European Journal of Cardiovascular Nursing 10 (2011) 228–233www.elsevier.com/locate/ejcnurse

The advisory brought to practiceRoutine screening on depression (and anxiety) in coronary heart disease;

consequences and implications

M.L.A. Luttika,⁎, T. Jaarsmab,c, R. Sandermand, and J. Fleerd

a Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlandsb Institutionen för Samhälls- och Välfärdsstudier, Linköping University, Sweden

c Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlandsd Department of Health Sciences, Section Health Psychology, University Medical Center Groningen, University of Groningen, The Netherlands

Received 16 March 2010; received in revised form 5 July 2010; accepted 16 August 2010Available online 26 September 2010

Abstract

Introduction: Following the evidence, the American Heart Association recently published a Science Advisory with the recommendation thatpatients with Coronary Heart Disease (CHD) should be screened for depressive symptoms and depression. Also the Heart Failure Guidelinesrecommend routine screening for depressive symptoms. Screening for anxiety was not included in these recommendations, despite findingsin literature suggesting that cardiac patients are at risk for high levels of anxiety.Objective: The aim of the current study is to obtain a realistic estimation of the consequences and implications of this advice for clinicalpractice.Method: Data on anxiety, and depression, need for help, demographics and disease related variables were collected in a cross-sectional studywithin a 2-month period (July–August 2008) at the cardiac outpatient clinic of the University Medical Center Groningen (The Netherlands).Patients: Data of 217 patients were analyzed, mean age was 58 years (±16) and 62% of the respondents were male.Results: Of 217 patients, 26% indicated to have depressive symptoms and 42% indicated elevated levels of anxiety. About 35–50% of thesepatients indicated a moderate to high need for help. The prevalence of anxiety and depression was mainly associated with demographicfactors and the occurrence of stressful life events.Conclusion: Routine screening will put an increased demand on psychosocial diagnostics and treatment, therefore the availability ofprofessionals should be guaranteed in advance.© 2010 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

Keywords: Screening; Advisory; Cardiac; Heart failure; Anxiety; Guidelines

1. Introduction

Depression and anxiety are highly common in patientswith various cardiac conditions, such as acute coronarysyndrome (ACS) [1,2], myocardial infarction (MI) [3,4],

⁎ Corresponding author. Department of Cardiology, University MedicalCenter Groningen, Postbox 30.001, 9700 RB Groningen, The Netherlands.Tel.: +31 50 3611594.

E-mail address: m.l.a.luttik@thorax.umcg.nl (M.L.A. Luttik).

1474-5151/$ - see front matter © 2010 European Society of Cardiology. Publishdoi:10.1016/j.ejcnurse.2010.08.005

and heart failure (HF) [5–7]. Both depression and anxietyrelate to negative health outcomes such as recurrentcardiac events, impaired well being and quality of lifeand increased health care costs in these patient populations[8–12]. Early identification and accurate treatment areconsidered important in view of the patient's health andwell being and from the perspective of cost-effectiveness.Following the evidence, the American Heart Associationrecently published a Science Advisory with the recom-mendation that patients with Coronary Heart Disease

ed by Elsevier B.V. All rights reserved.

229M.L.A. Luttik et al. / European Journal of Cardiovascular Nursing 10 (2011) 228–233

should be screened for depressive symptoms and depres-sion [13]. Also the Heart Failure Guidelines [14,15]recommend routine screening for depressive symptoms.Screening for anxiety was not included in these recom-mendations, despite findings in literature suggesting thatcardiac patients are at risk for highly levels of anxiety [16].The aim of the current study is to calculate theimplications of the recommendation to screen for depres-sion in clinical practice. Given the evidence, however, wewill not only focus on depression, but also include anxietyin our analyses.

To obtain a realistic estimation of the clinical implica-tions of screening, several factors should be taken intoaccount. First, data on the prevalence of depression andanxiety should be obtained from an unselected sample ofpatients visiting a cardiac outpatient clinic. Currently,however, prevalence data are mostly obtained from patientpopulations that are not representative for the patients thatvisit outpatient clinics in day to day practice. For instance,randomized clinical trials tend to include younger patientswith a better cardiovascular risk profile compared topatients in everyday practice [17]. Also, many studiesfocus on specific cardiac patient populations (mostlypatients after MI or patients with HF); while patients ineveryday practice often cannot be classified in one of thesecategories. Patients develop heart failure after a myocardialinfarction or heart failure patients are confronted witharrhythmic complications.

