Positive psychological constructs and health behavior adherence in heart failure: A qualitative research study.

Psychological well-being may play an important role in health behavior adherence and cardiovascular health, but there has been limited study of well-being in patients with heart failure. In this descriptive qualitative research study, we interviewed 30 patients with heart failure to explore their psychological experiences with heart failure and the perceived associations between positive psychological constructs and adherence to physical activity, diet, and medication recommendations. Interviews were transcribed, then coded in NVivo using directed and conventional content analysis, and the Consolidated Criteria for Reporting Qualitative Research checklist was applied to report our findings. Participants spontaneously reported positive psychological constructs both during an acute phase of illness and 3 months later. Participants most commonly experienced gratitude, acceptance, connectedness, and faith in the setting of heart failure. In contrast, pride, determination, and hope were identified most frequently as playing a role in health behavior adherence. Finally, participants reported a reinforcing relationship between positive constructs and health behavior engagement. These findings suggest that interventions to boost positive constructs have the potential to improve well-being and health behavior adherence in patients with heart failure.

A positive psychology intervention for patients with bipolar depression: a randomized pilot trial.

Background: There are few effective treatments for bipolar depression, a common and debilitating illness.Aims: We aimed to examine the feasibility and preliminary efficacy of a four-week, telephone-delivered positive psychology (PP) intervention for patients with bipolar depression.Methods: Twenty-five patients hospitalized for bipolar depression were randomized to receive a PP (n = 14) or control condition (CC; n = 11) intervention. Following discharge, participants completed weekly exercises and phone calls with a study trainer. PP intervention feasibility was assessed by the number of exercises completed, and acceptability was examined on five-point Likert-type scales of ease and utility. Between-group differences on psychological constructs at 4 and 8 weeks post-enrollment were assessed using mixed effects regression models.Results: Participants in the PP group completed an average of three out of four PP exercises and found PP exercises to be subjectively helpful, though neither easy nor difficult. Compared to CC, the PP intervention led to trends towards greater improvements in positive affect and optimism at follow-up, with large effect sizes (modified Cohen's d = 0.95-1.24). PP had variable, non-significant effects on negative psychological constructs.Conclusions: Larger, randomized trials are needed to further evaluate the efficacy of this intervention in this high-risk population.

Development of the State Optimism Measure.

BACKGROUND: Optimism, or positive expectations about the future, is associated with better health. It is commonly assessed as a trait, but it may change over time and circumstance. Accordingly, we developed a measure of state optimism. METHODS: An initial 29-item pool was generated based on literature reviews and expert consultations. It was administered to three samples: sample 1 was a general healthy population (n = 136), sample 2 was people with cardiac disease (n = 96), and sample 3 was persons recovering from problematic substance use (n = 265). Exploratory factor analysis and item-level descriptive statistics were used to select items to form a unidimensional State Optimism Measure (SOM). Confirmatory factor analysis (CFA) was performed to test fit. RESULTS: The selected seven SOM items demonstrated acceptable to high factor loadings on a single dominant factor (loadings: 0.64-0.93). There was high internal reliability across samples (Cronbach's alphas: 0.92-0.96), and strong convergent validity correlations in hypothesized directions. The SOM's correlations with other optimism measures indicate preliminary construct validity. CFA statistics indicated acceptable fit of the SOM model. CONCLUSIONS: We developed a psychometrically-sound measure of state optimism that can be used in various settings. Predictive and criterion validity will be tested in future studies.

Optimizing a Positive Psychology Intervention to Promote Health Behaviors After an Acute Coronary Syndrome: The Positive Emotions After Acute Coronary Events III (PEACE-III) Randomized Factorial Trial.

