The Relationship Between Incidence of Depression After Myocardial Infarction (MI)

1. INTRODUCTION

Cardiovascular diseases are known as the leading cause of mortality and disability, globally [1]. Acute myocardial infarction is characterized by reduced blood supply, oxygen, and nutrition to cardiomyocytes, which eventually leads to cell injury and death [2]. Nausea/vomiting, chest pain, shortness of breath, and cold sweats are some commonly known indications of MI [3, 4]. Stress and depression are common in patients with a history of myocardial infarction (MI) [5]. Psychiatric disorders are also commonly reported in these patients [6]. Depression is also characterized by increased mortality and morbidity following MI [7]. Studies have indicated that patients with coronary heart disease are at a greater risk of mortality due to depression and low perceived social support [8, 9]. Furthermore, 20% of these patients would like to have major depression, whereas 27% are known to have minor depression [10]. Antidepressants effectively treat depression in patients with MI [1]. 20-40% of the MI patients experience anxiety and depression, 18 months after the onset of MI [11]. Studies have shown that psychological stress leads to dysregulation of hemostasis, such as causing hypercoagulation, alteration of fibrinolysis, and platelet functioning [12]. Post-MI anxiety is also associated with 9.37 folds increased risk of recurrent MI [13]. The aim of this study is to evaluate the incidence of depression of co-morbid psychiatric disorders among patients with a recent history of myocardial infarction (MI).

2. PATIENTS AND METHODS

In this retrospective study, 100 patients who were reported to our psychiatric center after myocardial infarction in 2020, were included. Each patient had a proven history of myocardial infarction diagnosed by electrocardiography (MMPI) and enzyme evaluation. The Minnesota Multiphasic Personality Inventory (MMPI) Questionnaire was used to assess MI patients after 16-18 months of MI. Written consent was obtained from the patients prior to participation in the study. Exclusion criteria of the study included patients with severe chronic diseases like malignancy, family history of depression or other psychiatric disorders, those taking SSRIs [selective serotonin reuptake inhibitors], history of postpartum depression, and those who did not consent to participate in the study.

MMPI is a widely used psychiatric test in which each patient responds to 550 multiple choice questions under the supervision of the psychiatrist. Scores are calculated based on ‘cannot say’, inconsistencies (F), lies (L), and symptoms (K). Hypochondria, Hysterical Depression, Psychopanical Attitudes, Paranoid, Schizophrenia, Hypomania, Masculinity-Feminity, Obsessive-Compulsive Disorder and depression are also measured in the questionnaire. With the help of clinicians, patients were asked to fill MMPI questionnaire, along which demographic information of the patients was obtained.

The data obtained from these questionnaires were analyzed by the clinical psychiatrist in collaboration with the cardiologist and was statistically analyzed using SPSS v18.

This study was approved by the Research Ethics Board of Lorestan University of Medical Sciences. The unique identification number is: research registry 7430. The methods have been reported according to the CARE guidelines [14]. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation of the institute and with the Helsinki Declaration of 1975, as revised in 1983.

3. RESULTS

Of the 100 patients with myocardial infarction (MI) according to the type of MI, 22 (22%) men and 22 (22%) women had inferior ST-segment elevation MI (STEMI), where 14 of these had depression, 4 (4%) men and 6 (6%) women had non-Q MI, and extensive anterior MI and 6 of them had depression, while 24 (24%) men and 22 (22%) women had anterior septal MI and 30 had depression Table 1.

Of 50 patients evaluated for the study, 24 (24%) males and 13 (26%) females were without depressive symptoms, whereas, 26 (26%) females and 24 (24%) males had depressive symptoms. Furthermore, among these, 54 (54%) patients presented with depression had other psychiatric comorbidities: anxiety (n=4), aggression (n=10), hysteria (n=24), hypochondria (n=6), and schizophrenia (n=12). 54 (54%) of the total patients had psychiatric depression Table 2. Of 50 females in the study, 26 were depressed, and 4 had sixth-degree. Of the 50 male patients, 8 were literate, 4 of whom were depressed. Of the 34 literate people, 14 were depressed. And one out of two people with a high school diploma was depressed, and one out of two with a high school diploma or higher were both depressed. Among 50 deceased patients, out of 20 farmers, 4 died and 16 patients with other jobs (employees, teachers, etc.) died, 4 of which had depression. Based on the age-group distribution, 26 of the total patients aged < 50 years, 6 had depression, where 20 patients were aged between 50-59 years in which, 10 had depression, and 24 of those <70 years had depression.

4. DISCUSSION

In a recent meta-analysis, Feng, Li et al. [15] reported that the prevalence of post-MI depression was 28.7% from 19 studies based in 10 countries. The researchers also found that the Asian region, female sex, anterior MI, diabetes, and hypertension were significant risk factors for post-MI depression. Our findings from the MMPI test suggest that 63% of patients with post-MI depression have anterior MI.

In a study, Kjellstrom and Gustafsson [1] showed that 39% of MI patients had depression. In addition, they also found that patients who received cognitive behavioral therapy along with a selective serotonin reuptake inhibitor (when required) were associated with an improvement in mental health in these patients. However, it did not affect the survival rate [16]. Serpytis, Navickas [17] randomly selected 50 patients with a history of myocardial infarction, admitted to our psychiatric clinic. Given that the percentage of depression in the community is about 15%, based on the above analysis, we found that 50% of our population had post-MI depression [18]. However, data on the mental state of these patients before MI are not known. Smolderen, Buchanan [19], in their study, reported that 18.7% of MI patients had depression, and the rate of mortality was higher in the untreated group of these patients.

Doyle, McGee [20] and Serpytis, Navickas [17] indicated in their studies that women are at a greater risk of developing post-MI depression. However, our findings did not report any significant differences in the incidence of post-MI depression. Studies have shown that depression is associated with the increased risk of adverse cardiovascular events such as coronary heart disease [21]. Post-MI depression not only adds to increased incidence of other cardiovascular diseases but also mortality following the bypass, percutaneous angiography or other associated treatments [22, 23]. Anxiety and other psychological disorders reduce the overall survival rate following the diagnosis of cardiovascular diseases. Intake of anti-depressants, serotonin inhibitors and cognitive therapies are known to decrease the risk of death and recurrent myocardial infarction in these patients [24].

In our study, patients’ evaluation was conducted by means of the MMPI test, nonetheless, Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder Scale (GAD-7) are more clinically applicable tests with greater reliability. Furthermore, our study did not evaluate the therapeutic outcomes in these patients and did not include the control group. Overcoming these limitations can help clinicians find a better conclusion about these psychiatric disorders after cardiovascular events and can be controlled in their early stages.

CONCLUSION

Given that the prevalence of depression in people after MI is approximately three times than general population, therapeutic measures and detailed investigation are required in this field of study. Following MI, psychological rehabilitation should be provided to the patients.

AUTHORS’ CONTRIBUTIONS

Dr. Alireza Gheini conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript.

Dr. Ali Pooria designed the data collection instruments, collected data, carried out the initial analyses, and reviewed and revised the manuscript.

Dr. Afsoun Pourya and Dr. Ermia Farokhi coordinated and supervised data collection and critically reviewed the manuscript for important intellectual content.

REFERENCES