Post-infarction depression in the clinical Liaison-Psychiatry in the general hospital
Ch. ISTIKOGLOU1, N. KOUTOUVIDIS2, G. HARITAKIS3, D. VLISSIDES1
1Department of Psychiatry, “Asklepeion" General Hospital, Voula, Athens-Greece
2Department of Psychiatry, NIMTS Military Hospital
3Karpenissi Mental Health Center

Abstract
According to the international standards, Post-infarction Depression constitutes a special factor, shown at a rate of 15-30% in patients treated in Infarction Care Units, 48-72 hours following an Acute Myocardial Infarction crisis. In the course of our study, we examined 283 post-infarctal inpatients treated at the Infarction Care Unit of the “Asklepeion” General Hospital of Voula, during one year during the year 2007. These patients were submitted to the MMSE (Mini Mental State Examination) for evaluation of their cognitive functions and the MADRS (Montgomery-Asberg Depression Rating Scale). The statistical analysis of the results has been performed using the Χ2 test and the variance analysis (ANOVA). Patients with a MMSE<2 were excluded from the study. No statistically significant differences were found between the depressive and non-depressive patients based on sex, age, and infarction prognosis. The ratio of depressive patients versus non-depressive patients was 53.3% versus 46.7%, according to the MADRS results. With regard to complications, there were 19 depressive patients with complications, versus 5 non-depressive patients (x2=7.41, p<0.01); this difference is statistically significant. From 283 patients, 202 (71%) were men and 81 (29%) were women. From 150 patients with depression, 98 (65%) were men and 52 (35%) were women. The ages of the patients treated were 38-78 years for men and 55-86 years for women. The age span for patients with depression was 42-68 years for men, and 56-79 years for women. Furthermore, a statistically significant difference (p<0.02) was observed between unmarried and divorced infarctal patients, and married, depressive post-infarctal patients, regarding depression percentages. Out of 150 infarctal patients with depression found during the course of the study, 63 were divorced (42%), 43 were unmarried (34.8%), and the remaining 46 were married (27%). Patients with a Killip level of 3q4 (n=7) were excluded from the study. We should underline here that the Killip level evaluated the severity of pulmonary oedema and heart failure co-existence. Post-infarct Depression is directly connected to the patients suffering from Acute Myocardial Infarction and are treated in the Infarction Units of General Hospitals.

Successful infarction treatment requires:

1) Close collaboration between the Cardiologist and the Psychiatrist;
2) Anti-depressive treatment, and
3) Thrombolysis.

Finally, the contribution of Combinatorial Psychiatry for the diagnosis and treatment of Post-infarctal Depression in the General Hospital is also vital. Encephalos 2011, 48(3):114-117.

Key words: Infarction, myocardium, depression, Infarction Unit, General Hospital, Liaison-Psychiatry.

Introduction

Post-infarction Depression is a special psychopathological entity at the General Hospital and is observed at a rate of 15-30% in patients undergoing treatment in the Care Units, within 48-72 hours following an acute Myocardial Infarction. This problem is faced by the Clinical Psychiatrist working in a General Hospital at a daily bases, both in the Infarction Care Units and in the Cardiology Clinic, within the framework of their Liaison Consultative Psychiatry. In order to solve these problems and for the optimal treatment of the patient, the Psychiatrist ought to have a good level of knowledge in the fields of internal Pathology and Cardiology, and the collaborating Cardiologist should have looked more closely on psychiatric problems and possess knowledge on Psychiatry1,2.

Patients with cardiac conditions, especially those suffering from angina and myocardial infarction, often show intense anxiety, as a reaction to their cardiac disorder, pain and fear of death[18-20]. This anxiety appears immediately after the infarction crisis in hospitalized patients, it comes to a peak on the second day and, usually, subsides after the first few days. Nevertheless, in certain patients this intense anxiety persists for quite enough time following the incident3,4,21,22.

Among General Hospital in-patients treated for infarction, major depression is observed at a rate of 15-30%, while 65% show signs of mild depression, as per the international standards5,6.

According to a study held among in-patients treated for acute myocardial infarction in the Cardiology Clinic of the Nikaia General State Hospital in Piraeus, depression was the prevailing psychiatric condition, observed at a rate of 24%. Major depression frequency was 5,4%, and this condition co-existed with other disorders at a total rate of 17.7%, i.e. 1 in 5 post-infarctal patients suffered from major depression5-7.

Purpose

The purpose of the present thesis is to underline the association between Depression and Acute Myocardial Infarction (AMI)8-10.

