[Experiences of Burden and Coping Strategies and their Associations with Mental Health and Well-Being in COPD - a Mixed Methods Study]. / Zusammenhänge von Belastungsthemen und Coping-Strategien mit psychischer Gesundheit und Lebenszufriedenheit bei COPD ­ eine Mixed-Methods-Studie.

Understanding trigger and maintaining factors regarding psychiatric comorbidities in COPD is of great importance. In the presented mixed-methods study, qualitative interview data on burden experience and coping were related to psychiatric comorbidity (using PHQ-D) and quality of live (Positive Affect Negative Affect Schedulde, PANAS and Satisfaction with Life Scale, SWLS) and extended by the Freiburg Questionnaire on Coping with Illness (FKV-LIS). The two interview questions prompting narrative were 1.) "What is currently bothering you most?"; 2.) "How do you cope with your chronic disease in everyday life?" A total of 62 patients who were hospitalized due to COPD participated. The severity of physical impairment was assessed using GOLD stage and the Charlson Comorbidity Index (CCI). The interviews conducted were content analyzed and then quantified. The collected data were then compared between two groups with regard to mental distress. 13 themes of burden and 11 coping strategies were identified by content analysis. A total of 42 patients showed signs of mental distress, while 20 patients did not show signs of distress. There were no significant differences between the two groups in terms of sociodemographic characteristics and the severity of their physical symptoms. In the first interview question, the stressed group more frequently addressed issues related to death (35.7% versus 15.0%) and social stress (21.4% versus 0.0%). With respect to the second interview question, the nonstressed group was significantly more likely to mention strategies for consciously emphasizing positive emotions (70.0% versus 31.0%). In addition, higher scores on the FKV scales for depressive coping and trivialization and wishful thinking were evident in the stressed group. Quality of life and mental distress should be considered in clinical care for COPD. Interventions to influence illness perception and related coping styles are important, especially with regard to the development of a realistic and optimistic perspective on life and disease burden, as well as the inclusion of group and family therapeutic interventions.

[Use of complementary and alternative medicine in chronic pain : A survey among patients in a pain clinic]. / Anwendung von Komplementärmedizin bei chronischen Schmerzen : Eine Fragebogenerhebung unter Patienten einer Schmerztagesklinik.

BACKGROUND: Chronic pain patients represent the population with the highest use of complementary and alternative medicine (CAM). Current data on the usage, prescription and reasons for using CAM in Germany remain unclear and have not yet been published. OBJECTIVES: The aim of this study was to evaluate details regarding interest and use as well as reasons for using CAM in chronic pain patients. METHODS: In all, 60 of 64 consecutive patients referred to the multimodal pain therapy program in a specialized day hospital participated in the study. In addition to the German Pain Questionnaire, patients answered a self-developed questionnaire on CAM use. CAM was defined according to the guidelines of the NCCIH (National Center for Complementary and Integrative Health). RESULTS: The study showed that 96.7% of patients were interested in CAM and all 60 participants had used CAM to influence pain (3-26 different CAM modalities, median: 12). The most frequently used were massage (95%), acupuncture (73%), nutriceuticals and vitamin preparations (72% each). The success of the therapies was predominantly evaluated as short-lasting. CAM was often prescribed by a specialist (61.7%) or family doctor (60%). For most patients, the greatest motivation for using CAM was the desire to become active themselves (76.7%). Greater impairment due to pain was associated with increased use of biological CAM methods, while higher pain intensity was associated with decreased use of biological and alternative CAM methods. CONCLUSIONS: The high use of CAM in chronic pain patients highlights the need for physicians to have adequate medical knowledge about each CAM modality and to communicate competently with the patients about them.

Psychiatric and Psychosomatic Consultation-Liaison Services in General Hospitals: A Systematic Review and Meta-Analysis of Effects on Symptoms of Depression and Anxiety.

