alexa Prevalence and Assessment of Severity of Depression Among Ischemic Heart Disease Patients Attending Outpatient Cardiology Department Baghdad Teaching Hospital, Baghdad, Iraq

ISSN: 2378-5756

Journal of Psychiatry

  • Research Article   
  • J Psychiatry, Vol 21(2): 438
  • DOI: 10.4172/2378-5756.1000438

Prevalence and Assessment of Severity of Depression Among Ischemic Heart Disease Patients Attending Outpatient Cardiology Department Baghdad Teaching Hospital, Baghdad, Iraq

Shalan Joodah Al-Abbudi*, Faris Hassan Lami and Zainab Abd Wady
Department of Psychiatry, College of Medicine Al- Nahrain University, Imamain Kadhimain Medical City, Baghdad, Iraq
*Corresponding Author: Shalan Joodah Al-Abbudi, Department of Psychiatry, College of Medicine Al- Nahrain University, Imamain Kadhimain Medical City, Baghdad, Iraq, Tel: +9647810705221, Email: [email protected]

Received Date: Nov 05, 2017 / Accepted Date: Dec 06, 2017 / Published Date: Dec 16, 2017

Abstract

Background: Depression and ischemic heart disease present a major comorbidity.
Objective: To determine the prevalence and to estimate the severity of depression, and some of sociodemographic variables among patients with ischemic heart disease.
Methods: A cross-sectional study conducted in Baghdad Teaching Hospital, Baghdad, Iraq. Study included all patients with ischemic heart disease excluding those with unstable medical illness. Socio-demographic variables, history of comorbid illnesses and complications were compiled. Self-Reporting Questionnaire (SRQ-20) to identify mental illnesses; DSM-IV criteria for depression and Hamilton-17 Scale for severity of depression, were used.
Results: A total of 271 patients were approached; 94.1% responded. About a half was having myocardial infarction (50.6%), stable angina (31.4%), and (18%) unstable angina. 45.1% had depression; 14.9% mild, 20% moderate, 7.06% sever, and 3.14% very severe depression. Depressed was significantly associated with age (P=0.008), sex (P=0.000), marital status (P=0.026), occupation (P=0.000), education (P=0.005), income (P=0.000), duration of ischemia (P=0.001), comorbidity with other illnesses (P=0.000), cardiac surgery (P=0.025), and stressful life events (P=0.000).
Conclusion: Depression is high among ischemic heart disease patients, significantly associated with demographic variables. Treating physicians and cardiologists need to be aware of this co-morbidity.

Keywords: Prevalence; Depression; Outpatient; Ischemic heart disease

Introduction

The prevalence of depression in patients with coronary artery disease is between 19%-47% compared to 4%-7% in the general population [1]. Depression and Coronary Artery Disease (CAD) are both extremely prevalent diseases that compromised quality of life and life expectancy [2]. It has long been recognized that mild forms of depression are found in up to two thirds of patients in hospital after acute myocardial infarction (AMI), with major depression generally being found in about 15% of CVD patients [3]. There are a number of psychological reactions that can potentially occur after acute medical events. 13 Depressed moods is commonly experienced as a reaction to an acute coronary event, or for that matter to any illness or operation perceived to threaten one's life and well-being [4]. According to World Health Organization’s (WHO) estimate, depression and cardiovascular disease will be the two major causes of disability-adjusted life years by the year 2020. According to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), approximately 25% of the people with general medical conditions will become depressed during the course of their chronic condition [5]. The relationship between coronary heart disease (CHD) and major depressive disorder (MDD) has been investigated extensively over recent decades, as the prevalence of both conditions has risen around the world. Each condition remains a major contributor to the global burden of disease [6]. Though there are some inconsistencies in the literature, there are several established risk factors for depression in cardiac patients. Most studies have found that younger patients, women, and patients with premorbid histories of depression are more likely to have depression in the context of CVD. Among patients suffering from an acute coronary syndrome (ACS), social isolation and prior ACS, may also increase depression risk [7]. There is a clear consensus that depression is currently underdiagnosed in cardiac patients by cardiologists and primary care physicians alike. There is need for psychological intervention to manage and control the symptoms of depression in cardiovascular diseases in each and every cardiology units [8]. Due to the high prevalence, routine screening for depression in all patients with CHD is recommended when a patient first presents, and at the follow up appointment [3].

