Abstract
Depression has been associated with adverse outcomes in patients with cardiac disease. Data on its prevalence and the factors influencing it are limited in the cardiac rehabilitation program (CRP) setting. To elucidate the prevalence of and the factors that influence depression in patients attending CRP. Patients attending the CRP from 2003 to 2016 were included in the study. All patients had a Beck Depression Inventory-II (BDI-II) performed prior to commencement in CRP and were followed longitudinally. The BDI-II for the 4989 patients were as follows: 0 to 13 (normal) = 3623 (72%); 14 to 19 (mild depression) = 982 (20%); 20 to 28 (moderate depression) = 299 (6%); 29 to 63 (severe depression) = 85 (2%). The BDI-II (mean ± SEM) for males (mean age: 60.8 ± 0.1 years) and females (mean age: 63.4 ± 0.3 years, P < .001) were 7.0 ± 0.1 and 8.5 ± 0.2 (P < .001), respectively. Elevated BDI-II scores (14–63) were more common in type 1 (41.1%) and type 2 (30.5%) diabetics than nondiabetics (25.7%). Similarly, elevated scores were more common in smokers (36.1%) than never-smokers (24.7%). The BDI-II scores for Caucasians, South Asians, and East Asians were 7.3 ± 0.1, 8.0 ± 0.3, and 7.0 ± 0.3 respectively (P = .01 for CA vs SA by 1-way ANOVA and least significant difference test). The prevalence of depression is high in patients attending CRP affecting 28% of the population. BDI-II is a simple validated screening tool that can be applied to patients attending CRP. Diabetics, current smokers, and South Asians all had a higher prevalence of depression.
Keywords: Depression, Cardiac Rehabilitation, Prevention, Nutrition, Ethnicity, Sex
1. Introduction
Depression is known to coexist in many patients admitted to medical care including in patients admitted to hospital for cardiac disease. Though its exact prevalence is unknown, studies suggest that between 31% and 45% of coronary artery disease patients have depression.[1,2] Moreover, some studies have shown an association between depression and adverse cardiovascular outcomes.[1–4] Adverse outcomes include increased mortality, higher repeat myocardial infarction rates, higher hospital readmission rates, and reduced adoption of secondary prevention medications.[2–4] Several quality of life measures also appear to be significantly negatively impacted in patients with cardiac disease and depression.[2–4] Data specifically in patients in cardiac rehabilitation programs (CRP) are more limited with most studies being smaller than in the general cardiac population though there also appears to be a high prevalence of depression. Some studies suggest that CRP patients with depression are harder to convince to both attend and stay motivated in cardiac rehabilitation programs and have reduced compliance with suggested therapies.[5,6]
Despite the known clinical concerns, depression remains greatly underrecognized and undertreated, especially in medical clinical settings where the primary issue is not psychiatric.[7,8] Patients who experience a cardiac event are known to be more likely to experience depression.[9] In turn, within CRP, depression is prevalent but underrecognized.[10–13] This is partly due to lack of knowledge on the part of medical practitioners that are not well-versed in psychiatric medicine as well as lack of time to use the proper tools to diagnose depression in the clinical setting.[7] The Beck Depression Inventory (BDI-II) is a useful tool to screen patients for underlying depression. Despite the presence of tools such as the BDI-II, data regarding the prevalence of depression and the risk factors that influence it in the CRP setting are lacking. The purpose of the present study was to elucidate the prevalence of and the factors that influence depression in patients attending a CRP.
2. Methods
2.1. Study population
All patients who attended the CRP between January 2003 and April 2016 at the Grey Nuns Hospital in Edmonton, Alberta, Canada, were included in the study. The Grey Nuns Hospital is a tertiary care hospital that services the Edmonton region as well as the northern part of the Province of Alberta as well as parts of Eastern British Columbia, the Yukon, Northwest, and Nunavut Territories. Referrals are made to the CRP by cardiologists within these regions for patients who have had an acute cardiac event or have chronic cardiac conditions such as congestive heart failure that might benefit from CRP.