OBJECTIVE: Despite the clear benefits of physical activity and related behaviors on prognosis, most patients experiencing an acute coronary syndrome (ACS) remain nonadherent to these behaviors. Deficits in positive psychological constructs (e.g., optimism) are linked to reduced participation in health behaviors, supporting the potential utility of a positive psychology (PP)-based intervention in post-ACS patients. Accordingly, we aimed to identify optimal components of a PP-based intervention to promote post-ACS physical activity. METHODS: As part of a multiphase optimization strategy, we completed a randomized factorial trial with eight conditions in 128 post-ACS patients to efficiently identify best-performing intervention components. All participants received a PP-based intervention, with conditions varying in duration (presence/absence of booster sessions), intensity (weekly/daily PP exercises), and content (PP alone or combined with motivational interviewing), allowing three concurrent comparisons within the trial. The study aims included assessments of the overall feasibility, acceptability, and impact of the intervention, along with the primary aim of determining which components were associated with objectively measured physical activity and self-reported health behavior adherence at 16 weeks, assessed using longitudinal models. RESULTS: The intervention was well accepted and associated with substantial improvements in behavioral and psychological outcomes. Booster sessions were associated with greater activity to a nearly significant degree (ß = 8.58, 95% confidence interval = -0.49-17.65, effect size difference = .43, p = .064), motivational interviewing was associated with overall adherence (ß = 0.95, 95% confidence interval = 0.02-1.87, effect size difference = .39, p = .044), and weekly exercise completion was generally superior to daily. CONCLUSIONS: These findings will enable optimization of the PP-based intervention in preparation for a well-powered controlled trial. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT02754895.

A longitudinal investigation of the Concise Health Risk Tracking Self-Report (CHRT-SR) in suicidal patients during and after hospitalization.

The Concise Health Risk Tracking Self-Report (CHRT-SR) scale is a brief self-report instrument to assess suicide risk. Initial investigations have indicated good psychometric properties in psychiatric outpatients. The aims of this paper were to examine the construct validity and factor structure of the twelve- (CHRT-SR12) and seven-item (CHRT-SR7) versions and to test if clinically expected within-person changes in suicide risk over time were measurable using the CHRT-SR in two study cohorts hospitalized for suicidal ideation or behavior: (1) patients with major depressive disorder (MDD) who participated in a psychological intervention trial, n = 65, and (2) participants with bipolar disorder or MDD in an observational study, n = 44. The CHRT-SR12 and self-report measures of hopelessness, depression, and positive psychological states were administered during admission and several times post-discharge. Both versions showed good internal consistency in inpatients and confirmed the three-factor structure (i.e., hopelessness, perceived lack of social support and active suicidal ideation and plans) found in outpatients. CHRT-SR scores had strong correlations with negative and positive affective constructs in the expected directions, and indicated decreases in suicide risk following discharge, in line with clinical expectations. The CHRT-SR12 and CHRT-SR7 are promising self-report measures for assessing suicide risk in very high-risk patient populations.

Magnitude and sources of distress in mid-life adults with chronic medical illness: an exploratory mixed-methods analysis.

Most mid-life adults have at least one chronic medical condition (CMC) and are at risk for developing additional CMCs. Stressors specific to this life stage may contribute to CMC development by hindering healthy behaviors. The goal of this study was to compare sources and intensity of distress, as they relate to health behaviors, between mid-life and non-mid-life adults with CMCs. We utilized a mixed-methods approach by analyzing quantitative self-report measures of psychiatric symptoms and psychological well-being, with in-depth, semi-structured qualitative interviews to identify sources of stress in three cohorts of patients with CMCs (heart failure, type 2 diabetes, and coronary artery disease). Between-group differences on self-report measures were compared via independent samples t-tests and relevant themes from interview transcripts were compared via chi-square analysis. We found that mid-life participants (n = 30) reported greater psychological distress (depression/anxiety) than non-mid-life (n = 62) participants (Hospital Anxiety and Depression Scale scores 13.8 [SD 7.3] vs. 10.6 [SD 6.6]; t(90)=2.13; p = .035), and qualitative analysis revealed several specific sources of stress significantly more common (p < .001) in mid-life adults. Interventions targeting the needs of this population could reduce distress, improve health behaviors, and have a major impact on public health.

The Positive Emotions after Acute Coronary Events behavioral health intervention: Design, rationale, and preliminary feasibility of a factorial design study.