Objectives

This study was conducted with an aim to determine the prevalence and to estimate the severity of depression, and some of sociodemographic variables among patients with ischemic heart disease attending outpatient cardiology department, Baghdad teaching hospital, Baghdad, Iraq.

Patients and Methods

Design and setting

This is a cross-sectional study with analytic component. It was conducted in Baghdad Teaching Hospital, Baghdad, Iraq. The data collection was done during the period March 1st 2011 to June 30th 2011.

Study population and sampling technique

The study included patients attending the cardiology outpatient clinic at Baghdad teaching hospital during the data collection time. A systematic random sampling technique was applied, where every 3rd patient entering the clinic who accepts to participate in the study and to have the interview was selected.

Inclusion criteria

All patients with ischemic heart disease of any age and sex who welcomed participation were included.

Exclusion criteria

Current serious or unstable medical illnesses with severe chest pain or shortness of breath that cannot complete the interview were excluded.

Data collection tools

Basic socio-demographic variables, diagnosing methods, history of comorbid illnesses and complications were compiled using a questionnaire filled through a direct interview. Mental status of the patient was assessed using the SRQ-20 scale (self- reporting questionnaires) that was developed by the WHO and used in many countries. According to previous studies conducted in Iraq, the cutoff point identified used to categories “potential psychiatric cases” and more generally persons with significant psychological distress was seven [9]. Those with positive results were assessed for the presence of depression using the DSM-IV criteria of depression [10]. Those with “depression” were further assessed for the severity of depression using the Hamilton scale. It contains 17 items to be rated (HRSD-17). Each item on the questionnaire is scored on a 3 or 5 point scale, depending on the item, and the total score is compared to the corresponding descriptor. It is accepted by most clinicians that scores between 0 and 6 do not indicate the presence of depression, scores between 7 and 17 indicate mild depression, scores between 18 and 24 indicate moderate depression, and scores over 24 indicate severe depression. A total HAM-D score of 7 or less after treatment is for most raters a typical indicator of remission [11].

Definition of variables

The independent variables evaluated to explain depression were socio-demographics (age, gender, marital status, level of education, and occupation), smoking habits, characteristics of the disease, and comorbid condition or disease.

Statistical analysis

Statistical package of social sciences (SPSS) version 15 was used for data entry and analysis. Categorical variables were tested using chi square test. P<0.05 was considered statistically significant.

Ethical issue

Official approvals were granted from the officials in the study setting. Informed consent was obtained from each participant to be included in this study. Names were kept anonymous and interviews were conducted with full privacy.

Limitations of the study

Random sampling was not applied to choose cardiology clinic. The study was conducted in one cardiology clinic. Since this study is a cross-sectional study. Temporal relationship between depression and ischemic heart disease cannot be inferred. Similarly, selection bias cannot be excluded as the study was conducted in a specialized center.

Results

A total of 271 ischemic heart disease patients were approached; 255 accepted to participate, giving a response rate of (94.1%). About 70.2% of the sample was male; 79.6% were married; 39.6% were still working; and about 75.3% had poor education. About 90% were live in urban than rural areas. Myocardial infarction 50.6%, stable angina 31.4%, and 18% were have unstable angina. Distribution by socio-demographic and ischemic heart disease participants characteristics are shown in Table 1.