BACKGROUND: Psychiatric and psychosomatic consultation-liaison services (CL) are important providers of diagnosis and treatment for hospital patients with mental comorbidities and psychological burdens. OBJECTIVE: To perform a systematic review and meta-analysis investigating the effects of CL on depression and anxiety. METHODS: Following PRISMA guidelines, a systematic literature search was conducted until 2017. Included were published randomized controlled trials using CL interventions with adults in general hospitals, treatment as usual as control groups, and depression and/or anxiety as outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Level of integration was assessed using the Standard Framework for Levels of Integrated Healthcare. Meta-analyses were performed using random effects models and meta-regression for moderator effects. RESULTS: We included 38 studies (9,994 patients). Risk of bias was high in 17, unclear in 15, and low in 6 studies. Studies were grouped by type of intervention: brief interventions tailored to the patients (8), interventions based on specific treatment manuals (19), and integrated, collaborative care (11). Studies showed small to medium effects on depression and anxiety. Meta-analyses for depression yielded a small effect (d = -0.19, 95% CI: -0.30 to -0.09) in manual studies and a small effect (d = -0.33, 95% CI: -0.53 to -0.13) in integrated, collaborative care studies, the latter using mostly active control groups with the possibility of traditional consultation. CONCLUSIONS: CL can provide a helpful first treatment for symptoms of depression and anxiety. Given that especially depressive symptoms in medically ill patients are long-lasting, the results underline the benefit of integrative approaches that respect the complexity of the illness.

Length Polymorphisms in the Angiotensin I-Converting Enzyme Gene and the Serotonin-Transporter-Linked Polymorphic Region Constitute a Risk Haplotype for Depression in Patients with Coronary Artery Disease.

Genetic variations affecting the course of depressive symptoms in patients with coronary artery disease (CAD) have not yet been well studied. Therefore, we set out to investigate whether distinct haplotypes of the two insertion/deletion polymorphisms in the serotonin-transporter-linked polymorphic region (5-HTTLPR) and the angiotensin I-converting enzyme (ACE) gene located on chromosome 17 can be identified as risk factors for trajectories of depression. Clinical and genotyping data were derived from 507 depressed CAD patients participating in the randomized, controlled, multicenter Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease (SPIRR-CAD) trial, of whom the majority had an acute cardiac event before study inclusion. Depression scores on the Hospital Anxiety and Depression Scale (HADS) were assessed at baseline and at five follow-up time points up to 2 years after study entrance. At baseline, depression scores did not significantly differ between patients carrying the risk haplotype ACE D/D, 5-HTTLPR I/I (n = 46) and the non-risk haplotypes (n = 461, 10.9 ± 2.7 versus 10.4 ± 2.5, p = 0.254). HADS-depression scores declined from study inclusion during the first year irrespective of the genotype. At each follow-up time point, HADS-depression scores were significantly higher in ACE D/D, 5-HTTLPR I/I carriers than in their counterparts. Two years after study inclusion, the mean HADS depression score remained 1.8 points higher in patients with the risk haplotype as compared to subjects not carrying this haplotype (9.9 ± 4.2 versus 8.1 ± 4.0, p = 0.009). In summary, the presence of the ACE D/D, 5-HTTLPR I/I haplotype may be a vulnerability factor for comorbid depressive symptoms in CAD patients.

[Treatment of dementia patients in a geriatric day clinic : Improvement of behavioral abnormalities and distress of caring relatives]. / Therapie mit Demenzkranken in einer geriatrischen Tagesklinik : Verbesserung von Verhaltensauffälligkeiten und Belastungserleben der Angehörigen.

BACKGROUND AND OBJECTIVE: The aim of the study was to evaluate a specific treatment concept for patients suffering from dementia in a geriatric day clinic with respect to improvement of dementia-related behavioral abnormalities and effects on distress of the caring relatives. MATERIAL AND METHODS: Designed as a naturalistic study with a sample of 34 dementia patients (average age 83 years, 62% female, 82% mild dementia, 18% moderate dementia) surveyed at three time points, the dementia-related behavioral symptoms and the relatives' distress were measured using the neuropsychiatric inventory. A waiting time before treatment was implemented as a control condition. RESULTS: Compared with waiting time, a significant improvement of dementia-related behavioral abnormalities was found after treatment, especially in patients suffering from moderate dementia. The distress of caring relatives was clearly reduced. CONCLUSION: The interprofessional treatment of patients with dementia using a specific program in a geriatric day clinic leads to a clear improvement in behavioral symptoms and positively influences the distress of caring relatives.