Second, realistic estimations of the practical implica-tions can only be obtained when cardiac patients' need forhelp is taken into account. Indeed, studies in cancerpatients show that not all patients with elevated levels ofanxiety or depression feel the desire for psychologicalsupport [18,19]. The perceived need for help was, forinstance, lower among men, among older patients andamong patients with a lower educational level, and higheramong cancer patients treated with radiotherapy [17,18].Thus, not every cardiac patient with elevated levels ofdistress might feel the need for additional psychosocialcare.

Lastly, when hospitals are to adopt screening, appropriatereferral and treatment should be available [20]. Yet, one typeof intervention might not be effective for every patient. Toillustrate, the reduction in mortality after psychologicaltreatment that Linden et al. [21] found in their meta-analyseswas found only in men, not in women. These findingsindicate that female cardiac patients may benefit from adifferent type of intervention than male cardiac patients. So,for the development of appropriate interventions, it isrelevant to have insight into the characteristics of thepopulation of patients likely to be referred for additionalpsychosocial care.

In sum, the aim of the current study is to investigateprevalence of depression and anxiety in a day to day practice,outpatient population, as well as the perceived need for helpin this population. Furthermore, we will explore which

demographic and illness-related factors are associated withhigh levels of depression and anxiety.

2. Methods

2.1. Design and procedure

Data were collected in a cross-sectional study within a2-months period (July and August, 2008). Questionnaireswere handed out to all patients visiting the cardiacoutpatient clinic of the University Medical Center ofGroningen (UMCG) in The Netherlands during 3 days aweek, covering all different cardiac patient populations.Patients were free to fill in the questionnaire during theirvisit at the outpatient clinic or at home (and send it backby mail in a pre-stamped envelope).

The study conforms with the principles outlined in theDeclaration of Helsinki and was approved by the Committeefor Ethics in Medical Investigations of the UMCG. Allpatients signed a written informed consent.

2.2. Measures

Depressive symptoms were measured with the Center ofEpidemiologic Studies Depression Scale (CES-D)[22]. TheCES-D is a 20-item self-report questionnaire measuringdepressive symptoms in the general population and in themedically ill [22,23]. A total sum-score is used (0–60), withhigher scores indicating more depressive symptoms. Acutoff point of 16 is generally used to define patients at riskfor a clinical depression [24].

Anxiety was measured with the 6-item short form of theState Trait Anxiety Inventory (STAI). This short formversion has been validated for the Dutch situation, andproved to be sufficient in terms of reliability and validity[25]. Items can be scored on a four-point scale, giving a totalsum-score ranging from 20 to 80 with higher scoresindicating higher levels of anxiety. A threshold value forthe sum-score of 40 is suggested [26,27]. Above this scoreclinically significant anxiety should be suspected.

Perceived need for help was measured with a visualanalogue scale (thermometer format) with an 11 point Likertscale ranging from 0 (can manage by myself) to 10(desperately). This measure is derived from the EmotionThermometers developed by Mitchell et al. [28] and adaptedfor use in the Dutch situation. (See also http://www.psycho-oncology.info/ET.htm).

Questionnaires contained a set of self-report questionsregarding demographics, experienced life events and diseaserelated variables. Demographic data were collected on age,gender, marital status and educational status. The prevalenceof recent stressful life events was evaluated with a shortened,7-item version of a questionnaire developed by Holmes [29].The following disease related data were collected; type ofcardiac diagnosis, duration of the heart disease and thepresence of co-morbid diseases.

Table 1Patient characteristics (n=217).

DemographicsAge (yrs±SD; range) 58.5±16 (16–91)Gender (% male) 62%Marital status

Married/living with partner 79%Living alone 21%

EducationLow 62%High 38%

Illness-relatedDuration of heart disease

0–1 year 28%More than 1 year 72%

Diagnosis (self-reported yes)Myocardial Infarction 24%Arrhythmias 48%Heart Failure 22%Congenital Heart Disease 12%Valvular Heart Disease 21%Coronary Artery Disease 14%Do not know (n=14) 6%Other (n=2) 2%

Number of diagnosisDiagnosis unknown 6%1 diagnosis 59%N1 35%

Co-morbidity≥1 co-morbidity 44%

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2.3. Statistical analyses

All data were entered into an SPSS database. Perceivedneed for help was recorded into ‘no need for help’ (0–3),‘moderate need for help’ (4–6) and ‘high need for help’ (7–10). Marital status was dichotomized into patients that weremarried or living together as one category and patients livingalone, either single, divorced or widowed, as the othercategory. Educational status was categorized as into low forpatients having primary school or lower and middlesecondary school or a lower vocational degree. Patientswere categorized into a high educational status when havinghigh secondary school, a higher vocational or universitydegree. Descriptive statistics were used to describe the studypopulation. Student t-tests, Chi-square tests and one-wayANOVA tests were used to test associations betweendepression, anxiety and the demographic and illness-relatedvariables.

