Depression screening in patients with coronary heart disease : A narrative review of the current evidence.

In view of the large and sometimes conflicting body of research, this narrative review summarizes the current evidence on depression screening in patients with coronary heart disease. Depression is a risk factor for development and progression of coronary heart disease. Consequently, many international cardiac guidelines recommend screening for depression in patients with coronary heart disease. However, the efficacy and implementation of these guidelines are debated due to the lack of empirical evidence supporting the benefits of routine depression screening. Studies conducted in cardiac routine care support this assumption: Patients with positive depression screens do not receive adequate follow-up care, which highlights gaps in the detection-to-treatment pathway. Barriers to effective screening and treatment include system-level factors, such as insufficient integration of mental health resources in cardiology, and patient-related factors like stigma and low acceptance of mental health treatment. Innovative interventions that address these barriers and involve patients as active partners in depression care should be developed through a theory-driven, transparent, multistage process involving key stakeholders such as patients, nurses, and cardiologists. A sound methodological evaluation of such multilevel interventions could answer the question of whether early detection of depression in patients with coronary heart disease would lead to health benefits.

The efficacy of automated feedback after internet-based depression screening (DISCOVER): an observer-masked, three-armed, randomised controlled trial in Germany.

BACKGROUND: Despite the availability of effective treatments, most depressive disorders remain undetected and untreated. Internet-based depression screening combined with automated feedback of screening results could reach people with depression and lead to evidence-based care. We aimed to test the efficacy of two versions of automated feedback after internet-based screening on depression severity compared with no feedback. METHODS: DISCOVER was an observer-masked, three-armed, randomised controlled trial in Germany. We recruited individuals (aged ≥18 years) who were undiagnosed with depression and screened positive for depression on an internet-based self-report depression rating scale (Patient Health Questionnaire-9 [PHQ-9] ≥10 points). Participants were randomly assigned 1:1:1 to automatically receive no feedback, non-tailored feedback, or tailored feedback on the depression screening result. Randomisation was stratified by depression severity (moderate: PHQ-9 score 10-14 points; severe: PHQ-9 score ≥15 points). Participants could not be masked but were kept unaware of trial hypotheses to minimise expectancy bias. The non-tailored feedback included the depression screening result, a recommendation to seek professional diagnostic advice, and brief general information about depression and its treatment. The tailored feedback included the same basic information but individually framed according to the participants' symptom profiles, treatment preferences, causal symptom attributions, health insurance, and local residence. Research staff were masked to group allocation and outcome assessment as these were done using online questionnaires. The primary outcome was change in depression severity, defined as change in PHQ-9 score 6 months after random assignment. Analyses were conducted following the intention-to-treat principle for participants with at least one follow-up visit. This trial was registered at ClinicalTrials.gov, NCT04633096. FINDINGS: Between Jan 12, 2021, and Jan 31, 2022, 4878 individuals completed the internet-based screening. Of these, 1178 (24%) screened positive for depression (mean age 37·1 [SD 14·2] years; 824 [70%] woman, 344 [29%] men, and 10 [1%] other gender identity). 6 months after random assignment, depression severity decreased by 3·4 PHQ-9 points in the no feedback group (95% CI 2·9-4·0; within-group d 0·67; 325 participants), by 3·5 points in the non-tailored feedback group (3·0-4·0; within-group d 0·74; 319 participants), and by 3·7 points in the tailored feedback group (3·2-4·3; within-group d 0·71; 321 participants), with no significant differences among the three groups (p=0·72). The number of participants seeking help for depression or initiating psychotherapy or antidepressant treatment did not differ among study groups. The results remained consistent when adjusted for fulfilling the DSM-5-based criteria for major depressive disorder or subjective belief of having a depressive disorder. Negative effects were reported by less than 1% of the total sample 6 months after random assignment. INTERPRETATION: Automated feedback following internet-based depression screening did not reduce depression severity or prompt sufficient depression care in individuals previously undiagnosed with but affected by depression. FUNDING: German Research Foundation.