[Effects of psychosomatic treatment for the elderly on cognition and quality of life : Naturalistic study at the psychosomatic day care hospital for the elderly in Nuremberg]. / Einfluss einer psychosomatischen Behandlung für Ältere auf Kognition und Lebensqualität : Naturalistische Studie an der Psychosomatischen Tagesklinik für Ältere am Klinikum Nürnberg.

BACKGROUND AND OBJECTIVE: In 2006 the psychosomatic day care hospital for the treatment of acute mental illness of elderly people opened as the first clinic of its kind in Germany. The aim of the study was to determine treatment effectiveness regarding quality of life and cognition. MATERIAL AND METHODS: Designed as a naturalistic study of a population sample of 116 patients, the cognitive capacity (memory performance and cognitive speed) and the subjective quality of life were measured by the Nuremberg aging inventory (NAI) and the World Health Organization quality of life for elderly persons (WHOQOL-OLD). The patients were surveyed at four points in time including at 8­month follow-up. A 5-week waiting time before admission to the 5­week therapy was implemented as a control condition. RESULTS: In comparison with the waiting time, after treatment significant improvement (<0.05) was found in cognitive capacity and quality of life. Effect sizes were partly small and mostly moderate (ES 0.2-1.0) with larger effect sizes in the quality of life than in the cognitive domain. Improvements of cognition and quality of life remained stable at follow-up (admission to follow-up ES 0.1-1.0). No correlation was found between cognitive improvement and reduction of depressive symptoms. CONCLUSION: The results indicate that the psychosomatic day care hospital treatment of the elderly improves subjective quality of life and cognitive capacity.

[Psychosomatic medicine in old age]. / Psychosomatik im Alter.

Approximately 25% of people over 65 years old suffer from psychiatric disorders but in cases of simultaneously occurring somatic diseases the prevalence is increased. Sickness, loss of important reference persons and life crises in older age often reactivate traumatic experiences from earlier life stages. It can be difficult to differentiate between psychological disorders and the psychological symptoms accompanying somatic illness. The biographic medical history and estimation of cognitive skills within a geriatric basis assessment should be standard in geriatric diagnostics. Psychological disorders are often overlooked or inadequately treated in older people. In the case of psychopharmacological treatment, effects on somatic sickness as well as drug-drug interactions have to be kept in mind. Psychotherapeutic approaches focusing on resources and social support particularly in group therapy seem to be very helpful.

A Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease (SPIRR-CAD): Results of an Observer-Blinded, Multicenter, Randomized Trial in Depressed Patients With Coronary Artery Disease.

BACKGROUND: Depression predicts adverse prognosis in patients with coronary artery disease (CAD), but previous treatment trials yielded mixed results. We tested the hypothesis that stepwise psychotherapy improves depressive symptoms more than simple information. METHODS: In a multicenter trial, we randomized 570 CAD patients scoring higher than 7 on the Hospital Anxiety and Depression Scale-depression subscale to usual care plus either one information session (UC-IS) or stepwise psychotherapy (UC-PT). UC-PT patients received three individual psychotherapy sessions. Those still depressed were offered group psychotherapy (25 sessions). The primary outcome was changed in the Hospital Anxiety and Depression Scale-depression scores from baseline to 18 months. Preplanned subgroup analyses examined whether treatment responses differed by patients' sex and personality factors (Type D). RESULTS: The mean (standard deviation) depression scores declined from 10.4 (2.5) to 8.7 (4.1) at 18 months in UC-PT and from 10.4 (2.5) to 8.9 (3.9) in UC-IS (both p < .001). There was no significant group difference in change of depressive symptoms (group-by-time effect, p = .90). Preplanned subgroup analyses revealed no differences in treatment effects between men versus women (ptreatment-by-sex interaction = .799) but a significant treatment-by-Type D interaction on change in depressive symptoms (p = .026) with a trend for stronger improvement with UC-PT than UC-IS in Type D patients (n = 341, p = .057) and no such difference in improvement in patients without Type D (n = 227, p = .54). CONCLUSIONS: Stepwise psychotherapy failed to improve depressive symptoms in CAD patients more than UC-IS. The intervention might be beneficial for depressed CAD patients with Type D personality. However, this finding requires further study. TRIAL REGISTRATION: www.clinicaltrials.gov NCT00705965; www.isrctn.com ISRCTN76240576.