3. Results

3.1. Response and study population

During the 2-month period of data collection 450 sets ofquestionnaires were handed out. In total 217 were completedand returned, a response of 48%.

Patients participating in the study had a mean age of 58.5(SD 16) years and were mostly male (62%). Most oftenreported diagnoses were: arrhythmia's (48%), myocardialinfarction (24%), and heart failure (22%). Thirty-five percentof patients reported to have more than one diagnosis and44% of the patients reported to have one or more co-morbidities, such as diabetes and COPD (Table 1).

3.2. Prevalence of depression and anxiety

Using the CES-D to assess depressive symptoms, a meanscore of 11.5 (SD 9) was found for the total group. Elevatedlevels of depressive symptoms (≥16) were prevalent in 26%(n=53) of all patients. When using the STAI-6 to measureanxiety, patients had a mean score of 37.5 (SD 12). Forty-two percent of all patients (n=87) reported clinicallyelevated levels of anxiety (STAI6≥40). Forty-four patients(22% of all patients) scored above the cut off of both theCES-D and the STAI6. However, there were 37 patients(19%) who had scored above the cutoff of the STAI6,without having elevated scores on depressive symptoms.Only 6 patients with clinically elevated levels of depressivesymptoms (CES-D≥16) did not report significant levels ofanxiety (STAI6≥40).

3.3. Perceived need for help in patients with elevated levelsof depression and anxiety

Of the 53 patients with clinically elevated levels ofdepressive symptoms, 50% (n=26) reported feeling no or

little need for help (score 0–3), 50% indicated moderate tohigh perceived need for help (scoreN3). Of the 87 patientswith elevated levels of anxiety, 65% (n=55) indicated tohave little or no need for help and 35% (n=30) perceived amoderate to high need for help. No differences indemographics or illness-related variables were foundbetween patients that felt a need for help and patients whodid not.

3.4. Related factors

The prevalence of depression and anxiety was mainlyassociated with demographic variables such as gender andeducational status, with females and patients with loweducational levels indicating higher levels of depressivesymptoms and anxiety. Elevated levels of depressivesymptoms were also specifically present in patients whowere living alone. The prevalence of stressful live events wassignificantly associated with both depression and anxiety.Disease related factors such as the duration of the heartdisease, the number of cardiac diagnoses were not associatedwith depressive symptoms nor with anxiety (Table 2). Theprevalence of co-morbidities was associated with anxiety,not with depressive symptoms.

Although not significant, it was remarkable to see thatpatients who did not know their cardiac diagnosis (yet)(n=14), had a higher anxiety score compared to patients whoknew their cardiac diagnosis.

Table 2Factors associated with high levels of depression and anxiety.

Depression %≥16 Anxiety %≥40

χ2 p χ2 p

DemographicsAge a Mean, SDb16: 57.9, 15.7 t=−.46 .65 Mean, SD≤40: 58.3, 15.9 t=.36 .72

Mean, SD≥16: 59.1, 16.1 Mean, SDN40: 57.6, 15.5Gender Male 21 4.8 .03** 35 7.21 .00***

Female 35 55Marital status Married 19 14.5 .00*** 39 2.8 .09*

Living alone 48 53Educational status Low 31% 5.6 .02** 51 11.1 .00***

High 16% 27

Illness-relatedDuration of heart disease 0–1 year 27 .08 .78 45 .24 .62

N1 yr 25 41

DiagnosisMyocardial infarction Yes 19 1.4 .26 42 .01 .94

No 28 42Arrhythmia's Yes 32 3.7 .08* 44 .16 .69

No 20 41Heart failure Yes 38 4.4 .05* 49 1.07 .30

No 22 40Congenital heart disease Yes 12 2.8 .14 35 .69 .40

No 28 43Valvular heart disease Yes 20 .82 .44 38 .45 .50

No 27 43Coronary artery disease Yes 22 .20 .81 45 .09 .75

No 26 42Do not know diagnosis Yes 33 .38 .51 58 1.37 .24

No 25 41Number of diagnoses b Diagnoses unknown 33 .38 .68 50 .55 .57

1 24 33N1 28 35

Co-morbidity Yes 29 .72 .41 49 3.75 .05*No 23 36

Life events Yes 36 5.9 .02** 51 3.4 .07*No 20 38

All other differences were tested by using Chi2-tests; *pb .10; **pb .05; ***pb .01.a Student t-test.b ANOVA.