Patient-centered evaluation of an expectation-focused intervention for patients undergoing heart valve surgery: a qualitative study.

Objective: Randomized controlled trials demonstrate the effectiveness of expectation-focused interventions in improving recovery outcomes following cardiac surgery. For dissemination in routine health care, it is important to capture the perspective of affected individuals. This qualitative study explores the perceived benefits and intervention-specific needs of patients who received expectation-focused intervention in the context of heart valve surgery. In addition, it explores potential barriers and adverse effects. Methods: As part of an Enhanced Recovery After Surgery (ERAS) program within a multicentered randomized controlled trial, patients undergoing minimally invasive heart valve surgery received an intervention focused on their expectations. Six weeks after the intervention, semi-structured interviews were conducted with 18 patients to assess its feasibility, acceptance, barriers, benefits, and side effects. The transcribed interviews were analyzed using qualitative content analysis. Results: The results indicate that both the intervention and the role of the patient and psychologist are key aspects in evaluating the expectation-focused intervention. Five key themes emerged from the patients' perspective: personal needs, expectations and emotions, relationship, communication, and individuality. Patients valued the preparation for surgery and recovery and the space for emotions. Establishing a trustful relationship and addressing stigmatization were identified as primary challenges within the intervention. Conclusion: Overall, patients experienced the expectation-focused intervention as helpful and no adverse effects were reported. Perceived benefits included enhanced personal control throughout the surgery and recovery, while the potential barrier of stigmatization towards a psychologist may complicate establishing a trustful relationship. Addressing personal needs, as a relevant topic to the patients, could be achieved through additional research to identify the specific needs of different patient subgroups. Enhancing the expectation-focused intervention could involve the implementation of a modular concept to address individual needs better.

The Treatment Expectation Questionnaire (TEX-Q): Validation of a generic multidimensional scale measuring patients' treatment expectations.

BACKGROUND: Patients' expectations, as a central mechanism behind placebo and nocebo effects, are an important predictor of health outcomes. Yet, theoretically based generic assessment tools allowing for an integrated understanding of expectations across conditions and treatments are lacking. Based on the preliminary 35-item version, this study reports the development and validation of the Treatment Expectation Questionnaire (TEX-Q), a generic, multidimensional self-report scale measuring patients' expectations of medical and psychological treatments. METHODS: The TEX-Q was developed in a validation sample of n = 251 patients undergoing different treatments using exploratory factor analyses and item analyses, as well as analysis of convergent and divergent validity. Confirmatory factor analysis was conducted in an independent sample of n = 303 patients undergoing cancer treatment. Two-weeks test-retest reliability was assessed in n = 28 psychosomatic outpatients. RESULTS: Factor analyses revealed six theoretically founded stable subscales. The TEX-Q assesses expectations of treatment benefit, positive impact, adverse events, negative impact, process and behavioural control with a total of 15 items. Results for the subscales and the sum score indicated good internal consistency (α = .71-.92), moderate to high test-retest reliability (r = .39-.76) as well as good convergent validity with regard to other expectation measures (r = .42-.58) and divergent validity with regard to measures of generalized expectations (r < .32) and psychopathology (r < .28). CONCLUSIONS: While further validation is needed, the results suggest that the TEX-Q is a valid and reliable scale for the generic, multidimensional assessment of patients' treatment expectations. The TEX-Q overcomes constraints of ad-hoc and disease-specific scales, while allowing to compare the impact of different expectation constructs across conditions and treatments.

Interdisciplinary and cross-sectoral perioperative care model in cardiac surgery: implementation in the setting of minimally invasive heart valve surgery (INCREASE)-study protocol for a randomized controlled trial.