2.2. Beck depression inventory
The Beck Depression Inventory is a multiple-choice questionnaire created by Aaron Beck that is done via self-report by patients. It has been integrated and administrated at the beginning of CRP at the Grey Nuns Community Hospital with the most current iteration of the inventory (BDI-II) being used.[14] The BDI-II consists of 21 statements that queries emotions and feelings regarding various topics such as sadness, appetite, fatigue, and interest in sex. Patients answer each statement on a scale of zero to 3 with higher scores typically indicating more severe depressive symptoms. Nurses also instructed patients to answer based on their experiences in the last 2 weeks. Once the patient is finished, scores are tallied into a composite number. The severity of depressive symptoms is classified by the following cutoffs: a score of 0 to 13 is minimal/normal, 14 to 19 is mild depression, 20 to 28 is moderate depression, and 29 to 63 is severe depression.
2.3. Cardiac rehabilitation program and follow-up
CRP consisted of an 8 to 12 week program whereby patients partook in a 1 hour exercise regimen 2 to 3 times a week. Patients undertook aerobic exercise on treadmills, stationary bikes, elliptical machines, and arm ergometers. They were also given isometric exercises using weights. Nurses were always present to supervise the patients, to provide teaching, and to track their pace and exertion levels. All patients were seen individually by a dedicated registered dietitian attached to the CRP with spouses strongly encouraged to attend the sessions as well. In addition, group classes on nutrition were held. Physicians with a specific interest in cardiac rehabilitation saw all patients prior to commencement in the CRP, at the end of CRP, and in-between as needed based on nursing assessment in order to optimize the secondary prevention measures related to lipids, blood pressure, blood glucose, LV dysfunction, and so on. Six-week post-CRP follow-up phone calls were also made by the nurses to track patient progress. Patients requiring psychiatric assessment were referred to an external clinical psychologist and psychiatrist as appropriate following discussion with each patient.
2.4. Data collection
Baseline demographics were collected at the beginning CRP and included individual patient medical, demographic, and physical information. In addition, socioeconomic, emotional wellbeing, and lifestyle information was collected along with the BDI-II. All information was entered into a database within the Statistical Package for the Social Sciences data management system version 21 (SPSS, International Business Machines Corporation, Armonk, NY).
2.5. Ethics
Approval for this study was given by the Human Research Ethics Board of the Research Ethics Office of the University of Alberta (Pro00083746).
2.6. Statistical analysis
Statistics were performed within SPSS. Variables were tested and had normal distributions based on the histograms, box plots, and large size of the dataset. Continuous variables were described using means and standard deviations. Categorical variables were converted into percentages. The cohort was split into 2 groups based on normal (0–13) and elevated (14–63) BDI-II scores and were then compared. Continuous variables were compared using the Student t-test while categorical variables were placed into crosstabulations and tested with a 1-way ANOVA test. A P-value of ≤.05 was considered significant for all analyses.
2.7. Outcomes
The cohort was divided based on “normal” (0–13) or “elevated” (14–63) BDI-II scores. Baseline characteristics and outcomes that were measured and compared included sex, ethnicity, BMI, waist circumference, diabetes, smoking status, lipid levels and pre- and post-CRP 6-minute walk distances.
3. Results
Four thousand nine hundred eighty-nine patients performed a BDI-II questionnaire at entry into CRP at Grey Nuns Hospital. Of the cohort, 72.6% were male, 84.0% Caucasian, 12.8% South Asian, and 3.2% East Asian. The mean age was 61.8 ± 0.2 years. As shown in Figure 1, 3623 patients (72.6%) had a normal BDI-II score between 0 and 13. Nine hundred eighty-two patients (19.7%) had a score between 14 and 19, which is considered mild depression. Two hundred ninety-nine patients (6.0%) had a score from 20 to 28, which is considered moderate depression. Finally, 85 patients (1.7%) had a score from 29 to the maximum of 63, considered severe depression.
Figure 1.
BDI-II score distribution of 4989 patients attending the CRP; 27.4% of all participants had at least mild depression. BDI-II = Beck Depression Inventory-II, CRP = cardiac rehabilitation program.