  Classification of Ischemia Total % P value
stable angina unstable angina myocardial infarction
No. % No. % No. %
Age Groups ≤ 30 Years 0 0 0 0 4 3.1 4 1.6 0.083
31 - 40 Years 2 2.5 0 0 6 4.7 8 3.1
41 - 50 Years 12 15 8 17.4 28 21.8 48 18.8
51 - 60 Years 20 25 20 43.5 35 27.1 75 29.4
61 - 70 Years 28 35 16 34.8 40 31 84 33
71 - 80 Years 16 20 2 4.3 14 10.8 32 12.5
81+  Years 2 2.5 0 0 2 1.5 4 1.6
Sex Male 42 52.5 34 73.9 103 79.9 179 70.2 0.000
Female 38 47.5 12 26.1 26 20.1 76 29.8
Marital Status Single 6 7.5 0 0 0 0 6 2.4 0.000
Married 52 65 38 82.6 113 87.6 203 79.6
Widowed 22 27.5 8 17.4 16 12.4 46 18
Occupation unemployed 2 2.5 6 13 6 4.6 14 5.5 0.000
Gov. Work 4 5 6 13 12 9.3 22 8.6
Private Work 12 15 16 34.8 41 31.8 69 27.1
Military 2 2.5 0 0 8 6.2 10 3.9
Retired 24 30 8 17.4 40 31 72 28.2
Housewife 36 45 10 21.8 22 17.1 68 26.7
Education Illiterate 34 42.5 12 26.1 30 23.2 76 29.8 0.031
Primary 26 32.5 26 56.5 64 49.6 116 45.5
Secondary 10 12.5 6 13 22 17.1 38 14.9
university 10 12.5 2 4.4 13 10.1 25 9.8
Total   80 100% 46 100% 129 100% 255 100%  

Table 1: Show the socio-demographic characteristic features of the participants according to the type of ischemia.

The mean age of patients was (58.945 ± 11.026) years. The family size mean was (8.76 ± 5.2), crowding index mean was (3.07 ± 4.21), and the average (±SD) monthly family income was (533.3 ± 56.9) ID (Table 2).

Variables N Mean Median Std. Deviation
Age 255 58.94 60.00 11.02
Family size 255 8,76 8.00 5.20
Crowding Index 255 3.07   4.21
Monthly family income (ID) 255 533302 360000.00 569512.8

Table 2: Mean, median and standard deviation of some sociodemographic features of the sample.

The methods used in the diagnosis of ischemic heart disease were depend mostly on the sign and symptoms of chest pain and ECG changes (98.9%), admission to CCU (78.8%), other investigations like treadmill test (24.7%) and Echocardiograph study (6.6%) (Table 3).

Way of Diagnosis Classification of Ischemia Total P value
stable angina unstable angina myocardial infarction
chest pain Negative 0 0 3 3 0.227
Positive 80 46 126 252
ECG changes Negative 0 0 3 3 0.227
Positive 80 46 126 252
CCU admission Negative 34 4 16 54 0.000
Positive 46 42 113 201
Treadmill Test Negative 60 40 92 192 0.107
Positive 20 6 37 63
Catheterization Negative 48 26 67 141 0.514
Positive 32 20 62 114
Echo Study Negative 68 44 126 238 0.001
Positive 12 2 3 17
Total 80 46 129 255  

Table 3: The way of diagnosis of ischemic heart disease among the study participants.

The diagnosis of ischemic heart disease was associated with high comorbidity of other illnesses (72.5%). The majority show comorbidity with hypertension (50.9%), Diabetes Mellitus (33.7%), asthmatic bronchitis (1.56%), heart failure (9.4%), cerebrovascular accidents (3.1%), and duodenal ulceration (1.56%) (Table 4).

  Classification of Ischemia Total %
stable angina unstable angina myocardial infarction
Comorbidity No 14 12 44 70 27.5
Yes 66 34 85 185 72.5
HT Negative 20 30 80 130 50.9
Positive 60 16 49 125 49.1
DM Negative 48 28 93 169 66.3
Positive 32 18 36 86 33.7
Asthma Negative 78 46 127 251 98.44
Positive 2 0 2 4 1.56
HF Negative 70 40 121 231 90.6
Positive 10 6 8 24 9.4
CVA Negative 74 44 129 247 96.9
Positive 6 2 0 8 3.1
DU Negative 80 44 127 251 98.44
Positive 0 2 2 4 1.56
Total 80 46 129 255 100%

Table 4: The comorbidity with ischemic heart disease among study sample.

Nearly one third of the participants were smoker (33.3%), range 3-100 cigarettes per day, the most frequent is 10-40 cigarettes per day (26.3%). The sample shows 3.2% were alcohol drinker of regular drinking habits (Table 5).

  Classification of Ischemia Total %
stable angina unstable angina myocardial infarction
SMOKING No 60 36 74 170 66.6
Yes 20 10 55 85 33.3
ALCOHOL No 80 46 121 247 96.8
Yes 0 0 8 8 3.2
Total 80 46 129 255 100%

Table 5: Smoking and alcohol drinking with ischemic heart disease among participants of the study.

