likely emotional responses to a cardiac event.
Implications for policy and practice
The present study has two key implications for practice:
1. The appropriate timing and methods for screening for depressive symptoms in cardiac patients.
Findings from the study confirm what has been emerging through other studies undertaken at the Heart Research Centre – that many cardiac patients with elevated depression scores in hospital improve without intervention in the first few months after discharge. Indeed, the present findings demonstrate that, even amongst patients with highly elevated in-hospital depression scores, resolution of symptoms by two months is common. Other patients have relatively low depression scores in hospital but their symptoms worsen over time, suggesting later onset depression.
These trajectories of depressive symptoms bring into question the appropriateness of in-hospital screening for depression, and highlight the need for later depression screening to identify ‘at risk’ patients, as well as the need for other indicators or ‘red flags’ for depression risk that can assist with identification of ‘at risk’ patients during hospitalisation.
2. The need to inform all patients about the common emotional response to a cardiac event.
There is a need for all cardiac patients to be made aware of the emotional symptoms and responses that are common after a cardiac event. By normalising symptoms, patients can feel supported and reassured when they do experience an emotional response. Patients can also be reassured that their symptoms are likely to resolve without intervention. Again, this has the effect of normalising their experiences and reassuring them that they will recover emotionally from the event.
Patients also need to know when early symptoms might lead to more severe or persistent depression, and to know how to distinguish whether they are experiencing an ‘adjustment response’ or are at risk of developing depression.