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4. Discussion

In an unselected, day to day outpatient cardiac populationwe found that 26% of the patients experienced depressivesymptoms. Compared to a prevalence of 16% in a referencepopulation of healthy elderly [30], these cardiac patients doworse. Furthermore, 42% of patients indicated elevated levelsof anxiety. Of these patients, a substantial number scored highon anxiety without having depressive symptoms. These scoresare higher compared to the 29% in the study of Jiang [31] andlower compared to the 45% in the study of Friedmann [10]. In astudy on patients after coronary artery or valve surgery,Szekely [12] found that 42% of these patients presentedclinically significant anxiety symptoms. These results stressthe importance to screen for anxiety as well as for depression.

Our findings also indicate that the implementation of theguidelines' recommendation to screen, refer and treat

depression in patients with coronary heart disease [13]would have serious consequences for clinical practice. Inabout 26–42% of patients, elevated levels of depression oranxiety would be found and, as a consequence, should bediscussed with patients. This is likely to cost extra time fromthe health care professional assigned to discuss the results.Furthermore, health care professionals probably need trainingto be able to accurately refer patients, as some patients mightbenefit from consultation with a psychiatrist or psychologistwhereas others might benefit from rehabilitation in whichphysical training is combined with psychological care.

Screening also would have serious consequences in termsof the number of referrals and treatment capacity. Thirty-fiveto fifty percent of the patients with elevated levels of anxietyor depression might indicate to feel the need for additionalpsychosocial care. Within a population of 1000 cardiacpatients, 100–200 (10–20%) patients would need a referral

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for further diagnostics. These percentages indicate thatclinics should have or should set up an extensivepsychosocial unit with psychologists and social workers toaccommodate these patients with their needs.

Although most of the current guidelines in Cardiologyrecommend routine screening on depression in cardiacpatients, one should realize the serious consequences fordaily practice before starting up such a screening. First of all,the availability of sufficient psychological and psychiatriccare should be guaranteed. Given the number of patients thatwill be in need for psychological or psychiatric care, it willbe important to develop cost-effective and efficient ways ofproviding this care. In this respect one might considerfollowing a stepped care model, in which one starts withlow-intensity treatments (e.g., self-help such as biblio-therapy, or brief therapies), and only turn to high-intensitywhen gain is not achieved with those simpler treatments [32].The current developments in e-health may offer new andefficient ways of treatment as well. For instance, the study ofHill et al. [33] showed that a computer-based interventionwas useful in providing support for socially isolatedchronically ill women.

Based on our findings we suggest that several aspectsshould be taken into account when developing a programwith interventions for cardiac patients. Firstly, there is a needfor interventions that focus on both depression and anxiety.Anxious patients might need a different approach thandepressed patients. Secondly, interventions should beespecially appropriate for women, those with a loweducational status, and those who lack social support (i.e.,live alone), as these are the cardiac patients at high risk for adepressed or anxious mood.

The response rate of 48% may have caused bias limitingthe representativeness of the study population. It might verywell be that the prevalence of depressive symptoms inroutine screening in daily practice is even higher than foundin our study, as depressed patients are more likely not to havethe energy or willingness to fill in a questionnaire.Furthermore, it should be noted that, although the ques-tionnaires that we used are valid and highly sensitive indetecting patients at risk for depression and anxiety,sensitivity was not 100%, and thus the figures do not reflectthe absolute prevalence of patients at risk for a clinicaldepression or of patients with an anxiety disorder. Thereforewe are strong advocates of stepped screening, in whichscreening with questionnaires (step 1) is followed by furtherscreening with diagnostic interviews (step 2) to determinetheir actual psychiatric diagnoses and the type of help thatseems most appropriate given the diagnosis.

5. Conclusion

Once again this study indicated that depression andanxiety are highly present in cardiac patients. Given theproven association between depression and anxiety and forexample recurrent cardiac events and impaired well being in

patients, we acknowledge the importance of adequatediagnosis and treatment. However, when routine screeningof depression and anxiety in patients with coronary heartdisease is to be put into practice, the consequences should bewell considered beforehand. It should be discussed how andby whom the results of screening are to be discussed.Moreover as an increased demand on psychosocial diag-nostics and treatment can be expected, the availability ofwell trained professionals should be guaranteed in advancein order to ensure that patients will receive accurate treatmentafter being diagnosed.

Acknowledgement

Financial support from The Netherlands Heart Foundation(NHF) for this study is gratefully acknowledged.

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