[Attachment Representation and Emotion Regulation in Patients with Burnout Syndrome]. / Repräsentationen früher Bindungsbeziehungen und Emotionsregulation bei Patienten mit Burnout-Syndrom.

OBJECTIVE: Burnout describes a syndrome of exhaustion resulting from insufficient coping with work-related distress. We investigated if patients that are being clinically treated for burnout show insecure and unresolved attachment representation more often compared with healthy controls. METHODS: 50 out of 60 consecutive burnout patients participated in the study. Mental representation of attachment was measured by using the Adult Attachment Interview. Additionally, we administered the Self Report Questionnaire to Assess Emotional Experience and Emotion Regulation and several burnout specific questionnaires. A population sample was used as control group. RESULTS: Burnout patients were classified as insecurely attached significantly more often than controls. Unresolved attachment status concerning loss or trauma was found significantly more often within the burnout sample. Patients with insecure attachment representation reported a lower subjective significance of work. Patients with avoidant insecure attachment showed more depersonalisation. Patients with unresolved loss/trauma reported less social support. They showed more passive-negative emotion experience and emotion regulation characterized by externalization. CONCLUSION: The results of the study suggest that an insecure or unresolved attachment representation might constitute an intrapersonal risk factor for the development of burnout syndrome.

[Evaluation of the German Version of the "INTERMED-Self-Assessment"-Questionnaire (IM-SA) to Assess Case Complexity]. / Evaluation der deutschsprachigen Version des "INTERMED-Self-Assessment"- Fragebogens (IM-SA) zur Erfassung von Patienten mit komplexem Versorgungsbedarf.

INTRODUCTION: The INTERMED- interview (IM-CAG=INTERMED complexity assessment grid) is a well validated instrument for the identification of complex patients in need of integrated health care (score ≥21). The IM-SA (INTERMED self-assessment)-questionnaire, derived from the INTERMED- interview, was developed in cooperation with the international INTERMED group in order to facilitate its use in various clinical settings and to foster the patients' perspective on health-care needs. METHODS: The German version of the IM-SA was evaluated in a clinical sample (n=136) of psychosomatic outpatients and compared to the IM-CAG. Construct validity was examined by analyzing the correlations of the IM-SA with quality-of-life (SF-36) and anxiety/depression (HADS). Sensitivity and specificity for the identification of complex patients were examined by using ROC (Receiver Operating Characteristic) analysis. RESULTS: The correlations between the total score and the subscales of the IM-SA, compared to the INTERMED, were high (total score r=0.79 (95%-KI: [0.70; 0.85]). Cronbach's α was 0.77, and construct validity was high (SF-36 mental component score: r=-0.57; HADS Depression: r=0.59). The IM-SA total score was significantly lower compared to IM-CAG, mainly because of low IM-SA scores in the somatic domain. According to ROC analysis, the IM-SA-cut-off for identifying complex patients has to be lowered (score ≥17). DISCUSSION: The IM-SA can be used as an instrument to identify complex patients in need of integrated bio-psycho-social care. CONCLUSION: The IM-SA is a reliable instrument to be used in various clinical settings to identify complex patients and to provide integrated, bio-psycho-social care.

Inpatient and Day Hospital Treatment of Patients with Depression and Job-related Burnout.