BACKGROUND: Valvular heart diseases are frequent and increasing in prevalence. Minimally invasive heart valve surgery embedded in an interdisciplinary enhanced recovery after surgery (ERAS) program may have potential benefits with regard to reduced length of stay and improved patient reported outcomes. However, no prospective randomized data exist regarding the superiority of ERAS program for the patients' outcome. METHODS: We aim to randomize (1:1) a total of 186 eligible patients with minimally invasive heart valve surgery to an ERAS program vs. standard treatment at two centers including the University Medical Center Hamburg-Eppendorf, Germany, and the University Hospital Augsburg, Germany. The intervention is composed out of pre-, peri-, and postoperative components. The preoperative protocol aims at better preparation for the operation with regard to physical activity, nutrition, and psychological preparedness. Intraoperative anesthesiologic and surgical management are trimmed to enable an early extubation. Patients will be transferred to a specialized postoperative anesthesia care unit, where first mobilization occurs 3 h after surgery. Transfer to low care ward will be at the next day and discharge at the fifth day. Participants in the control group will receive treatment as usual. Primary endpoints include functional discharge at discharge and duration of in-hospital care during the first 12 months after index surgery. Secondary outcomes include health-related quality of life, health literacy, and level of physical activity. DISCUSSION: This is the first randomized controlled trial evaluating the effectiveness of an ERAS process after minimally invasive heart valve surgery. Interprofessional approach is the key factor of the ERAS process and includes in particular surgical, anesthesiological, physiotherapeutic, advanced nursing, and psychosocial components. A clinical implication guideline will be developed facilitating the adoption of ERAS model in other heart teams. TRIAL REGISTRATION: The study has been registered in ClinicalTrials.gov ( NCT04977362 assigned July 27, 2021).

Investigating patients´ views on screening for depression in cardiac practice: A qualitative interview study.

OBJECTIVE: Recommendations on screening for depression in patients with coronary heart disease (CHD) are highly debated. While recent research has prioritized efficacy studies, little is known about what is potentially required for screening to be efficacious. Expanding our knowledge of how patients with CHD view screening is likely to pose a first step towards addressing this gap. We aimed to investigate patients ́ views on routine screening for depression in cardiac practice. METHODS: This exploratory, qualitative study was conducted among 12 patients with CHD, who completed semi-structured interviews. We used a purposive sampling strategy to include patients within a range of ages, gender and self-reported depression. Thematic analysis was carried out. RESULTS: We identified four main themes: Acceptance, utility, barriers and expectations. Patients in this sample appeared to be in favor of standardized routine screening for depression in cardiac practice, if the rationale was disclosed. Patients reported that standardized screening addresses holistic care demands, promotes validation of individual symptom burden and legitimizes the display of psychological distress in cardiac practice. Yet, skepticism towards the validity of screening instruments and perceived stigmatization could pose a main barrier to screening efficacy. Patients expected to receive feedback on results and consecutive recommendations. CONCLUSION: We found that depression screening is endorsed by patients with CHD in this study sample. Standardized routine screening procedures could serve as a useful tool to combat stigmatization, and encourage patients to display symptoms of depression towards cardiologists. The efficacy of depression screening could potentially be enhanced by tailoring the screening process towards patients´ needs.

[Screening for mental comorbidities in dermatology : Successful implementation of a screening for mental comorbidities in the field of inpatient dermatological treatment]. / Screening auf psychische Komorbiditäten in der Dermatologie : Erfolgreiche Implementierung eines Screenings auf psychische Komorbiditäten im Bereich der stationären dermatologischen Versorgung.

BACKGROUND: Anxiety and depression are common in the field of inpatient somatic treatment. Especially in dermatology in which the treatment of chronic diseases is very common and the risk of stigmatization by society is particularly high, mental disorders appear in every third patient. Dermatological diseases and mental disorders often negatively interact with each other leading to increased morbidity. Dermatological guidelines recommend early detection, but this is often not adequately done in practice. MATERIALS AND METHODS: We present the implementation of an easy screening for mental comorbidities in the field of inpatient dermatological treatment by using a short questionnaire. This so-called Patient Health Questionnaire­4 (PHQ-4) consists of four questions regarding anxiety disorders and depression. Upon reaching a certain number of points, a psychosomatic consult is automatically requested. As a result the patient's stress is relieved and the necessary holistic treatment becomes possible. RESULTS: In 2019, 83% of inpatients in our clinic were screened using the PHQ­4; 98 psychosomatic consults were performed. CONCLUSION: Our findings so far have shown the benefit of the screening with a minimal investment of time. We recommend its comprehensive use in the field of inpatient dermatological treatment.