BACKGROUND: Positive psychological constructs, such as optimism, are associated with greater participation in cardiac health behaviors and improved cardiac outcomes. Positive psychology interventions, which target psychological well-being, may represent a promising approach to improving health behaviors in high-risk cardiac patients. However, no study has assessed whether a positive psychology intervention can promote physical activity following an acute coronary syndrome. OBJECTIVE: In this article we will describe the methods of a novel factorial design study to aid the development of a positive psychology-based intervention for acute coronary syndrome patients and aim to provide preliminary feasibility data on study implementation. METHODS: The Positive Emotions after Acute Coronary Events III study is an optimization study (planned N = 128), subsumed within a larger multiphase optimization strategy iterative treatment development project. The goal of Positive Emotions after Acute Coronary Events III is to identify the ideal components of a positive psychology-based intervention to improve post-acute coronary syndrome physical activity. Using a 2 × 2 × 2 factorial design, Positive Emotions after Acute Coronary Events III aims to: (1) evaluate the relative merits of using positive psychology exercises alone or combined with motivational interviewing, (2) assess whether weekly or daily positive psychology exercise completion is optimal, and (3) determine the utility of booster sessions. The study's primary outcome measure is moderate-to-vigorous physical activity at 16 weeks, measured via accelerometer. Secondary outcome measures include psychological, functional, and adherence-related behavioral outcomes, along with metrics of feasibility and acceptability. For the primary study outcome, we will use a mixed-effects model with a random intercept (to account for repeated measures) to assess the main effects of each component (inclusion of motivational interviewing in the exercises, duration of the intervention, and inclusion of booster sessions) from a full factorial model controlling for baseline activity. Similar analyses will be performed on self-report measures and objectively-measured medication adherence over 16 weeks. We hypothesize that the combined positive psychology and motivational interviewing intervention, weekly exercises, and booster sessions will be associated with superior physical activity. RESULTS: Thus far, 78 participants have enrolled, with 72% of all possible exercises fully completed by participants. CONCLUSION: The Positive Emotions after Acute Coronary Events III study will help to determine the optimal content, intensity, and duration of a positive psychology intervention in post-acute coronary syndrome patients prior to testing in a randomized trial. This study is novel in its use of a factorial design within the multiphase optimization strategy framework to optimize a behavioral intervention and the use of a positive psychology intervention to promote physical activity in high-risk cardiac patients.

Cost-Effectiveness of a Collaborative Care Depression and Anxiety Treatment Program in Patients with Acute Cardiac Illness.

OBJECTIVE: To use data from a randomized trial to determine the cost-effectiveness of a collaborative care (CC) depression and anxiety treatment program and to assess effects of the CC program on health care utilization. METHODS: The CC intervention's impact on health-related quality of life, depression-free days (DFDs), and anxiety-free days (AFDs) over the 24-week postdischarge period was calculated and compared with the enhanced usual care (EUC) condition using independent samples t tests and random-effects regression models. Costs for both the CC and EUC conditions were calculated on the basis of staff time, overhead expenses, and treatment materials. Using this information, incremental cost-effectiveness ratios were calculated. A cost-effectiveness acceptability plot was created using nonparametric bootstrapping with 10,000 replications, and the likelihood of the CC intervention's cost-effectiveness was assessed using standard cutoffs. As a secondary analysis, we determined whether the CC intervention led to reductions in postdischarge health care utilization and costs. RESULTS: The CC intervention was more costly than the EUC intervention ($209.86 vs. $34.59; z = -11.71; P < 0.001), but was associated with significantly greater increases in quality-adjusted life-years (t = -2.49; P = 0.01) and DFDs (t = -2.13; P = 0.03), but not AFDs (t = -1.92; P = 0.057). This translated into an incremental cost-effectiveness ratio of $3337.06 per quality-adjusted life-year saved, $13.36 per DFD, and $13.74 per AFD. Compared with the EUC intervention, the CC intervention was also associated with fewer emergency department visits but no differences in overall costs. CONCLUSIONS: This CC intervention was associated with clinically relevant improvements, was cost-effective, and was associated with fewer emergency department visits in the 24 weeks after discharge.

Understanding motivations to participate in an observational research study: Why do patients enroll?