More than half of the participants exposed to one of the major life events (54.5); 21.6% exposed to death of close relative; 7.9% death of spouse, 20.4% money loss, 18.9% serious illness or accidents and 0.8% exposed to job loss (Table 6).

  Classification of Ischemia Total %
stable angina unstable angina myocardial infarction
Life Events Negative 30 42 62 116 45.5
Positive 50 22 67 139 54.5
Death of close relative Negative 58 36 106 200 78.4
Positive 22 10 23 55 21.6
Death of Spouse Negative 70 44 121 235 92.1
Positive 10 2 8 20 7.9
Money Loss Negative 62 38 103 203 79.6
Positive 18 8 26 52 20.4
Job Loss Negative 78 46 129 253 99.2
Positive 2 0 0 2 0.8
Home Change Negative 74 46 125 245 96.07
Positive 6 0 4 10 3.93
Serious illness or accident Negative 64 38 105 207 81.1
Positive 16 8 24 48 18.9
Total 80 46 129 255 100%

Table 6: Stressful life events associated with ischemic heart disease among study sample.

All participants were on treatment; antiplatelet (95.3%), nitrate (93.4%), lipid lowering agents (67.9%), B-blocker (62.8%), ACE inhibitors (45.6%), diuretics (27.9%), calcium channel blocker (17.3%), angiotensin (7.6%), and anticoagulants (3.2%) (Table 7).

  Classification of Ischemia Total %
stable angina unstable angina myocardial infarction
B Blocker No 30 20 45 95 37.2
Yes 50 26 84 160 62.8
Lipid Lowering Agents No 32 16 34 82 32.1
Yes 48 30 95 173 67.9
Nitrate No 8 2 7 17 6.6
Yes 72 44 122 238 93.4
ACE inhibitor No 40 26 73 139 54.5
Yes 40 20 56 116 45.6
Angiotensin No 70 46 120 236 92.5
Yes 10 0 9 19 7.6
Antiplatelate No 2 4 6 12 4.7
Yes 78 42 123 243 95.3
Calcium Channel Blocker No 68 42 101 211 82.7
Yes 12 4 28 44 17.3
Diuretics No 52 28 104 184 72.1
Yes 28 18 25 71 27.9
Anticoagulant No 76 46 125 247 96.8
Yes 4 0 4 8 3.2
Total 80 46 129 255 100%

Table 7: Type of medication taken by ischemic heart disease participants of the study.

SRQ-20 positive responses were (145) (56.86%); stable angina (52) (63.4%), myocardial infarction (96) (53.4%), unstable angina (24) (52.1%) (Table 8).

  Classification of Ischemia Total
stable angina unstable angina myocardial infarction
SRQ Responses Negative 28 11% 22 8.6% 60 23.5% 110 43.1%
Positive 52 20.3% 24 9.4% 69 27.% 145 56.9%
Total 80 31.3% 46 18% 129 50.5% 255 100%

Table 8: SRQ-20 positive and negative responses among ischemic heart disease participants of the study.

Participants show 115 (45.1%) were met DSM-IV criteria of depressed; 51 (44.3%) of them were myocardial infarction, 42 (36.5%) stable angina, and 22 (19.1%) were unstable angina (Table 9).

  Classification of Ischemia Total %
stable angina unstable angina myocardial infarction
Depression No 38 14.9% 24 9.4% 78 30.5% 140 54.9%
Yes 42 16.4% 22 8.6% 51 20% 115 45.1%
Total 80 31.3% 46 18% 129 50.5% 255 100%

Table 9: Depression among ischemic heart disease participants of the study.

The severity of depression was investigated by applying the Hamilton depression scale (HAMD-17) among positive DSM-IV criteria of depression found that; 38 (14.9%) mild depression, 51 (20%) moderate depression, 18 (7.06%) severe depression, and 8 (3.14%) very severe depression. Moderate and severe depression was more among myocardial infarction while very severe depression was among stable angina (Table 10).