Depression screening with patient-targeted feedback in cardiology: The cost-effectiveness of DEPSCREEN-INFO.

BACKGROUND: Although depression is common in patients with heart disease, screening for depression is much debated. DEPSCREEN-INFO showed that a patient-targeted feedback in addition to screening results in lower depression level six months after screening. The purpose of this analysis was to perform a cost-effectiveness analysis of DEPSCREEN-INFO. METHODS: Patients with coronary heart disease or arterial hypertension were included. Participants in both groups were screened for depression. Participants in the intervention group additionally received a patient-targeted feedback of their result and recommended treatment options. A cost-utility analysis using quality-adjusted life years (QALY) based on the EQ-5D was performed. The time horizon was 6 months. Resource utilization was assessed by a telephone interview. Multiple imputation using chained equations was used. Net-benefit regressions controlled for prognostic variables at baseline were performed to construct cost-effectiveness acceptability curves. Different sensitivity analyses were performed. RESULTS: 375 participants (intervention group: 155; control group: 220) were included at baseline. After 6 months, in the intervention group adjusted total costs were lower (-€2,098; SE: €1,717) and more QALY were gained (0.0067; SD: 0.0133); yet differences were not statistically significant. The probability of cost-effectiveness was around 80% independent of the willingness-to-pay (range: €0/QALY-€130,000/QALY). The results were robust. CONCLUSIONS: A patient-targeted feedback in addition to depression screening in cardiology is cost-effective with a high probability. This underpins the use of the patient-targeted feedbacks and the PHQ-9 that are both freely available and easy to implement in routine care.

Expressive Suppression of Emotions and Overeating in Individuals with Overweight and Obesity.

Emotions have a considerable impact on eating behaviour; however, research addressing emotion regulation in obesity is rare. The present study is the first to investigate the association between emotional suppression and overeating in individuals with overweight. In total, 314 participants including 190 individuals with obesity filled in a cross-sectional online survey, which assessed emotional suppression, eating behaviour and psychopathology. A hierarchical linear regression analysis was conducted to identify factors associated with overeating. Individuals with obesity reported more frequent overeating compared with individuals without obesity. The habitual use of emotional suppression was associated with more overeating; however, this link was moderated by increased body mass index (BMI). The results suggest that suppression of emotional expression contributes to overeating and is maladaptive especially in individuals with obesity. Further research should longitudinally investigate the predictive value of emotional suppression on overweight, as the training of emotion regulation could contribute to treating obesity. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Profiling illness perceptions to identify patients at-risk for decline in health status after heart valve replacement.

OBJECTIVE: Identification of risk factors for decline in health status by profiling illness perceptions before and one year after heart valve replacement surgery. METHODS: Prospective data from N=225 consecutively admitted first time valve replacement patients was assessed before and one year after surgery. Patients were asked about their illness perceptions (Illness Perception Questionnaire-Revised) and mood state (Hospital Anxiety and Depression Scale). Health status was defined by quality of life (Short-Form 36) and New York Heart Association (NYHA) class. Cluster analyses were conducted to identify illness perception profiles over time. Predictors of health status after surgery were analyzed with multivariate methods. RESULTS: Patients were grouped according to the stability and nature (positive, negative) of their illness perception profile over one year. One year after surgery patients holding a negative illness perception profile showed a lower physical quality of life and were diagnosed in a higher New York Heart Association class than patients changing to positive and patients with stable positive illness perceptions (P<.001). Over and above biological determinants, post-surgery physical quality of life and NYHA class were both predicted by pre-surgery illness perception profiles (P<.05). CONCLUSION: Patients going for heart valve replacement surgery can be easily categorized into illness perception profiles that predict health status one year after surgery. These patients could benefit from early screening as negative illness perceptions are modifiable risk factors.