OBJECTIVE: Burnout is a process of physical and emotional exhaustion that often results in clinical depression. Detailed descriptions and evaluations of specialized psychosomatic treatment are rare. This pilot study investigates the feasibility of inpatient and day hospital treatment of patients with burnout syndrome. Additionally, we present results of an initial, noncontrolled, pre-post-evaluation of changes in symptoms and individual work-related risk factors for burnout. METHODS: Sixty-four consecutive patients with burnout syndrome were assessed before and after specialized multimodal treatment using a clinical symptom checklist (ICD-10 Symptom Rating) and burnout-specific instruments (Maslach Burnout Inventory, Occupational Stress & Coping Inventory). RESULTS: Patients' average age was 45 (range 23 to 61), 70% were currently employed, 24% in managerial positions or self-employed, and 89% diagnosed with an affective disorder. The average length of time off work due to illness in the past year was 13 weeks. Treatment lasted five weeks on average. After treatment, depression (p < 0.001; effect size d = 0.79), emotional exhaustion (p = 0.001; d = 0.41), and the subjective significance of work (p = 0.001; d = 0.36) decreased, while emotional distancing (p < 0.001; d = 0.56), balance and mental stability (p < 0.001; d = 0.38) and life satisfaction (p < 0.001; d = 0.37) increased. Clinical significance was determined using the Reliable Change Index. CONCLUSIONS: The treatment program described here is well accepted by patients with severe burnout. It contributes to positive changes in symptoms and work-related risk factors. Controlled studies are necessary to establish treatment efficacy.

Updates in Psychosomatic Medicine: 2014.

BACKGROUND: The amount of literature published annually related to psychosomatic medicine is vast; this poses a challenge for practitioners to keep up-to-date in all but a small area of expertise. OBJECTIVES: To introduce how a group process using volunteer experts can be harnessed to provide clinicians with a manageable selection of important publications in psychosomatic medicine, organized by specialty area, for 2014. METHODS: We used quarterly annotated abstracts selected by experts from the Academy of Psychosomatic Medicine and the European Association of Psychosomatic Medicine in 15 subspecialties to create a list of important articles. RESULTS: In 2014, subspecialty experts selected 88 articles of interest for practitioners of psychosomatic medicine. For this review, 14 articles were chosen. CONCLUSIONS: A group process can be used to whittle down the vast literature in psychosomatic medicine and compile a list of important articles for individual practitioners. Such an approach is consistent with the idea of physicians as lifelong learners and educators.

Significance and costs of complex biopsychosocial health care needs in elderly people: results of a population-based study.

OBJECTIVE: To improve health care for the elderly, a consideration of biopsychosocial health care needs may be of particular importance-especially because of the prevalence of multiple conditions, mental disorders, and social challenges facing elderly people. The aim of the study was to investigate significance and costs of biopsychosocial health care needs in elderly people. METHODS: Data were derived from the 8-year follow-up of the ESTHER study-a German epidemiological study in the elderly population. A total of 3124 participants aged 57 to 84 years were visited at home by trained medical doctors. Biopsychosocial health care needs were assessed using the INTERMED for the Elderly (IM-E) interview. Health-related quality of life (HRQOL) was measured by the 12-Item Short-Form Health Survey, and psychosomatic burden was measured by the Patient Health Questionnaire. RESULTS: The IM-E correlated with decreased mental (mental component score: r = -0.38, p < .0001) and physical HRQOL (physical component score: r = -0.45, p < .0001), increased depression severity (r = 0.53, p < .0001), and costs (R = 0.41, p < .0001). The proportion of the participants who had an IM-E score of at least 21 was 8.2%; according to previous studies, they were classified as complex patients (having complex biopsychosocial health care needs). Complex patients showed a highly reduced HRQOL compared with participants without complex health care needs (mental component score: 37.0 [10.8] versus 48.7 [8.8]; physical component score: 33.0 [9.1] versus 41.6 [9.5]). Mean health care costs per 3 months of complex patients were strongly increased (1651.1 &OV0556; [3192.2] versus 764.5 &OV0556; [1868.4]). CONCLUSIONS: Complex biopsychosocial health care needs are strongly associated with adverse health outcomes in elderly people. It should be evaluated if interdisciplinary treatment plans would improve the health outcomes for complex patients.

Assessing psychosocial vulnerability and care needs of pretransplant patients by means of the INTERMED.