  Classification of Ischemia Total % P value
stable angina unstable angina myocardial infarction
HAMD Degree Not done 38 14.9% 24 9.4% 78 30.5% 140 54.9 0.003
Mild depression 16 6.2% 6 2.3% 16 6.2% 38 14.9
Moderate depression 14 5.4% 12 4.7% 25 9.8% 51 20
Severe depression 4 1.5% 4 1.5% 10 3.9% 18 7.06
Very severe depression 8 3.1% 0 0% 0 0% 8 3.14
Total 80 31.3% 46 18.03% 129 50.5% 255 100%  

Table 10: The severity of depression among Ischemic heart disease patients obtained from HAMD-17 of the study sample.

Depressed ischemic heart disease participants were more among 51- 60 years age group (32.2%), male (53%) compared with female (47%). Depression found more within married (74%), widowed (24.3%), and single (1.7%). Regarding the occupation founded that house wife form 41.7% of the depressed participants, while retired (24.3%), private work (21.7%), and unemployed (7%). Depression founded more among low educated participants; illiterate (43.5%) and primary school (41.7%) (Table 11).

  Degree of Depression Total % P value
Mild depression Moderate depression Severe depression Very severe depression
Age Groups 26 - 30 Years 2 0 0 0 2 1.7 0.003
31 - 40 Years 0 0 2 0 2 1.7
41 - 50 Years 8 8 4 6 26 22.6
51 - 60 Years 10 21 6 0 37 32.2
61 - 70 Years 10 16 4 0 30 26
71 - 80 Years 8 4 2 2 16 14
81+  Years 0 2 0 0 2 1.7
Sex Male 24 27 10 0 61 53 0.014
Female 14 24 8 8 54 47
Marital Status Single 0 2 0 0 2 1.7 0.107
Married 32 33 16 4 85 74
Widowed 6 16 2 4 28 24.3
Occupation Unemployed 6 0 2 0 8 7 0.001
Gov. work 0 4 0 0 4 3.5
Private Work 14 7 2 2 25 21.7
Military 0 0 2 0 2 1.7
Retired 6 16 6 0 28 24.3
Housewife 12 24 6 6 48 41.7
Education Illiterate 16 24 6 4 50 43.5 0.432
Primary 14 20 10 4 48 41.7
Secondary 6 2 2 0 10 8.7
University 2 5 0 0 7 6.1
Total 38 51 18 8 115 100%  

Table 11: Show the socio-demographic features according to the degree of depression which resulted from the HAMD-17.

Of the 115 (45.1%) depressed participants; myocardial infarction (44.3%), stable angina (36.5%), and unstable angina (19.1%). the correlation between the degree of depression and the type of ischemia was of highly statistical significant (Tables 12 and 13).

  Depression Total P value
no Yes
Age Groups 26 - 30 Years 2 2 4 0.338
31 - 40 Years 6 2 8
41 - 50 Years 22 26 48
51 - 60 Years 38 37 75
61 - 70 Years 54 30 84
71 - 80 Years 16 16 32
81+  Years 2 2 4
Sex Male 118 61 179 0.000
Female 22 54 76
Marital Status Single 4 2 6 0.05
Married 118 85 203
Widowed 18 28 46
Occupation Unemployed 6 8 14 0.000
Govt. work 18 4 22
Private work 44 25 69
Military 8 2 10
Retired 44 28 72
Housewife 20 48 68
Education Illiterate 26 50 76 0.000
Primary 68 48 116
Secondary 28 10 38
University 18 7 25
Total 140 115 255  

Table 12: Sociodemographic features of depressed ischemic heart disease participants of the study.

  Degree of Depression Total % P value
mild depression moderate depression severe depression very severe depression
Classification of Ischemia stable angina 16 14 4 8 42 36.5 0.006
unstable angina 6 12 4 0 22 19.1
myocardial infarction 16 25 10 0 51 44.3
Total 38 51 18 8 115 100%

Table 13: The correlation between the degree of depression and the type of ischemic heart disease.

Depressed participants were of mean age ± SD = 58.945 ± 11.02 years, the monthly income by Iraqi dinar = 533.301 ± 56.951. The living circumstances at the home atmosphere; the number of persons at one home was 8.76 ± 5.2, the number of rooms at one home was 2.85 ± 1.23. The duration of ischemic heart disease among depressed participants was 53.38 ± 68.746 months. About 33.3% of the sample was smokers and 32.3% of depressed participants were smokers with number of cigarette per day 11.435 ± 19.754 cigarettes (Tables 14 and 15).