Baseline characteristics for the entire cohort are listed in Table 1. Patients that had a normal BDI-II (0 to 13–72.6%) were compared to those with an elevated BDI-II (14 to 63–27.4%) (Table 2). Patients with elevated BDI-II scores were younger (62.5 ± 0.2 years vs 60.3 ± 0.3 years, P < .001) and were more often female (21.4% vs 30.1%, P < .001). They also had a higher BMI (29.1 ± 0.1 kg/m2 vs 29.8 ± 0.2 kg/m2, P < .001) and waist circumference (100.6 ± 0.3 cm vs 103.0 ± 1.0 cm, P = .002). The mean weight between both cohorts were similar (84.2 ± 0.3 kg vs 85.8 ± 0.6 kg, P < .327).
Table 1.
Baseline characteristics of entire CRP patient cohort.
| Patient characteristics | All CRP patients (n = 4989) |
|---|---|
| Demographics | |
| Male, % | 72.6 (n = 3622) |
| Female, % | 27.4 (n = 1367) |
| Age, mean (SEM), yrs | 61.8 (0.2) |
| Pre-CRP weight, mean (SEM), kg | 84.5 (0.3) |
| Pre-CRP body mass index, mean (SEM), kg/m2 | 29.1 (0.1) |
| Pre-CRP laboratory characteristics | |
| Total cholesterol, mean (SEM), mmol/L | 5.92 (0.02) |
| LDL, mean (SEM), mmol/L | 3.79 (0.01) |
| HDL, mean (SEM), mmol/L | 1.20 (0.02) |
| Triglycerides, mean (SEM), mmol/L | 2.30 (0.05) |
| Ejection fraction, mean (SEM), % | 51.8 (0.2) |
| Ethnic Origin | |
| Caucasian, % | 84.0 (n = 4192) |
| South Asian, % | 12.8 (n = 639) |
| East Asian, % | 3.2 (n = 158) |
| Diabetic | |
| Nondiabetic, % | 77.3 (n = 3837) |
| Type 1, % | 17.7 (n = 248) |
| Type 2, % | 5.0 (n = 883) |
| Smoking status at CRP start | |
| Never smoked, % | 35.3 (n = 1759) |
| Quit smoking < 1 yr, % | 4.6 (n = 230) |
| Quit smoking > 1 yr, % | 37.0 (n = 1845) |
| Quit smoking after cardiac event, % | 13.7 (n = 681) |
| Currently smoking, % | 9.4 (n = 482) |
| Quit rate of smokers at 3-month post-CRP | |
| Smoking, % | 31.7 (n = 1582) |
| Not smoking, % | 68.3 (n = 3407) |
BDI = Beck depression inventory, CRP = cardiac rehabilitation program, HDL = high-density lipoprotein, LDL = low-density lipoprotein, SEM = standard error of the mean.
Table 2.
Patient characteristics of CRP patients with normal (0–13) and abnormal (14–63) BDI scores.
| Patient characteristics | Normal | Abnormal | P-value |
|---|---|---|---|
| (0–13) | (14–63) | ||
| n = 3623 | n = 1366 | ||
| (72.6%) | (27.4%) | ||
| Demographics | |||
| Male, % | 78.6 | 69.9 | <.001 |
| Female, % | 21.4 | 30.1 | <.001 |
| Age, mean (SEM), years | 62.5 (0.2) | 60.3 (0.3) | <.001 |
| Pre-CRP weight, mean (SEM), kg | 85.2 (0.3) | 85.8 (0.6) | .327 |
| Pre-CRP body mass index, mean (SEM), kg/m2 | 29.1 (0.1) | 29.8 (0.2) | <.001 |
| Waist circumference, mean (SEM), cm | 100.6 (0.3) | 103.0 (1.0) | .002 |
| Pre-CRP laboratory characteristics | |||
| Total cholesterol, mean (SEM), mmol/L | 5.88 (0.02) | 6.02 (0.04) | .001 |
| LDL, mean (SEM), mmol/L | 3.77 (0.02) | 3.83 (0.03) | .126 |
| HDL, mean (SEM), mmol/L | 1.20 (0.03) | 1.21 (0.01) | .906 |
| Triglycerides, mean (SEM), mmol/L | 2.20 (0.03) | 2.57 (0.17) | .002 |
| Hemoglobin A1c, mean (SEM), % | 6.7 (0.1) | 6.7 (0.2) | .894 |
| Ejection fraction, mean (SEM), % | 51.9 (0.2) | 51.3 (0.3) | .170 |
| CRP results | |||
| Duration of time on CRP, mean (SEM), weeks | 7.00 (0.04) | 6.95 (0.09) | .619 |
| Pre-CRP 6-minute walk test, mean, meters | 451.0 | 420.6 | <.001 |
| Post-CRP 6-minute walk test, mean, meters | 521.3 | 491.8 | <.001 |
BDI = Beck depression inventory, CRP = cardiac rehabilitation program, HDL = high-density lipoprotein, LDL = low-density lipoprotein, SEM = standard error of the mean.
