Association between perceived stress, multimorbidity and primary care health services: a Danish population-based cohort study.

OBJECTIVES: Mental stress is common in the general population. Mounting evidence suggests that mental stress is associated with multimorbidity, suboptimal care and increased mortality. Delivering healthcare in a biopsychosocial context is key for general practitioners (GPs), but it remains unclear how persons with high levels of perceived stress are managed in primary care. We aimed to describe the association between perceived stress and primary care services by focusing on mental health-related activities and markers of elective/acute care while accounting for mental-physical multimorbidity. DESIGN: Population-based cohort study. SETTING: Primary healthcare in Denmark. PARTICIPANTS: 118 410 participants from the Danish National Health Survey 2010 followed for 1 year. Information on perceived stress and lifestyle was obtained from a survey questionnaire. Information on multimorbidity was obtained from health registers. OUTCOME MEASURES: General daytime consultations, out-of-hours services, mental health-related services and chronic care services in primary care obtained from health registers. RESULTS: Perceived stress levels were associated with primary care activity in a dose-response relation when adjusted for underlying conditions, lifestyle and socioeconomic factors. In the highest stress quintile, 6.8% attended GP talk therapy (highest vs lowest quintile, adjusted incidence rate ratios (IRR): 4.96, 95% CI 4.20 to 5.86), 3.3% consulted a psychologist (IRR: 6.49, 95% CI 4.90 to 8.58), 21.5% redeemed an antidepressant prescription (IRR: 4.62, 95% CI 4.03 to 5.31), 23.8% attended annual chronic care consultations (IRR: 1.22, 95% CI 1.16 to 1.29) and 26.1% used out-of-hours services (IRR: 1.47, 95% CI 1.51 to 1.68). For those with multimorbidity, stress was associated with more out-of-hours services, but not with more chronic care services. CONCLUSION: Persons with high stress levels generally had higher use of primary healthcare, 4-6 times higher use of mental health-related services (most often in the form of psychotropic drug prescriptions), but less timely use of chronic care services.

The Association Between Perceived Stress and Mortality Among People With Multimorbidity: A Prospective Population-Based Cohort Study.

Multimorbidity is common and is associated with poor mental health and high mortality. Nevertheless, no studies have evaluated whether mental health may affect the survival of people with multimorbidity. We investigated the association between perceived stress and mortality in people with multimorbidity by following a population-based cohort of 118,410 participants from the Danish National Health Survey 2010 for up to 4 years. Information on perceived stress and lifestyle was obtained from the survey. We assessed multimorbidity using nationwide register data on 39 conditions and identified 4,229 deaths for the 453,648 person-years at risk. Mortality rates rose with increasing levels of stress in a dose-response relationship (P-trend < 0.0001), independently of multimorbidity status. Mortality hazard ratios (highest stress quintile vs. lowest) were 1.51 (95% confidence interval (CI): 1.25, 1.84) among persons without multimorbidity, 1.39 (95% CI: 1.18, 1.64) among those with 2 or 3 conditions, and 1.43 (95% CI: 1.18, 1.73) among those with 4 or more conditions, when adjusted for disease severities, lifestyle, and socioeconomic status. The numbers of excess deaths associated with high stress were 69 among persons without multimorbidity, 128 among those with 2 or 3 conditions, and 255 among those with 4 or more conditions. Our findings suggested that perceived stress contributes significantly to higher mortality rates in a dose-response pattern, and more stress-associated deaths occurred in people with multimorbidity.

Contacts to general practice and antidepressant treatment initiation after screening for anxiety and depression in patients with heart disease.

INTRODUCTION: Anxiety and depression are found in 20-30% of all persons with heart disease, and depression is known to impact mortality. This paper aimed to describe the effect of systematic screening of this population in terms of use of general practice, psychological therapy and antidepressant treatment. METHODS: A population-based cohort study was conducted in 2011-2013 comprising 1,658 people with heart disease treated at a Danish regional hospital. Collected data were based on Danish national registers and patient questionnaires. RESULTS: Patients with heart disease and anxiety or depressive symptoms had more general practitioner (GP) contact rates than patients without anxiety or depressive symptoms both before and after the screening. Furthermore, patients with depressive symptoms increased their GP contact rate significantly in the first month after the screening, while this was not the case for patients with anxiety symptoms. Finally, patients with heart disease and anxiety or depressive symptoms more frequently initiated treatment with antidepressants than patients with heart disease without anxiety or depressive symptoms, whereas therapy sessions with a psychologist were rarely used. CONCLUSIONS: Heart patients with depressive symptoms may benefit from screening for depression, information about the screening result and a subsequent recommendation to consult their GP in case of signs of depression. -However, the observed effect seems to be modest. FUNDING: The study was supported by an unrestricted grant from the Lundbeck Foundation (grant number: R155-2012-11280). TRIAL REGISTRATION: none.

