Depression and anxiety are common in people with cardiovascular disease (CVD) and heart failure occurring in up to 20% of patients with CHD and 40% with heart failure.[#joynt-ke-oconnor-cm.-2005] Depression and anxiety are independently associated with poor prognosis including higher mortality and hospital use.[#konstam-v-moser-d-dejong-mj.-2006,#whooley-ma.-2006,#freedland-ke-carney-rm-rich-mw.-2011]

Depression and anxiety are under-recognised by health professionals, partly because some of the symptoms, such as fatigue, poor sleep, poor appetite and palpitations, may be attributed to cardiac disease and are difficult to distinguish from the usual worry associated with serious disease.

Screening for symptoms using a validated tool for the setting is advocated to improve recognition of these problems[#freedland-ke-carney-rm-rich-mw.-2011] and supports patient referral for full assessment and management by appropriate health professionals. There is some evidence that in addition to reducing distress, management may reduce future cardiac events and costs of care.

It is recommended that clinicians follow standard guidelines and screen every patient for symptoms of depression using a standardised screening instrument. Screening means asking the same questions of every patient.  Many studies have shown that health professionals can be very inaccurate in the identification of depression. When a patient screens positive, this is not a diagnosis, but should be followed up with a recommendation to talk to his or her GP about their mood. [#colquhoun-dm-bunker-sj-clarke-dm-et-al,#tully-pj-higgins-r]

Questionnaires

There are several questionnaires available to assess the presence of symptoms for depression including the Beck Depression Inventory,[#beck-a-ward-c-mendelson-m-et-al.-1961] the Cardiac Depression Scale[#hare-dl-davis-cr.-1996] and the Hospital Anxiety and Depression Scale.[#zigmond-as-snaith-rp.-1983] The questionnaire used may be dependent on the agency providing the service.

Screening for depression in patients with CVD

The following steps have been recommended by a number of groups on the American Heart Association Prevention Committee and have been endorsed by the American Psychiatric Association as shown in the figure below.[#lichtman-jh-bigger-jt-blumenthal-ja-et-al.-2008]. Repeated measurement of depression is recommended by the current Australian guidelines [#colquhoun-dm-bunker-sj-clarke-dm-et-al] to assist in identification of trajectories of depression symptoms.

Figure 1: Recommended steps for assessing depression[#lichtman-jh-bigger-jt-blumenthal-ja-et-al.-2008]

Patient health questionnaire (PHQ)-2 and PHQ-9 depression screen

PHQ-2 (initial screening question)

Over the past 2 weeks, have you often been bothered by any of the following?

1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless

If the answer is ‘Yes’ to either question, then refer for clinical evaluation by a professional qualified in the diagnosis and management of depression, or screen using PHQ-9.

PHQ-9

Over the past 2 weeks, have you often been bothered by any of the following?

1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling asleep, staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself, that you are a failure, or that you have let yourself or your family down
7. Trouble concentrating on activities such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed, or being so fidgety or restless that you have been moving around a lot more than usual
9. Thinking that you would be better off dead or that you want to hurt yourself in some way

The Patient Health Questionnaire-9 (PHQ-9) and instruction manual that explains scoring and interpretation is available from phqscreeners.com. N.B. Be aware that the final item in the Patient Health Questionnaire (PHQ) 9 asks patients whether they have “thoughts that they would be better off dead or hurting themselves in some way”. Patients responding positively to this item require immediate risk assessment in line with organisational protocols. 

Depression symptoms

Where a formal diagnosis is not required or available, ask about symptom patterns of various depression disorders (see www.behavenet.com).

Anxiety is a normal reaction to perceptions of danger or threat. Everyone experiences some level of anxiety from time to time, but some people experience anxiety either in short, intense bursts (panic attacks) or chronically (for example, in generalised anxiety disorder; GAD). While the evidence for anxiety being an independent risk factor for further coronary events is mixed, we do know that anxiety is a cause of decreased quality of life[#olatunji-bo-cisler-jm-tolin-df.-2007] impaired functioning and poor adherence to health practitioner’s recommendations.[#bonnet-f-irving-k-terra-j-et-al.-2005,#luyster-fs-hughes-jw-gunstad-j.-2009]

The impairment caused by anxiety can be profound, so it is important to identify high levels of anxiety and to refer affected patients to appropriate mental health professionals.

Consider the following two options for assessing anxiety:

• Assess the presence and intensity of symptoms of anxiety, using a self-rating questionnaire
• Assess symptom patterns to diagnose the nature of the anxiety

Questionnaires

The GAD-7 questionnaire can be used to assess for GAD. The instruction manual explains scoring and interpretation.

Anxiety symptoms

Where a formal anxiety diagnosis is not required or available, ask about symptom patterns of various anxiety disorders. Further information is available from www.behavenet.com/anxiety-disorders#301.

At the simplest level, ask the individual or a significant other about the patient's general levels of anger. However, if you sense that anger may be a significant problem, consider using a questionnaire.

Most research validated questionnaires for use with cardiac patients charge a fee to access. However, a simple and cheap option is the online Aggression Questionnaire which measures physical aggression, verbal aggression, hostility and anger and allows the respondent to compare scores with the average male or female.

The risk of suicide is an important consideration in anyone with a mental disorder, as up to 90% of people who commit suicide had suffered from a diagnosable mental disorder. Males and those over 75 years of age have a higher suicide risk.

For further details see www.cdc.gov/violenceprevention/suicide/index.html.

Approximately 15% (range 0-25%) of those who experience a myocardial infarction (MI) develop post-traumatic stress disorder (PTSD).[#gander-m-von-kaenel-r.-2006] In those with chronic heart disease, PTSD is associated with a lower quality of life, greater hospital admission rates and worse general health outcomes.[#kubzansky-ld-koenen-kc-jones-c-et-al.-2009]

PTSD symptoms cluster around hyper-arousal, reliving and avoidance.[#american-psychiatric-association.-2013]

• Hyper-arousal may manifest as high levels of stress or anxiety, fidgeting, muscle tension, difficulty falling or staying asleep, irritability, difficulty concentrating, feeling ‘on guard’ or being easily startled
• Reliving may manifest as nightmares, flashbacks or intrusive images or thoughts of the traumatic experience
• Avoidant behaviour centres around avoiding anything reminiscent of the trauma, such as conversations, thoughts, activities, pictures, places or people

Useful screening tools are the Primary Care PTSD Screen and the Assessing PTSD screen.