  Mean ± SD Depression Total P value
NO YES
Age 58.945 11.02 140 115 255 0.007
Income ID 533.301 56.951 140 115 255 0.000
No. of Persons 8.76 5.2 140 115 255 0.000
No. of Rooms 2.85 1.23 140 115 255 0.020
Duration of illness in Months 53.38 68.746 140 115 255 0.001
No. of Cigarette per day 11.435 19.754 140 115 255 0.05

Table 14: Some sociodemographic variables of depressed participants with their statistical significant.

  Depression Total
NO YES  
SMOKING No 92 78 170
Yes 48 37 85
ALCOHOL No 134 113 247
Yes 6 2 8
Total 140 115 255

Table 15: Sociodemographic variables of depressed participants with their statistical significant.

Depressed ischemic heart disease participants show highly significant comorbidity with other diseases. Table 16 show the comorbidity and the statistical significant of the findings.

  Depression Total P value
NO YES
Co Morbidity NO 54 16 70 0.000
YES 86 99 185
HT Negative 86 44 130 0.000
Positive 54 71 125
DM Negative 104 65 169 0.003
Positive 36 50 86
Asthma Negative 138 113 251 0.843
Positive 2 2 4
HF Negative 132 99 231 0.026
Positive 8 16 24
CVA Negative 134 113 247 0.246
Positive 6 2 8
 DU Negative 138 113 251 0.843
Positive 2 2 4
Total 140 115 255  

Table 16: Comorbidity and statistical significant among depressed ischemic heart disease participants.

Depressed ischemic heart disease participants show highly significant association with stressful life events (P=0.000). About 54.5% of the whole participants and about 80% of depressed participants have at least one major life event (Table 17).

  Depression Total P value
NO YES
Life Events No 92 24 116 0.000
Yes 48 91 139
Death of close relative Negative 126 74 200 0.000
Positive 14 41 55
Death of Spouse Negative 130 105 235 0.646
Positive 10 10 20
Money Loss Negative 124 79 203 0.000
Positive 16 36 52
Job Loss Negative 138 115 253 0.198
Positive 2 0 2
Home Change Negative 138 107 245 0.024
Positive 2 8 10
Serious illness or accident Negative 124 83 207 0.001
Positive 16 32 48
Total 140 115 255  

Table 17: Major life events among depressed participants and the statistical significant.

Depressed participants of ischemic heart disease patients were of medication either for the ischemia or for comorbidity of other illnesses. Table 18 shows some of the medication that taken by the participants currently and the statistical significance with depression.

Treatment Depression Total P value
NO YES
B-Blocker No 60 35 95 0.041
Yes 80 80 160
Lipid Lowering Agents No 44 38 82 0.784
Yes 96 77 173
Nitrate No 14 3 17 0.019
Yes 126 112 238
ACE inhibitor No 76 63 139 0.937
Yes 64 52 116
Angiotensin No 132 104 236 0.244
Yes 8 11 19
Antiplatelet No 4 8 12 0.124
Yes 136 107 243
Calcium Channel Blocker No 114 97 211 0.539
Yes 26 18 44
Diuretics No 102 82 184 0.783
Yes 38 33 71
Anticoagulant No 132 115 247 0.009
Yes 8 0 8
Total 140 115 255  

Table 18: Medications taken by depressed participant and the degree of statistical significant with depression.

More than 90% of ischemic heart disease patients were live in urban areas than rural areas. All the participants were of negative family history of depression. 2.4% of the participants were underwent cardiac surgery and no one of them was depressed (P=0.025) (Table 19).

  Depression Total P value
NO YES No. %
Residence Urban 130 103 233 91.3% 0.352
Rural 10 12 22 8.7%
Family Hx Of Depression No 140 115 255 100% --
Heart Surgery No 134 115 249 97.6% 0.025
Yes 6 0 6 2.4%
Total 140 115 255 100%  

Table 19: The statistical significance of some variables with the diagnosis of depression.