OBJECTIVE: We investigated whether the INTERMED, a generic instrument for assessing biopsychosocial case complexity and direct care, identifies organ transplant patients at risk of unfavourable post-transplant development by comparing it to the Transplant Evaluation Rating Scale (TERS), the established measure for pretransplant psychosocial evaluation. METHOD: One hundred nineteen kidney, liver, and heart transplant candidates were evaluated using the INTERMED, TERS, SF-36, EuroQol, Montgomery-Åsberg Depression Rating Scale (MADRS), and Hospital Anxiety & Depression Scale (HADS). RESULTS: We found significant relationships between the INTERMED and the TERS scores. The INTERMED highly correlated with the HADS,MADRS, and mental and physical health scores of the SF-36 Health Survey. CONCLUSIONS: The results demonstrate the validity and usefulness of the INTERMED instrument for pretransplant evaluation. Furthermore, our findings demonstrate the different qualities of INTERMED and TERS in clinical practice. The advantages of the psychiatric focus of the TERS and the biopsychosocial perspective of the INTERMED are discussed in the context of current literature on integrated care.

Care complexity, mood, and quality of life in liver pre-transplant patients.

RATIONALE: This study was intended to document the frequency of care complexity in liver transplant candidates, and its association with mood disturbance and poor health-related quality of life (HRQoL). METHODS: Consecutive patients fulfilling inclusion criteria, recruited in three European hospitals, were assessed with INTERMED, a reliable and valid method for the early assessment of bio-psychosocial health risks and needs. Blind to the results, they were also assessed with the Hospital Anxiety and Depression Scale (HADS). HRQoL was documented with the EuroQol and the SF36. Statistical analysis included multivariate and multilevel techniques. RESULTS: Among patients fulfilling inclusion criteria, 60 patients (75.9%) completed the protocol and 38.3% of them were identified as "complex" by INTERMED, but significant between-center differences were found. In support of the working hypothesis, INTERMED scores were significantly associated with all measures of both the SF36 and the EuroQol, and also with the HADS. A one point increase in the INTERMED score results in a reduction in 0.93 points in EuroQol and a 20% increase in HADS score. CONCLUSIONS: INTERMED-measured case complexity is frequent in liver transplant candidates but varies widely between centers. The use of this method captures in one instrument multiple domains of patient status, including mood disturbances and reduced HRQoL.

[KoMPASS--design, implementation and experiences concerning a structured communication skills training for physicians dealing with oncology]. / KoMPASS - Konzeption, Implementierung und Erfahrungen mit einem strukturierten Kommunikationstraining für onkologisch tätige Ärzte.

Goal of the KoMPASS project is to develop and test a training program that effectively improves oncologists' communication skills. The training draws with regard to concept, content and didactic methods to the specific challenges arising in interactions with cancer patients. Concept and didactical methods for an intensive training (KoMPASS Training) are being presented and complemented with experiences gathered during 39 trainings with 335 physicians, as well as findings from the training evaluation by participants. The participants' feedback after 4 months indicates successful transfer into clinical practice along with personal relief, improved self-efficacy, and communicative competencies. Even experienced practitioners ascribe high practical usefulness, and personal learning achievements to the KoMPASS training. The results of the concomitant study concerning self-efficacy, empathy, work-related stress and communicative competence will be published later.

Assessment of health-related quality of life in individuals with depressive symptoms: validity and responsiveness of the EQ-5D-3L and the SF-6D.