Total cholesterol was higher in patients with elevated BDI-II scores (5.88 ± 0.02 mmol/L vs 6.02 ± 0.04 mmol/L, P = .001) as were triglycerides (2.20 ± 0.03 mmol/L vs 2.57 ± 0.17 mmol/L, P = .002). Low-density lipoproteins (LDL) (3.77 ± 0.02 mmol/L vs 3.83 ± 0.03 mmol/L, P = .126) and high-density lipoproteins (HDL) were similar (1.20 ± 0.03 mmol/L vs 1.21 ± 0.01 mmol/L, P = .906). Hemoglobin A1c (6.7% ± 0.1% vs 6.7% ± 0.2%, P = .894) and echocardiographic ejection fraction (51.9% ± 0.2% vs 51.3% ± 0.3%, P = .170) were also similar between patients with normal and elevated BDI-II scores. While all patients spent a similar time on CRP (7.00 ± 0.04 weeks vs 6.95 ± 0.09 weeks, P = .619), patients with elevated BDI-II scores had lower average 6-minute walk distances prior to entering CRP (451.0 m vs 420.6 m, P < .001). This trend continued following the conclusion of CRP where their 6-minute walk distance on average were still lower (521.3 m vs 491.8 m, P < .001).
Several subgroups were examined. There were differences in BDI-II scores between ethnic groups. As shown in Table 3, elevated BDI-II scores were observed in more patients that identified themselves as South Asians, followed by Caucasians, and East Asians (32.2% vs 26.8% vs 22.8%, P = .007) (Fig. 2). Patients with diabetes had more elevated scores, with type 1 diabetics having the highest proportion of elevated scores (41.1%) followed by type 2 diabetics (30.5%) compared with only 25.7% of nondiabetic patients (P < .001) (Fig. 3). Depression scores also differed by smoking status (Fig. 4). Patients who never smoked had lower scores than those who currently smoked (24.7% vs 36.1%, P < .001). Comparing those who quit smoking, patients that quit more than a year prior to entering CRP had lower BDI-II scores than those who quit after their cardiac event and those who quit less than 1 year prior to CRP (25.7% vs 31.1% vs 31.7%, respectively, P < .001). Finally, in terms of patients that smoked at the beginning of CRP, those who quit smoking by 3 months following conclusion of CRP had lower BDI-II scores than those who still continued to smoke (29.6% vs 34.0%, P < .001).
Table 3.
Subgroups of CRP patients with normal (0–13) and abnormal (14–63) BDI scores.
| Cohort | Normal | Abnormal | P |
|---|---|---|---|
| (0–13) | (14–63) | ||
| n = 3623 | n = 1366 | ||
| (72.6%) | (27.4%) | ||
| Ethnic Origin | |||
| Caucasian, % | 73.2 (n = 3068) | 26.8 (n = 1124) | .007 |
| South Asian, % | 67.8 (n = 433) | 32.2 (n = 206) | |
| East Asian, % | 77.2 (n = 122) | 22.8 (n = 36) | |
| Diabetic | |||
| nondiabetic, % | 74.3 (n = 2849) | 25.7 (n = 988) | <.001 |
| Type 1, % | 58.9 (n = 146) | 41.1 (n = 102) | |
| Type 2, % | 69.5 (n = 615) | 30.5 (n = 268) | |
| Smoking status at CRP start | |||
| Never smoked, % | 75.3 (n = 1324) | 24.7 (n = 435) | <.001 |
| Quit smoking < 1 year, % | 68.3 (n = 157) | 31.7 (n = 73) | |
| Quit smoking > 1 year, % | 74.3 (n = 1371) | 25.7 (n = 474) | |
| Quit smoking after cardiac event, % | 68.9 (n = 469) | 31.1 (n = 212) | |
| Currently smoking, % | 63.9 (n = 295) | 36.1 (n = 167) | |
| Quit rate of smokers at 3-month post-CRP | |||
| Smoking, % | 66.0 (n = 278) | 34.0 (n = 143) | <0.001 |
| Not smoking, % | 70.4 (n = 638) | 29.6 (n = 268) | |
CRP = cardiac rehabilitation program.