Material-Method

We examined 283 post-infarctal inpatients treated at the Infarction Care Unit of the “Asklepeion” General Hospital of Voula, during the year 2007. These patients were submitted to the MMSE (Mini Mental State Examination) for evaluation of their cognitive functions and the MADRS scale (Montgomery-Asberg Depression Rating Scale) for depression23. The MADRS scale is a diagnostic questionnaire comprising 10 items: 1) apparent sadness, 2) reported sadness, 3) inner tension, 4) reduced sleep, 5) reduced appetite, 6) concentration difficulties, 7) lassitude, 8) inability to feel, 9) pessimistic thoughts, 10) suicidal thoughts. The cut-off threshold between depression and non-depression in MADRS Scale is Score 12. Any patient scoring above 12 is considered to be a clinical depression case17. MADRS Scale has been evaluated 5, 15, 30, and 45 days following the myocardial infarction. The statistical analysis of the results has been performed using the x2 test and the variance analysis (ANOVA)11.

The diagnosis of depression and its classification as mild, moderate and severe, has been performed using the DSM-IV-TR criteria for diagnosis.

Results

No statistically significant differences were found between the depressive and non-depressive patients based on sex, age, and infarction prognosis24,25. The ratio of depressive patients versus non-depressive patients was 53.3% versus 46.7%, according to the MADRS results. The mean score of the MADRS Scale was initially higher (mean~14-30) during the 5th post-infarctal day, while on the 45th day the mean score was 5-12, given that all patients included in the study, with absolutely no exceptions, were treated with SSRI. With regard to complications, there were 19 depressive patients with complications, versus 5 non-depressive patients (x2=7.41, p<0.01); this difference is statistically significant.

From 283 patients, 202 (71%) were men and 81 (29%) were women. From 150 patients with depression, 98 (65%) were men and 52 (35%) were women. The ages of the patients treated were 38-78 years for men and 55-86 years for women. The age span for patients with depression was 42-68 years for men, and 56-79 years for women.

Furthermore, a statistically significant difference (p<0.02) was observed between unmarried and divorced infarctal patients, and married, depressive post-infarctal patients26,27. Out of 150 infarctal patients with depression found during the course of the study, 63 were divorced (42%), 43 were unmarried (34.8%), and the remaining 46 were married (27%). Patients with a MMSE<2 (n=3), and patients at a Killip level of 3 & 4 (n=7) were excluded from the study. We should underline here that the Killip level evaluated the severity of pulmonary oedema and heart failure co-existence.

Conclusions

Post-infarct Depression is directly connected to the patients suffering from Acute Myocardial Infarction (AMI) and are treated in the Infarction Units of General Hospitals. Therefore, this requires the close collaboration of the Cardiologist and the Psychiatrist and the initiation of anti-depressive treatment along with the administration of cardiac medication and thrombolysis, as this reduces complications from the Acute Myocardial Infarction, which are more frequent to the depressive patients. The safest anti-depressive medication for post-infarction depression are the Selective Serotonin Reuptake Inhibitor (SSRIs) Antidepressants.

Discussion

The post-infarctal depression rates of 53.3% observed in our study present a significant statistic diversion from the internationally reported rates (15-30%)12,13.

The statistic difference shown in our study compared to the international standards can be interpreted considering the fact that Depression measurements in all other studies were performed 30 and 45 days following the Myocardial Infarction, while our study was conducted 5, 15, 30, 45 days after the infarction. The MADRS Scale was performed on the 5th and 15th post-infarction day shows significantly higher scores.

The anti-thrombocyte effect of the SSRIs, which does not appear to have any relation with the reaction of cardiology patients suffering from depression, is an additional therapeutic action, possibly not possessed by the tricyclic antidepressants. The shift in thrombocyte activation may constitute a base patho-physiologic mechanism causing sudden death in cardiology patients suffering from depression; this condition seems to be cured with SSRI administration14.

A severe adverse effect of these two sub-categories of antidepressants and, maybe, the SSRIs is the bleeding tendency presented by the patient, due to the extension of the patient's prothrombin time observed when they are co-administered with anti-coagulants or thrombolysis. The need for co-administration requires a frequent examination of blood coagulability and good collaboration with the Cardiologist regarding a possible modification of the patient’s coagulant treatment, given that post-infarctal depression severely hinders patient recovery following an acute myocardial infarction (AVI)28.

Furthermore, it is possible that Post-Infarctal Depression diagnosis may be substituted by other conditions, e.g. post-traumatic anxiety disorder, chronic alcoholism, etc.15,16.

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