By understanding common motivations for participating in observational research studies, clinicians may better understand the perceived benefits of research participation from their clients' perspective. We enrolled 164 cardiac patients in a study about the effects of gratitude and optimism. Two weeks post-enrollment, participants completed a four-item questionnaire regarding motivations for study enrollment. Altruistic motivation ranked highest, while intellectual, health-related, and financial motivations rated lower. Four subgroups of participants emerged, each with distinct characteristics and different priorities for participating. These findings may help front-line clinicians to understand which motivations for participation apply to their clients who enroll in non-treatment-based research projects.

A Positive Psychology Intervention for Patients with an Acute Coronary Syndrome: Treatment Development and Proof-of-Concept Trial.

Positive psychological constructs are associated with superior outcomes in cardiac patients, but there has been minimal study of positive psychology (PP) interventions in this population. Our objective was to describe the intervention development and pilot testing of an 8-week phone-based PP intervention for patients following an acute coronary syndrome (ACS). Initial intervention development and single-arm proof-of-concept trial, plus comparison of the PP intervention to a subsequently-recruited treatment as usual (TAU) cohort. PP development utilized existing literature, expert input, and qualitative interview data in ACS patients. In the proof-of-concept trial, the primary outcomes were feasibility and acceptability, measured by rates of exercise completion and participant ratings of exercise ease/utility. Secondary outcomes were pre-post changes in psychological outcomes and TAU comparisons, measured using effect sizes (Cohen's d). The PP intervention and treatment manual were successfully created. In the proof-of-concept trial, 17/23 PP participants (74 %) completed at least 5 of 8 exercises. Participants rated the ease (M = 7.4/10; SD = 2.1) and utility (M = 8.1/10, SD = 1.6) of PP exercises highly. There were moderate pre-post improvements (ds = .46-.69) in positive affect, anxiety, and depression, but minimal effects on dispositional optimism (d = .08). Compared to TAU participants (n = 22), PP participants demonstrated greater improvements in positive affect, anxiety, and depression (ds = . 47-.71), but not optimism. A PP intervention was feasible, well-accepted, and associated with improvements in most psychological measures among cardiac patients. These results provide support for a larger trial focusing on behavioral outcomes.

Positive psychological states and health behaviors in acute coronary syndrome patients: A qualitative study.

Positive psychological states are linked to superior cardiac outcomes, possibly mediated through increased participation in health behaviors. Trained study staff conducted in-depth semi-structured interviews in the hospital and 3 months later for 34 patients diagnosed with an acute coronary syndrome. These interviews focused on positive psychological states, cardiac health behaviors, and their connection; the interviews were transcribed and independently coded using directed content analysis. Both optimism and positive affect were associated with completion of physical activity and healthy eating in a bidirectional manner. In contrast, gratitude, while common, was infrequently linked to completion of health behaviors.

Implementing collaborative care programs for psychiatric disorders in medical settings: a practical guide.

OBJECTIVE: Collaborative care is a systematic, team-based approach to the management of depression and other psychiatric disorders in medical settings. Collaborative care has been found to be effective and cost-effective, but there is little information to guide its implementation in clinical care. The objective of this article is to provide a practical guide to the implementation of collaborative care programs in real-world settings. METHODS: Based on our experience delivering collaborative care programs, we provide (a) specific, stepwise recommendations for the successful implementation of collaborative care in outpatient settings and (b) an examination of the additional benefits and challenges of collaborative care programs that begin during hospitalization. RESULTS: The implementation of collaborative care requires senior buy-in, an effective team, clear treatment components, engaged clinicians, procedures to ensure quality and adequate infrastructure. Beginning these programs with hospitalized patients may offer additional advantages but also requires additional flexibility to adapt to the inpatient setting. CONCLUSION: A systematic approach to the development and implementation of collaborative care programs may allow clinicians to effectively and efficiently treat psychiatric illness in medical populations in both inpatient and outpatient settings.

Use of the Patient Health Questionnaire-9 and a detailed suicide evaluation in determining imminent suicidality in distressed patients with cardiac disease.