Figure 2.
Normal versus abnormal BDI-II scores based on ethnicity. BDI-II = Beck Depression Inventory-II.
Figure 3.
Normal versus abnormal BDI-II scores based on diabetes. BDI-II = Beck Depression Inventory-II.
Figure 4.
Normal versus abnormal BDI-II scores based on smoking status. BDI-II = Beck Depression Inventory-II.
4. Discussion
In examining this group of patients participating in the CRP at the Grey Nuns Hospital, it is important to first acknowledge that depression occurs at a high rate in CRP patients and depression is clinically underdiagnosed. Depression in general is known to be associated with worse clinical outcomes.[15–17] Therefore, patient intervention can be a potential avenue to improve long-term outcomes as well as quality of life. For example, medical therapies such as antidepressants can reduced depressive symptoms and may improve clinical psychiatric outcomes.[18] It is however not clear if antidepressants can improve cardiovascular outcomes, but patients who experienced improvements with their depressive symptoms were more likely to adhere to their cardiovascular medications.[19–21] Other interventions, such as cognitive based therapy, have also been found to improve depressive symptoms for cardiovascular patients,[22] albeit only conclusively in the short term.[23]
In the present study, there were several interesting differences when comparing those with normal and elevated BDI-II scores. Patients with elevated BDI-II scores had a higher proportion of females and were younger. This is not unexpected as depression is known to be more prevalent in females and in younger adults.[24–26] In terms of ethnic origins, there were differences as well. South Asians had the worst scores with Caucasians in the middle and East Asians having the most normal scores. Similar findings have been seen in other studies.[27,28] Notably, there is evidence that minority populations are less likely to experience minor depressive episodes versus Caucasians, but are more likely to suffer major, prolonged, and severe episodes.[29] This could be because minorities, specifically South and East Asians, are less inclined to self-report or describe symptoms of depression.[30] Due to cultural norms, they may not feel the need to share or prioritize a possible depressive episode with others, resulting in less likelihood of proper diagnosis and treatment. For South Asians living in the Western world, there is also a higher proportion who experience depressive episodes because they feel a lack of social support.[31] The language barrier is also a possible factor in that many of those who do not report mental health issues may simply not know where to go to seek attention or that there is no one to aid in relaying their problems to someone. This is particularly worrisome given that a cardiac event is a huge life stressor and may precipitate a more major depressive episode in a patient that has otherwise not clinically presented before. A possible solution would be to provide and reiterate information regarding the mental health services available to CRP patients and maintain an open discussion and to consider integrating mental health services into CRP given that up to 28% of all patients within CRP have depression.
Certain risk factors also seem to have a higher proportion of elevated BDI-II scores. Obesity is known to be a risk factor for increased depression and depressive episodes and was similarly associated in our study.[32–34] Patients with diabetes also had a higher proportion of elevated BDI-II scores as noted in other studies.[35,36] Differences were also found in BDI-II scores based on smoking status. Patients who never smoked or quit longer than a year prior to their cardiac event had proportionally less elevated scores than those who quit less than a year prior, after their event, or who were currently smoking. There is precedence for the association between mental illness and smoking,[37] but a clear link between the 2 is uncertain.[38] Regardless, there may be a beneficial association between quitting smoking and improved BDI-II scores or alternatively one must have a higher suspicion that there may be underlying depression in continued smokers and treating the depression may potentially improve the smoking quit rate.