Healthcare Contacts after Myocardial Infarction According to Mental Health and Socioeconomic Position: A Population-Based Cohort Study.

OBJECTIVE: To examine the long-term use of healthcare contacts to general practice (GP) and hospital after a first-time myocardial infarction (MI) according to mental health and socioeconomic position. METHODS: Population-based cohort study of all patients discharged with first-time MI in the Central Denmark Region in 2009 (n=908) using questionnaires and nationwide registers. We estimated adjusted incidence rates and incidence rate ratios (IRR) for GP and hospital contacts according to depressive and anxiety symptoms, educational level and cohabitation status. RESULTS: During the 24-month period after the MI, patients with anxiety symptoms had 24% more GP contacts (adjusted IRR 1.24, 95% confidence interval (CI) 1.12-1.36) than patients with no anxiety symptoms. In contrast, patients with depressive symptoms (1.05, 0.94-1.16) and with short and medium education (<10 years: 0.96, 0.84-1.08; 10-12 years: 0.91, 0.80-1.03) and patients living alone (0.95, 0.87-1.04) had the same number of GP contacts as their counterparts (patients with no depressive symptoms, with long education [>12 years] and patients living with a partner). During the first 6 months after the MI, patients living alone had 13% fewer hospital contacts (0.87, 0.77-0.99), patients with short education had 16% fewer hospital contacts (<10 years: 0.84, 0.72-0.98) and patients with anxiety symptoms had 27% fewer hospital contacts (0.73, 0.62-0.86) than their counterparts. In contrast, patients with depressive symptoms (0.92, 0.77-1.10) and medium education (10-12 years: 1.05, 0.91-1.22) had the same number of hospital contacts as their counterparts. CONCLUSIONS: This study indicates that patients with depressive symptoms, short and medium education and patients living alone have a lower long-term use of healthcare contacts following MI than patients without these risk factors. Patients with depressive symptoms and low socioeconomic position would be expected to have a higher need of healthcare after MI as they have a poorer prognosis.

Post-myocardial infarction anxiety or depressive symptoms and risk of new cardiovascular events or death: a population-based longitudinal study.

OBJECTIVE: To examine the association between anxiety symptoms 3 months after myocardial infarction (MI) and/or new cardiovascular events and death, taking into account established risk factors, and to compare the results with those of the impact of depressive symptoms. Post-MI anxiety symptoms have been associated with a composite outcome of new cardiovascular events or death, but previous studies have not fully adjusted for potential confounders. It remains unclear whether anxiety symptoms are independently associated with both new cardiovascular events and death. METHODS: A population-based cohort study of 896 persons (70% of eligible) with first-time MI between 1 January 2009 and 31 December 2009, completing the Hospital Anxiety and Depression Scale, were followed up until 31 July 2012. RESULTS: A total of 239 new cardiovascular events and 94 deaths occurred during 1975 person-years of follow-up. Cox proportional hazards models showed that anxiety symptoms were associated with both new cardiovascular events and death in analysis adjusted for age only. The estimates decreased when adjusted for dyspnea score, physical activity, and depressive symptoms, and anxiety symptoms were no longer associated with new cardiovascular events (hazard ratio [HR] = 1.02, 95% confidence interval [CI] = 0.98-1.07) or with death (HR = 0.94, 95% CI = 0.88-1.01). In fully adjusted models, depressive symptoms remained associated with death (HR = 1.13, 95% CI = 1.05-1.21), but not with new cardiovascular events (HR = 1.02, 95% CI = 0.99-1.06). CONCLUSIONS: Post-MI anxiety symptoms were not an independent prognostic risk factor for new cardiovascular events or for death, whereas depressive symptoms were associated with an increased risk of mortality.

Post-stroke mortality, stroke severity, and preadmission antipsychotic medicine use--a population-based cohort study.