BACKGROUND: The risk of suicide is elevated in patients with cardiac disease in comparison with the general population. OBJECTIVE: In distressed cardiac inpatients, we explored the use of Item 9 of the Patient Health Questionnaire-9, which inquires about thoughts of death or suicide, and a detailed suicide evaluation (DSE) triggered by positive responses to Item 9 as means of assessing suicide. METHODS: Among cardiac inpatients endorsing current emotional distress, we recorded the prevalence of positive responses to Item 9, gathered information about outcomes and time spent completing the DSE, and examined the frequency of imminent suicidality identified by the DSE among Item 9-positive patients. RESULTS: Among 366 patients, 77 (21%) answered affirmatively to Item 9. All DSEs were successfully completed but consumed 17 clinician hours. Among the 71 patients receiving the DSE, 2 (0.5% of total sample; 2.8% of Item 9-positive patients) were imminently suicidal (i.e., had intent or plan). CONCLUSION: Nearly 1 in 4 patients had a positive response to Item 9, but very few had imminent suicidality; the DSE was easy to use and acceptable to patients but time consuming. A more narrowly focused alternative to Item 9 may more accurately predict imminent suicidality and reduce the burden of further detailed suicide screening.

An exploratory mixed methods analysis of adherence predictors following acute coronary syndrome.

Adherence to cardiac health behaviors is a critical predictor of prognosis in the months following an acute coronary syndrome (ACS). However, there has been minimal concomitant study of multiple nonadherence risk factors, as assessed via record review, structured assessments, and qualitative interviews, among hospitalized ACS patients. Accordingly, we completed an exploratory mixed methods study with 22 individuals who were admitted for ACS and had suboptimal pre-ACS adherence to physical activity, heart-healthy diet, and/or medications, defined by a Medical Outcomes Study Specific Adherence Scale (MOS SAS) score <15/18. During hospitalization, participants underwent quantitative assessments of sociodemographic, medical, and psychological variables, followed by in-depth semi-structured interviews to explore intentions, plans, and perceived barriers related to post-discharge health behavior changes. The MOS SAS was readministered at 3 months and participants were designated as persistently nonadherent (MOS SAS <15; n = 9) or newly adherent (n = 13). Interviews were transcribed and coded by trained raters via content analysis, and quantitative variables were compared between groups using chi-square analysis and independent-samples t-tests. On our primary qualitative analysis, we found that participants with vaguely described intentions/plans regarding health behavior change, and those who focused on barriers to change that were perceived as static, were more likely to be persistently nonadherent. On exploratory quantitative analyses, greater medical burden, diabetes, depressive symptoms, and low optimism/positive affect at baseline were associated with subsequent post-ACS nonadherence (all p < .05). In conclusion, this appears to be the first study to prospectively examine all of these constructs in hospitalized ACS patients, and we found that specific factors were associated with nonadherence to key health behaviors 3 months later. Therefore it may be possible to predict future nonadherence in ACS patients, even during hospitalization, and specific interventions during admission may be indicated to prevent adverse outcomes among patients at highest risk for post-ACS nonadherence.

Collaborative care for depression and anxiety disorders in patients with recent cardiac events: the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized clinical trial.