Discussion

The study shows response rate of 94.1%. It was similar rates of participation with Salman 2009 (93.6%) [12] and Iraqi family health survey (IFHS) (95%) [13]. It was high rate since most of Iraqi people like sharing talk about their conditions where they feel someone take care of them. The other 5.9% have an excuse not to participate; they feel shame, just in hurry, or have no time.

Participants show (56.86%) positive responses to SRQ-20. It is higher than many Iraqi studies; Salman 2009 (36.81%) [12], Muffed et al. (one third) [9], Iraqi mental health survey IMHS (7.14%) [14], Iraqi family health survey (IFHS) (35.5%) [13]. High SRQ-20 positive responses may be explained that, Iraqis have witnessed many internal and external conflicts during the past three decades, including three wars and 12 years of sanctions. Since 2003, violence has been increasing throughout the country. These circumstances have affected the Iraqi population in every domain of life with varying degrees of repercussion. This population can be considered as having significant psychological distress and potential psychiatric cases.

Current study founded Depression was 45.1% of participants with ischemic heart disease. It is higher than; Fraz K et al. 27% [5], Liang JJ et al. 33% [14], Raj HSS and Sajimon PP (36.68%) [8] Iraqi mental health survey (IMHS) 2006/7 [9] (severe depression 3.50%, moderate depression 2.83% and mild depression 1.15%), Najeb GT [15] 38.67%, and Lawson R et al. [16] 38%. WHO educational program on depression, founded depression is 33% among patients with ischemic heart [17]. Leegte IL et al. [18] founded 41% percent of Netherlands sample had depression. Whooley MA (20%) [19]. Kemp DE et al. [20] founded the prevalence of depression 40%.

The prevalence of depression among ischemic heart disease patients of the current study was lower than; Carney (65%) [21], Pena FM et al. (67%) [22], Polikandrioti M et al. (65.4%) [23], Rosenthal MH (45%) [24], Manica et al. (45%) [25].

Many study founded wide range of depressive disorder among ischemic heart disease patients; Hwang B and Choi H founded the prevalence of depression ranged from 24% to 68% [26]. Huffman JC (15%-20%) [7] Rudisch and Nemeroff (17-27%) [27], Thomas SA et al. (13%-77.5%) [28], Shastri PC (40-65%) [29], Rao M (30% to 40%) [30], Blumental JA (14%-47%) [31].

Regarding the severity of depression, HAMD-17 was applied on the DSM-IV positive respondents ischemic heart disease patients showed 14.9% have mild depression, 20% have moderate depression, 7.06% severe depression and 3.14% very severe depression. The degree of severity of depression is highly significant correlation with the type of ischemic heart disease (P=0.003). Type of ischemia is highly statistical significant correlated with severity of depression (P=0.006). Faur A founded mild depression 17.4%, moderate depression 52.4%, severe depression 15.5, and very severe depression 14.5% [1]. IMHS 2006/7 [9] showed life time prevalence of severe depression 3.50%, moderate depression 2.83%, and mild depression 1.15%. Pena FM et al. [22], studied sample of 103 patient in Brazil founded that 69 (67%) were depressed; 35(34%) had mild depression, 22 (21.3%) had moderate depression, and 12 (11.6%) patients presented with severe depression. Polikandrioti M et al. [23] showed that 34.6% absence of depression, 27.3% mild depression, 20.9% moderate depression and 17.2% severe depression

Age

Most of the sample (93.7%) where aged above 40 years. mean age 58.945 ± 11.02 years. More than 63% of depressed patients were of 51- 70 years age group. The age group is highly significant correlation with the degree of depression (P=0.003). Since this period of age was at high risk for ischemic heart disease than other extremes, they have enough time for regular consultations, and they have high social supports from their families helping them for regular follow up of their health status. Pena FM et al. [22] founded the mean age was 65.4 years. Najeb GT [15] the mean age was 53.9 ± 791. Polikandrioti M et al. [23] founded 23.0% were between 50-59 years. Rothenbacher D et al. [32] founded that the largest proportion of subjects with increased symptom scores were found in the age categories 40–49 and 50–59 years (P=0.0003 and P=0.01, respectively).