BACKGROUND AND PURPOSE: It has been suggested that antipsychotic medication may be neuroprotective and may reduce post-stroke mortality, but studies are few and ambiguous. We aimed to investigate the post-stroke effects of preadmission antipsychotic use. METHODS: We conducted a nationwide, population-based cohort study of 81,143 persons admitted with stroke in Denmark from 2003-2010. Using Danish health care databases, we extracted data on preadmission use of antipsychotics and confounding factors. We examined the association between current, former, and never use of antipsychotics and stroke severity, length of hospital stay, and 30-day post-stroke mortality using logistic regression analysis, survival analysis, and propensity score matching. RESULTS: Current users of antipsychotics had a higher risk of severe or very severe stroke on The Scandinavian Stroke Scale than never users of antipsychotics (adjusted odds ratios, 1.43; 95% CI, 1.29-1.58). Current users were less likely to be discharged from hospital within 30 days of admission than never users (probability of non-discharge, 27.0% vs. 21.9%). Antipsychotics was associated with an increased 30-day post-stroke mortality among current users (adjusted mortality rate ratios, 1.42; 95% CI, 1.29-1.55), but not among former users (adjusted mortality rate ratios, 1.05; 95% CI, 0.98-1.14). CONCLUSIONS: Preadmission use of antipsychotics was associated with a higher risk of severe stroke, a longer duration of hospital stay, and a higher post-stroke mortality, even after adjustment for known confounders. Antipsychotics play an important role in the treatment of many psychiatric conditions, but our findings do not support the hypothesis that they reduce stroke severity or post-stroke mortality.

Depressive symptoms and risk of new cardiovascular events or death in patients with myocardial infarction: a population-based longitudinal study examining health behaviors and health care interventions.

BACKGROUND: Depressive symptoms is associated with adverse cardiovascular outcomes in patients with myocardial infarction (MI), but the underlying mechanisms are unclear and it remains unknown whether subgroups of patients are at a particularly high relative risk of adverse outcomes. We examined the risk of new cardiovascular events and/or death in patients with depressive symptoms following first-time MI taking into account other secondary preventive factors. We further explored whether we could identify subgroups of patients with a particularly high relative risk of adverse outcomes. METHODS AND RESULTS: We conducted a prospective population-based cohort study of 897 patients discharged with first-time MI between 1 January 2009 and 31 December 2009, and followed up until 31 July 2012. Depressive symptoms were found in 18.6% using the Hospital Anxiety and Depression Scale (HADS-D≥8). A total of 239 new cardiovascular events, 95 deaths, and 288 composite events (239 new cardiovascular events and 49 deaths) occurred during 1,975 person-years of follow-up. Event-free survival was evaluated using Cox regression analysis. Compared to the 730 patients without depressive symptoms (HADS-D<8), the 167 patients with depressive symptoms (HADS-D≥8) had age- and sex-adjusted hazard ratios [HR] (95% confidence interval [CI]) of 1.53 (95% CI, 1.14-2.05) for a new cardiovascular event, 3.10 (95% CI, 2.04-4.71) for death and 1.77 (95% CI, 1.36-2.31) for a composite event. The associations were attenuated when adjusted for disease severity, comorbid conditions and physical inactivity; HR = 1.17 (95% CI, 0.85-1.61) for a new cardiovascular event, HR = 2.01 (95% CI, 1.28-3.16) for death, and HR = 1.33 (95% CI, 1.00-1.76) for a composite event. No subgroups of patients had a particularly high risk of adverse outcomes. CONCLUSIONS: Depressive symptoms following first-time MI was an independent prognostic risk factor for death, but not for new cardiovascular events. We found no subgroups of patients with a particularly high relative risk of adverse outcomes.

Mental health status and risk of new cardiovascular events or death in patients with myocardial infarction: a population-based cohort study.

OBJECTIVE: To examine the association between mental health status after first-time myocardial infarction (MI) and new cardiovascular events or death, taking into account depression and anxiety as well as clinical, sociodemographic and behavioural risk factors. DESIGN: Population-based cohort study based on questionnaires and nationwide registries. Mental health status was assessed 3 months after MI using the Mental Component Summary score from the Short-Form 12 V.2. SETTING: Central Denmark Region. PARTICIPANTS: All patients hospitalised with first-time MI from 1 January 2009 through 31 December 2009 (n=880). The participants were categorised in quartiles according to the level of mental health status (first quartile=lowest mental health status). MAIN OUTCOME MEASURES: Composite endpoint of new cardiovascular events (MI, heart failure, stroke/transient ischaemic attack) and all-cause mortality. RESULTS: During 1940 person-years of follow-up, 277 persons experienced a new cardiovascular event or died. The cumulative incidence following 3 years after MI increased consistently with decreasing mental health status and was 15% (95% CI 10.8% to 20.5%) for persons in the fourth quartile, 29.1% (23.5% to 35.6%) in the third quartile, 37.0% (30.9% to 43.9%) in the second quartile, and 47.5% (40.9% to 54.5%) in the first quartile. The HRs were high, even after adjustments for age, sociodemographic characteristics, cardiac disease severity, comorbidity, secondary prophylactic medication, smoking status, physical activity, depression and anxiety (HR3rd quartile 1.90 (95% CI 1.23 to 2.93), HR2nd quartile 2.14 (1.37 to 3.33), HR1st quartile 2.23 (1.35 to 3.68) when using the fourth quartile as reference). CONCLUSIONS: Low mental health status following first-time MI was independently associated with an increased risk of new cardiovascular events or death. Further research is needed to disentangle the pathways that link mental health status following MI to prognosis and to identify interventions that can improve mental health status and prognosis.