BACKGROUND: The EQ-5D and the SF-6D are examples of commonly used generic preference-based instruments for assessing health-related quality of life (HRQoL). However, their suitability for mental disorders has been repeatedly questioned. OBJECTIVE: To assess the responsiveness and convergent validity of the EQ-5D-3L and SF-6D in patients with depressive symptoms. METHODS: The data analyzed were from cardiac patients with depressive symptoms and were collected as part of the SPIRR-CAD (Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease) trial. The EQ-5D-3L and SF-6D were compared with the HADS (Hospital Anxiety and Depression Scale) and PHQ-9 (Patient Health Questionnaire) as disease-specific instruments. Convergent validity was assessed using Spearman's rank correlation. Effect sizes were calculated and ROC analysis was performed to determine responsiveness. RESULTS: Data from 566 patients were analysed. The SF-6D correlated considerably better with the disease-specific instruments (|rs|= 0.63-0.68) than the EQ-5D-3L (|rs|= 0.51-0.56). The internal responsiveness of the SF-6D was in the upper range of a small effect (ES: - 0.44 and - 0.47), while no effect could be determined for the EQ-5D-3L. Neither the SF-6D nor the EQ-5D-3L showed acceptable external responsiveness for classifying patients' depressive symptoms as improved or not improved. The ability to detect patients whose condition has deteriorated was only acceptable for the EQ-5D-3L. CONCLUSION: Overall, both the convergent validity and responsiveness of the SF-6D are better than those of the EQ-5D-3L in patients with depressive symptoms. The SF-6D appears, therefore, more recommendable for use in studies to evaluate interventions for this population.

Cortisol Awakening Reaction and Anxiety in Depressed Coronary Artery Disease Patients.

Disturbances of HPA axis functioning as represented by cortisol awakening reaction (CAR) belong to the mediating pathways linking psychosocial distress and cardiovascular risk. Both depression and anxiety have been confirmed as independent risk factors for coronary artery disease (CAD). However, data on anxiety and cortisol output in CAD patients are scarce. Based on previous data, we hypothesized that anxiety would be associated with higher cortisol output and a more pronounced morning increase in moderately depressed CAD patients. 77 patients (60 y, 79% male) underwent saliva sampling (+0, +30, +45, +60 min after awakening, midday and late-night sample). Anxiety was measured using the Hospital Anxiety and Depression Scale (HADS) and patients were grouped into anxious versus non anxious subjects based upon the recommended score (≥11). A repeated measures ANOVA yielded a significant time and quadratic time effect referring to the typical CAR. Anxious patients showed a significantly steeper 30 min increase, higher AUCi, lower waking and late-night cortisol levels. The steeper cortisol increase in the anxious group is in line with previous data and may be interpreted as a biological substrate of affect regulation. The lower basal and late-night levels coupled with greater AUCi mirror a more dynamic reactivity pattern compared to depressed subjects without anxiety.

Depression, anxiety, and vital exhaustion are associated with pro-coagulant markers in depressed patients with coronary artery disease - A cross sectional and prospective secondary analysis of the SPIRR-CAD trial.

INTRODUCTION: A hyper-coagulant state is a biological mechanism that triggers cardiac events in patients with coronary artery disease (CAD). Depressive symptoms and anxiety predict an unfavourable course of CAD. The SPIRR-CAD-RCT examined the effects of a psychological intervention and provided the opportunity to explore cross-sectional associations between indices of psychological strain and coagulation parameters, as well as prospective changes in depression scores and coagulation parameters. METHODS: In this secondary analysis, we investigated 253 CAD patients (194 male; age m 58.9, SD 8.3 yrs.) with mild to moderate depression (≥8 on the HADS-D) at baseline and at follow-up 18 months later: TF, fibrinogen, D-dimer, VWF, FVII and PAI-1 and the course of depression (HAM-D), vital exhaustion (VE) and anxiety scores (HADS-A) were examined by ANOVA in the total and younger age groups (≤ 60). RESULTS: HAM-D at baseline was correlated with TF (corr. R2 = 0.27; F = 9.31, p = 0.001). HADS anxiety was associated with fibrinogen (corr. R2.20; F = 7.27, p = 0.001). There was no detectable therapeutic effect on coagulation. Fibrinogen and VWF decreased within 18 months (time effect; p = 0.02; p = 0.04), as did HADS-D in both treatment groups (p < 0.001). Fibrinogen decreased more in patients ≤60 years with high VE compared to low VE (interaction time x group, p = 0.01). CONCLUSIONS: This is the first study to show an association between TF and depression. Coagulation parameters as potential mediators of CAD progression correlated cross-sectionally with depression and anxiety and prospectively with VE. Further studies should replicate these correlations in depressed and non-depressed CAD patients. ISRCTN: 76240576; clinicaltrials.gov.