IMPORTANCE: Depression and anxiety are associated with adverse cardiovascular outcomes in patients with recent acute cardiac events. There has been minimal study of collaborative care (CC) management models for mental health disorders in high-risk cardiac inpatients, and no prior CC intervention has simultaneously managed depression and anxiety disorders. OBJECTIVE: To determine the impact of a low-intensity CC intervention for depression, generalized anxiety disorder, and panic disorder among patients hospitalized for an acute cardiac illness. DESIGN, SETTING, AND PARTICIPANTS: Single-blind randomized clinical trial, with study assessors blind to group assignment, from September 2010 through July 2013 of 183 patients admitted to inpatient cardiac units in an urban academic general hospital for acute coronary syndrome, arrhythmia, or heart failure and found to have clinical depression, generalized anxiety disorder, or panic disorder on structured assessment. INTERVENTIONS: Participants were randomized to 24 weeks of a low-intensity telephone-based multicomponent CC intervention targeting depression and anxiety disorders (n = 92) or to enhanced usual care (serial notification of primary medical providers; n = 91). The CC intervention used a social work care manager to coordinate assessment and stepped care of psychiatric conditions and to provide support and therapeutic interventions as appropriate. MAIN OUTCOMES AND MEASURES: Improvement in mental health-related quality of life (Short Form-12 Mental Component Score [SF-12 MCS]) at 24 weeks, compared between groups using a random-effects model in an intent-to-treat analysis. RESULTS: Patients randomized to CC had significantly greater estimated mean improvements in SF-12 MCS at 24 weeks (11.21 points [from 34.21 to 45.42] in the CC group vs 5.53 points [from 36.30 to 41.83] in the control group; estimated mean difference, 5.68 points [95% CI, 2.14-9.22]; P = .002; effect size, 0.61). Patients receiving CC also had significant improvements in depressive symptoms and general functioning, and higher rates of treatment of a mental health disorder; anxiety scores, rates of disorder response, and adherence did not differ between groups. CONCLUSIONS AND RELEVANCE: A novel telephone-based, low-intensity model to concurrently manage cardiac patients with depression and/or anxiety disorders was effective for improving mental health-related quality of life in a 24-week trial. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01201967.

Patient Health Questionnaire-9 score and adverse cardiac outcomes in patients hospitalized for acute cardiac disease.

OBJECTIVE: The Patient Health Questionnaire-9 (PHQ-9) is increasingly used as a depression assessment tool in cardiac patients. However, in contrast to older depression instruments, there is little data linking PHQ-9 scores to adverse cardiac outcomes. Our goal was to evaluate whether higher PHQ-9 scores were predictive of subsequent cardiac readmissions among depressed patients hospitalized for an acute cardiac event. METHODS: Patients diagnosed with depression during hospitalization for acute coronary syndrome, heart failure, or arrhythmia were enrolled in a randomized depression management trial. Participants were administered PHQ-9 at enrollment, and data was collected regarding cardiac readmissions and mortality over the next 6months. To evaluate the independent association of PHQ-9 score with subsequent cardiac readmission, Cox regression analysis that included relevant sociodemographic and medical covariates was used. Survival analysis examining time to first event, stratified by quartile of initial PHQ-9 score, was performed using Kaplan-Meier curves and log-rank test for trend. Analyses were then repeated using a composite (cardiac readmission or mortality) outcome. RESULTS: Among 172 subjects, 62 (36.0%) had a cardiac-related rehospitalization. Higher initial PHQ-9 score predicted cardiac-related rehospitalization, independent of multiple relevant covariates (hazard ratio 1.09 [95% confidence interval=1.02-1.17]; p=0.015). On survival analysis, log-rank test for trend revealed a significant rise in event rates across increasing PHQ-9 quartiles (χ(2)=6.36; p=0.012). Findings were similar (p<.05) for the composite outcome. CONCLUSION: In depressed cardiac patients, each additional point on the PHQ-9 was independently associated with a 9% greater risk of cardiac readmission over the subsequent 6months.

Design and baseline data from the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized controlled trial.

BACKGROUND: Depression and anxiety in cardiac patients are independently associated with adverse cardiovascular outcomes, including mortality. Collaborative care (CC) programs, which use care managers to assess patients, coordinate care, and perform therapeutic interventions, have proven effective in managing depression in this population. However, no prior CC intervention has simultaneously managed depression and anxiety disorders, and there has been minimal study of CC in high-risk cardiac inpatients. MATERIALS AND METHODS: The Management of Sadness and Anxiety in Cardiology (MOSAIC) study was a prospective randomized trial of a low-intensity CC intervention, compared to enhanced usual care, for patients hospitalized for acute coronary syndrome, heart failure, or arrhythmia, and diagnosed with depression, generalized anxiety disorder (GAD), or panic disorder (PD). The primary outcome measure for MOSAIC was mental health-related quality of life (HRQoL), measured using the Medical Outcomes Study Short Form-12. Additional outcomes included psychological, functional, and medical outcomes, including rehospitalizations. RESULTS: A total of 183 eligible participants were enrolled (92 collaborative care, 91 enhanced usual care); 94% of depressed patients reported being depressed for >1month, and 53% of those with GAD reported clinically significant anxiety for >1year. One hundred thirty-three patients had depression, 118 had GAD, and 19 had PD; 74 participants (40%) had two or more of the disorders. CONCLUSION: The MOSAIC trial will provide data regarding whether an intervention that concurrently manages these common psychiatric disorders results in meaningful improvements in HRQoL, psychiatric symptoms, and medical outcomes in cardiac patients at high risk for adverse outcomes.