Depression following myocardial infarction--an overseen complication with prognostic importance.

BACKGROUND AND AIMS: Myocardial infarction (MI) is a severe life event that is accompanied by an increased risk of depression. Mounting evidence suggests that post-MI depression is associated with adverse outcomes, but the underlying mechanisms of this association remain unclear, and no previous studies have examined whether the mental burden of MI is so heavy that it increases the risk of suicide. Although post-MI depression is common and burdensome, the condition remains under-recognised and under-treated. The development of new strategies to improve the quality of care for people with post-MI depression requires thorough understanding of the mechanisms that influence the prognosis as well as knowledge of the present care provided. The purpose of this PhD thesis is accordingly subdivided into four specific aims: 1. To estimate the prevalence of depression in people with MI after three months, and to estimate the provided hospital-based psychosocial rehabilitation (Paper I); 2. To examine GPs' practice of screening for depression in people with MI, and to analyse whether the screening rate varied among subgroups of people with a particularly high risk of post-MI depression (Paper II); 3. To examine the association between post-MI depression and new cardiovascular events or death, taking potential mediators into account (Paper III); 4. To examine the association between MI and suicide (Paper IV). METHODS: Two different study designs were employed: a population-based cohort study using data obtained from registers and questionnaires sent to MI patients and their GPs (Paper I-III); a nationwide population-based matched case-control study using data obtained from registers (Paper IV). RESULTS: Three months after having suffered MI, about one fifth of the patients in our study had depression according to the Hospital Anxiety and Depression Scale (HADS). Upwards of half of the patients had participated in some rehabilitation, thirty per cent had participated in psychosocial support and three per cent reported that they had been examined for depression by questionnaire during the hospital-based rehabilitation. The rate of participation in psychosocial support and examination for depression was the same for patients with or without depression at three months following MI. A good fourth of the patients' GPs stated that they had screened the patient for depression within the first year after the patient suffered an MI. Three months after the MI, the screening rate was higher among patients with a history of mental illness and among patients with anxiety or depression than among patients without these conditions. Most of the GPs who performed screening followed guidelines by asking about specific depressive symptoms. According to the HADS, depression three months after MI was associated with an increased risk of a new cardiovascular event or death. This association was partly explained by the underlying cardiac disease severity and physical inactivity, but depression remained an independent prognostic risk factor after adjusting for these potential confounders. We found a tendency towards a weaker association with increasing physical activity and among users of antidepressants. MI was strongly associated with an increased risk of suicide. This risk was particularly high immediately after the MI, but remained high for more than five years after the MI. The association between MI and suicide remained stable throughout the study period (1981-2006), although many other factors changed (e.g. suicide rate, treatment of MI). CONCLUSIONS AND PERSPECTIVES: This thesis demonstrated that post-MI depression is common, under-recognized and has a strong prognostic impact. About one in five patients have depression three months after MI. Guidelines recommend screening for depression, but the guidelines have not been systematically implemented either in the hospital-based rehabilitation or in Danish general practice. In the absence of systematic screening, we found that a significant part of those who had depression were not recognized. MI increases the risk of suicide, and depression following MI impairs the overall prognosis. The thesis indicates that physical activity and antidepressants modify the adverse prognosis in patients with post-MI depression, but larger studies are needed to clarify the impact of these potential modifiers and to evaluate how they may be catered for in the treatment of post-MI patients with depression.

Screening for depression in patients with myocardial infarction by general practitioners.

