Research report
Cardiovascular disease in persons with depressive and anxiety disorders

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Abstract

Background

Associations between depression, and possibly anxiety, with cardiovascular disease have been established in the general population and among heart patients. This study examined whether cardiovascular disease was more prevalent among a large cohort of depressed and/or anxious persons. In addition, the role of specific clinical characteristics of depressive and anxiety disorders in the association with cardiovascular disease was explored.

Methods

Baseline data from the Netherlands Study of Depression and Anxiety were used, including persons with a current (i.e. past year) or remitted DSM-IV depressive or anxiety disorder (N = 2315) and healthy controls (N = 492). Additional clinical characteristics (subtype, duration, severity, and psychoactive medication) were assessed. Cardiovascular disease (stroke and coronary heart disease) was assessed using algorithms based on self-report and medication use.

Results

Persons with current anxiety disorders showed an about three-fold increased prevalence of coronary heart disease (OR anxiety only = 2.70, 95%CI = 1.31–5.56; OR comorbid anxiety/depression = 3.54, 95%CI = 1.79–6.98). No associations were found for persons with depressive disorders only or remitted disorders, nor for stroke. Severity of depressive and anxiety symptoms—but no other clinical characteristics—most strongly indicated increased prevalence of coronary heart disease.

Limitations

Cross-sectional design.

Conclusions

Within this large psychopathology-based cohort study, prevalence of coronary heart disease was especially increased among persons with anxiety disorders. Increased prevalence of coronary heart disease among depressed persons was largely owing to comorbid anxiety. Anxiety—alone as well as comorbid to depressive disorders—as risk indicator of coronary heart disease deserves more attention in both research and clinical practice.

Introduction

In 1993 Frasure-Smith et al. showed that after a myocardial infarction, depressed persons were four-to-five times as likely to die within the next six months than their non-depressed counterparts. Although this initial observation turned out to overestimate the true relationship between depression and heart disease (e.g. Nicholson et al., 2006), since then, many studies have examined their association. Both depression and heart disease are leading disorders when considering disease burden. The World Health Organization projected depression and heart disease to become numbers 1 and 2, respectively, on the list of diseases with the greatest loss of ‘disability adjusted life years’ in 2030 in high-income countries and numbers 2 and 3 worldwide (Mathers and Loncar, 2006). This suggests an enormous possible gain in public health and disease burden when depression, heart disease and especially their comorbidity could be prevented through increasing knowledge on the link between these two disabling diseases.

Research thus far has mainly focused on two kinds of populations: heart disease patients and the general population. Meta-analyses have shown that among heart patients depression is associated with an 1.8 to 2.6 increased risk of a subsequent cardiovascular event or death (Barth et al., 2004, Nicholson et al., 2006, van Melle et al., 2004), while in the general population depression increases risk of cardiovascular disease (CVD) about 1.6 to 1.8 times (Nicholson et al., 2006, Rugulies, 2002, Van der Kooy et al., 2007, Wulsin and Singal, 2003). Although, as suggested by Nicholson et al. (2006), these estimates may still be inflated due to incomplete and biased reporting of adjustment for conventional risk factors and CVD severity. Studies on prevalence of CVD within a psychopathology-based population are largely lacking. From a psychiatrist perspective, it would be of great importance to know whether clinically depressed patients indeed have a higher prevalence of CVD and how much increased exactly this prevalence is. What's more, it has hardly been addressed whether specific characteristics of depression, such as age of onset, duration, or severity of the disorder could further determine the exact CVD probability, or whether the association is restricted to specific subtypes, such as atypical or melancholic depression. This knowledge could give insight into underlying mechanisms that relate depression and CVD as well as into which patients should be most closely monitored for cardiovascular dysfunctioning.

Besides depression, some studies have suggested anxiety to be associated with CVD as well (Albert et al., 2005, Fan et al., 2008, Kawachi et al., 1994). Anxiety disorders lead to comparable levels of disability as depression and heart disease (Buist-Bouwman et al., 2006) and have been found to increase risk of premature all-cause and cardiovascular death (Denollet et al., 2009, Phillips et al., 2009). The association between anxiety and CVD, however, has been far less studied than the link between depression and heart disease. Even less studied has been the association between anxiety characteristics (subtype, duration, and severity) and CVD. Furthermore, as depression and anxiety are often found to be comorbid, it would be of great importance to study the association between depression and anxiety with CVD in concert. This could shed light on the specificity of associations between depressive and anxiety disorders and CVD.

Therefore, in the present study within a large cohort of depressed and/or anxious persons and healthy controls we examined the (extent of the) association between the presence of a psychiatric diagnosis of depressive and/or anxiety disorder with CVD. In addition, we assessed the specificity of these associations by directly comparing depressive with anxiety disorders and by examining whether specific characteristics of depressive and/or anxiety disorders (subtype, duration, severity, and psychoactive medication) could be identified that indicate increased probability of CVD.

Section snippets

Sample

The Netherlands Study of Depression and Anxiety (NESDA) is an ongoing cohort study designed to investigate the long-term course and consequences of depressive and anxiety disorders. Participants were 18 to 65 years old at baseline assessment in 2004–2007 and were recruited from the community (19%), general practice (54%) and secondary mental health care (27%). A total of 2981 persons were included, consisting of persons with a current or past depressive and/or anxiety disorder (N = 2329) and

Results

Mean age of the present sample was 41.8 (SD = 13.0) years, 66.4% were women, 19.4% had a remitted and 63.1% had a current depressive or anxiety disorder, while 5.6% had CVD. Table 1 describes sample characteristics comparing persons with and without CVD. Persons with CVD were older, more often men, less educated, more often former smoker, less often moderate drinker, and had a higher BMI. Also, persons with CVD more often had a current anxiety disorder, but not depressive disorder.

Table 2

Discussion

This study examined the association between diagnosed depressive and anxiety disorders and cardiovascular disease within a large cohort of depressed and/or anxious persons and healthy controls. The results show that, individually, both depressive and anxiety disorders are associated with CVD. However, the increased prevalence of CHD among depressive persons appeared to be mainly owing to comorbidity of anxiety disorders. No associations were found with stroke. Severity of depressive and anxiety

Role of funding source

Study sponsors had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

All other authors declare that they have no conflicts of interest.

Acknowledgements

The infrastructure for the NESDA study (www.nesda.nl) is funded through the Geestkracht program of the Netherlands Organisation for Health Research and Development (Zon-Mw, grant number 10-000-1002) and is supported by participating universities and mental health care organizations (VU University Medical Center, GGZ inGeest, Arkin, Leiden University Medical Center, GGZ Rivierduinen, University Medical Center Groningen, Lentis, GGZ Friesland, GGZ Drenthe, Institute for Quality of Health Care (IQ

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