In terms of specific patient outcomes from CRP, although the duration on CRP for both groups was similar, both pre- and post-CRP 6-minute walk test results were higher in patients with normal BDI-II score. This may be in keeping with other studies that found exercise improved mental health and lowered the risk of depression or possibly that depression is associated with less functional ability.[39,40]
4.1. Limitations
The results of our study should be considered within its limitations. First, the BDI-II test is a self-reported questionnaire. Therefore, responses and scores can be exaggerated or understated. In addition, scores could vary based on the patient’s emotional state at the time of administration. Furthermore, at this time, we do not have any BDI-II scores done well prior to the index cardiac event nor after cardiac rehabilitation to compare to. This makes it difficult to infer directionality from the association given that we cannot tell whether depression precedes the cardiac event or if it is brought on by the stress of the acute medical illness. The BDI-II score is also in English and so there may be some differences in how it is translated to other languages when being administered which may affect results. Finally, in some cultures, depression may be less accepted leading to untruthful answers in the BDI-II.
5. Conclusions
In our study, we found that female, younger and overweight/obese patients were more likely to have elevated BDI-II scores. South Asian patients also had a higher rate of elevated scores, as were patients with diabetes and those who were smokers. Finally, patients with elevated scores had lower 6-minute walk test scores both pre- and post-CRP compared to those with normal scores. Our study suggests that over one-quarter of all patients in CRP have some degree of depression and that the presence of depression may not only affect the incoming characteristics of the patients but may also modulate their ability to change cardiovascular risk factors such as smoking and improve their exercise capacity. As well, we noticed that depression seems to lessen the potential benefits of CRP for patients. Knowing these factors and the detrimental effects, one may need to consider altering CRP in order to aid patients in understanding depression and offering and reiterating avenues of mental health support such as medical and cognitive based therapy.
Author contributions
Conceptualization: Janek M Senaratne, Manohara P.J. Senaratne
Data curation: Gami L Nanayakkara, Lena Krincic, Rhonda Lightfoot, Wendy Reinhardt, Keshani De Silva
Formal analysis: Gami L Nanayakkara, Keshani De Silva, Janek M Senaratne, Manohara P.J. Senaratne
Funding acquisition: N/A
Investigation: Gami L Nanayakkara, Keshani De Silva, Janek M Senaratne, Manohara P.J. Senaratne
Methodology: Gami L Nanayakkara, Keshani De Silva, Janek M Senaratne, Manohara P.J. Senaratne
Project administration: Gami L Nanayakkara, Keshani De Silva, Janek M Senaratne, Manohara P.J. Senaratne
Resources: Janek M Senaratne, Manohara P.J. Senaratne
Software: Janek M Senaratne, Manohara P.J. Senaratne
Supervision: Janek M Senaratne, Manohara P.J. Senaratne
Validation: Gami L Nanayakkara, Janek M Senaratne, Manohara P.J. Senaratne
Visualization: Gami L Nanayakkara, Janek M Senaratne, Manohara P.J. Senaratne
Writing - original draft: Gami L Nanayakkara, Janek M Senaratne, Manohara P.J. Senaratne
Writing - review and editing: Gami L Nanayakkara, Janek M Senaratne, Manohara P.J. Senaratne
Abbreviations:
- CRP =
- cardiac rehabilitation program
- BDI-II =
- Beck Depression Inventory-II
- LDL =
- low-density lipoproteins
- HDL =
- high-density lipoproteins
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
The authors have no funding and conflicts of interest to disclose.
All authors have read and approved the manuscript.
How to cite this article: Nanayakkara GL, Krincic L, Lightfoot R, Reinhardt W, Silva KD, Senaratne JM, Senaratne MP. Demographics and Risk Factors that Influence the Prevalence of Depression in Patients Attending Cardiac Rehabilitation. Medicine 2022;101:36(e30470).
Contributor Information
Gami L. Nanayakkara, Email: nanayakk@ualberta.ca.
Lena Krincic, Email: Krincic.Lena@albertahealthservices.ca.
Rhonda Lightfoot, Email: Lightfoot.Rhonda@albertahealthservices.ca.
Wendy Reinhardt, Email: Reinhardt.Wendy@albertahealthservices.ca.
Keshani De Silva, Email: desilvak@mymacewan.ca.
Janek M. Senaratne, Email: manosenaratne@shaw.ca.
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