BACKGROUND: Depression in patients with myocardial infarction (MI) is highly prevalent and associated with increased morbidity and mortality. Routine screening for post-MI depression is recommended. We studied general practitioners' practice of screening for post-MI depression and analysed whether the screening rate varied among subgroups of MI patients with a particular high risk of depression. DESIGN: Population-based cohort study in the Central Denmark Region. METHODS: All patients with a first-time MI in 2009 received a questionnaire 3 months after discharge from hospital. The questionnaire included information on anxiety and depression according to the Hospital Anxiety and Depression Scale (HADS), severity of the disease, and smoking habits. The responders' general practitioners received a questionnaire 1 year after the patient had been discharged from hospital. This questionnaire provided information on screening for depression, comorbidity, and previous mental illness of the patient. Nationwide registers supplied the patients' sociodemographic status the year before the MI. RESULTS: Response rates were 70.5% (908) among patients, and 64.9% (589) among general practitioners. According to the general practitioners, 27.3% (95% CI 23.7-30.9%) MI patients were screened for depression. The screening rate was higher among patients with a history of mental illness (50.0%, p < 0.001), and among patients with anxiety (37.0%, p = 0.002) or depression (37.5%, p = 0.007) as compared with those without these conditions. CONCLUSION: Screening for depression was neither complete among patients with MI or in subgroups of these with a particularly high risk of post-MI depression. More detailed guidelines and initiatives for implementing them may help to optimize general practitioners' screening for post-MI depression.

Rehabilitation status three months after first-time myocardial infarction.

OBJECTIVE: To describe the rehabilitation status three months after first-time myocardial infarction (MI) to identify focus areas for long-term cardiac rehabilitation (CR) in general practice. Design. Population-based cross-sectional study. SETTING AND SUBJECTS: Patients with first-time MI in 2009 from the Central Denmark Region. Data were obtained from patient questionnaires and from registers. RESULTS: Of the 1288 eligible patients, 908 (70.5%) responded. The mean (SD) age was 67.1 (11.7) years and 626 (68.9%) were men. Overall, 287 (31.6%) of the patients lived alone and 398 (45.4%) had less than 10 years of education. Upwards of half (58.5%) of the patients stated that they had participated in hospital-based rehabilitation shortly after admission. A total of 262 (29.2%) were identified with anxiety or depressive disorder or both, according to the Hospital Anxiety and Depression Scale. Of these, 78 (29.8%) reported that they had participated in psychosocial support, and 55 (21.0%) used antidepressants. One in five patients smoked three months after MI although nearly half of the smokers had stopped after the MI. Regarding cardioprotective drugs, 714 (78.6%) used aspirin, 694 (76.4%) clopidogrel, 756 (83.3%) statins, and 735 (81.0%) beta-blockers. CONCLUSION: After three months, there is a considerable potential for further rehabilitation of MI patients. In particular, the long-term CR should focus on mental health, smoking cessation, and cardioprotective drugs.

Myocardial infarction and risk of suicide: a population-based case-control study.

BACKGROUND: Myocardial infarction (MI) is associated with an increased risk of anxiety, depression, low quality of life, and all-cause mortality. Whether MI is associated with an increased risk of suicide is unknown. We examined the association between MI and suicide. METHODS AND RESULTS: We conducted a population-based case-control study by retrieving data from 5 nationwide longitudinal registers in Denmark. As cases, we selected all persons aged 40 to 89 years who died by suicide from 1981 to 2006. As controls, we randomly selected up to 10 persons per case matched by sex, day of birth, and calendar time. We identified 19,857 persons who committed suicide and 190,058 controls. MI was associated with a marked increased risk of suicide. The risk of suicide was highest during the first month after discharge for MI for patients with no history of psychiatric illness (adjusted rate ratio, 3.25; 95% confidence interval, 1.61 to 6.56) and for patients with a history of psychiatric illness (adjusted rate ratio, 64.05; 95% confidence interval, 13.36 to 307.06) compared with those with no history of MI or psychiatric illness. However, the risk remained high for at least 5 years after MI. CONCLUSIONS: MI is followed by an increased risk of suicide for persons with and without psychiatric illness. Our results suggest the importance of screening patients with MI for depression and suicidal ideation.

Vascularity in thyroid neoplasms: a methodological investigation with a view to diagnostics.

The aim of the present study was to evaluate the reliability of four different methods (vascular grading, Chalkley count, microvessel density (MVD) and stereological estimation) for quantifying intratumoral microvascularity in thyroid neoplasms, by comparing the variability within and between observers. In addition, the diagnostic and prognostic potential of neovascularity expressed by the four methods was evaluated. The study had a retrospective design and involved 24 follicular adenomas (FA), 19 follicular carcinomas (FC), and 17 papillary carcinomas (PC). Chalkley count was reproducible both within and between observers. MVD was not reproducible. Within observer the reproducibility of vascular grading was substantial, between observers it was fair to moderate. Stereological estimation was a priori considered reproducible. Keeping time consumption, cost and reproducibility in mind, Chalkley count should be the preferred method for assessing microvascularity in thyroid neoplasms. The diagnostic evaluation revealed a tendency towards higher degree of vascularity in FA compared to both FC and PC for all methods. No statistically significant association was seen between vascular density and prognosis.