Baseline physical health-related quality of life and subsequent depression outcomes in cardiac patients.

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

Feasibility and utility of screening for depression and anxiety disorders in patients with cardiovascular disease.

BACKGROUND: Depression and anxiety in patients with cardiac disease are common and independently associated with morbidity and mortality. We aimed to explore the use of a 3-step approach to identify inpatients with cardiac disease with depression, generalized anxiety disorder (GAD), or panic disorder; understand the predictive value of individual screening items in identifying these disorders; and assess the relative prevalence of these disorders in this cohort. METHODS AND RESULTS: To identify depression and anxiety disorders in inpatients with cardiac disease as part of a care management trial, an iterative 3-step screening procedure was used. This included an existing 4-item (Coping Screen) tool in nursing data sets, a 5-item screen for positive Coping Screen patients (Patient Health Questionnaire-2 [PHQ-2], GAD-2, and an item about panic attacks), and a diagnostic evaluation using PHQ-9 and the Primary Care Evaluation of Mental Disorders anxiety disorder modules. Overall, 6210 inpatients received the Coping Screen, 581 completed portions of all 3 evaluation steps, and 210 received a diagnosis (143 depression, 129 GAD, 30 panic disorder). Controlling for age, sex, and the other screening items, PHQ-2 items independently predicted depression (little interest/pleasure: odds ratio [OR]=6.65, P<0.001; depression: OR=5.24, P=0.001), GAD-2 items predicted GAD (anxious: OR=4.09, P=0.003; unable to control worrying: OR=10.46, P<0.001), and the panic item predicted panic disorder (OR=49.61, P<0.001). CONCLUSIONS: GAD was nearly as prevalent as depression in this cohort, and GAD-2 was an effective screening tool; however, panic disorder was rare. These results support the use of 2-step screening for depression and GAD beginning with a 4-item scale (GAD-2 plus PHQ-2). CLINICAL TRIAL REGISTRATION: Unique Identifier: NCT01201967. URL: http://www.clinicaltrials.gov/ct2/show/NCT01201967.

Risk factors for positive depression screens in hospitalized cardiac patients.

BACKGROUND: Depression is common in patients with cardiac illness and is independently associated with elevated morbidity and mortality. There are screening guidelines for depression in cardiac patients, but the feasibility and cost-effectiveness of screening all cardiac patients is controversial. This process may be improved if a subset of cardiac patients at high risk for depression could be identified using information readily available to clinicians and screened. OBJECTIVE: To identify risk factors for a positive depression screen at the time of admission in hospitalized cardiac patients. METHODS: A total of 561 consecutively screened cardiac inpatients underwent the Patient Health Questionnaire-2 (PHQ-2). A prospective chart review was performed to assess potential risk factors for depression that would be readily available to front-line clinicians. Rates of risk factors were compared between patients with positive and negative PHQ-2 depression screens, and multivariate logistic regression was performed to assess whether specific risk factors were independently associated with positive screens. RESULTS: Of the 561 patients screened, 13.5% (n=76) had a positive depression screen (PHQ-2≥2). In the univariate analyses, several variables were associated with a positive depression screen. On multivariate analysis, an elevated white blood cell (WBC) count (>10×10(9) cells per liter) and prescription of an antidepressant on admission were independently associated with a positive depression screen, while current smoking showed a trend toward significance. CONCLUSION: Information on these three identified risk factors (WBC count, antidepressant use, and smoking) is readily available to clinicians, and patients with these diagnoses may represent a cohort who would benefit from targeted depression screening in certain settings.