Gender

Male was about 70% of participants while female was about 30%. Male depressed participants were 53% and female were 47%. The gender is highly statistical significant correlation with the degree of depression (P=0.014). Fraz K et al. founded 19.7%% males and 7.5% females [5] Polikandrioti M et al. [23] founded 79.1% were male and only 20.9% patients were female. Najeb GT [15] founded male 62.1% and female 37.9% of depressed participants. Pena FM et al. [22] 36.9% were male and 63.1% were female. Vural et al. [33] founded that female patients had higher scores of depression.

Marital status

About 80% of sample and more than 75% of depressed were married. Marital status is significant statistical correlation with the diagnosis of depression (P=0.05). Najeb GT [15] founded that 69% were married than 31% were single. Polikandrioti M et al. [23] founded that 72.2% were married. Pena FM et al. [22] founded 49.5% were married. Dowlati Y et al. [34], founded that there was significant statistical correlation of married status (married) with depression.

Occupation

House wife, the occupation that never be retired unless be disabled, form 41.7%, retired 24.3%, private work 21.7% among depressed ischemic heart disease patients. The occupation is highly statistical significant correlation with the diagnosis of depression (P=0.001) and the degree of severity of depression (P=0.000). Najeb GT [15] founded 53.4% not employed, 20.7% private work and 12% retired. Polikandrioti M et al. [23] founded higher levels of depression were observed for those retired (p=0.028).

Education

About 75% of the sample and about 85% of depressed ischemic heart disease patients were of low educational level or illiterate. The level of education of ischemic heart disease patients is of statistically significant correlation with the diagnosis of depression (P=0.000). Polikandrioti M et al. [23] founded that 47.5% of participants had received only basic education, 25.2% had received high school education, 27.3% had attended some college or university. Pena FM et al. [22] only 26.2% were illiterate. Najeb GT [15] founded 46% illiterate, about 70% of low education.

Income

All participants and depressed ischemic heart disease patient (100%) were have monthly income = 533.301 ± 56.951 Iraqi dinar. The income is highly statistical significant correlation with depression among ischemic heart disease patients (P=0.000). Pena FM et al. [22] founded 43.7% have monthly income. Duration of ischemic heart disease: Current study founded Depression with ischemic heart disease of duration mean of 5 years (53.38 ± 68.746 months), range from one month to 30 years. The duration of ischemic heart disease is statistically significant correlated with depression (P=0.001).

Comorbidity

86.1% have comorbidity. Statistically significant comorbidity with depression were; hypertension (61.7%) (P=0.000), diabetes mellitus (43.4%) (P=0.003), and heart failure (13.9%) (P=0.026). Pena FM et al. [23] founded 92.2% hypertension and 34% diabetes mellitus.

Life events

About 80% of depressed ischemic heart disease patients have at least one major life event. The life events were statistically significant correlation with depression (P=0.000). Significant life events were; death of close relative (35.6%) (P=0.000), loss of money (31.3%) (P=0.000), changing home or displaced (6.9%) (P=0.024), and serious illness or accidents (27.8%) (P=0.001). Michael AJ et al. [35] founded that 32% of psychiatric illness attributed to stressful life events. Michael AJ et al. [36]. Founded that 25-26% of the patients had life events.

Medications

Depressed ischemic heart disease patients were of medication for the ischemia. Statistically significant correlation with depression was; B-blocker (P=0.041), nitrate (P=0.019), and anticoagulant (P=0.009). Dowlati et al. [34] founded no significant statistical correlation of medications (B-blockers and ACE inhibitors) with depression. Vural et al. [33]. Founded that Statin usage (47.5% of all patients) was not associated with increased depression scores.

Smoking

About 32.1% of depressed ischemic heart disease patients were smokers. Number of cigarettes per day was 11.435 ± 19.754 (P=0.05). Pena FM et al. [22] founded 35% were smokers.

Alcohol

Only 1.7% of depressed ischemic heart disease patients were alcoholics on regular pattern. Alcohol consumption was statistically not significant (P=0.246). Pena FM et al. [22] founded 21.4% were alcoholics.

Residence

More than 90% were live in the urban than rural areas. These finding were statistically investigated show no significant correlation with depression (P=0.352). Polikandrioti M et al. [23] founded; urban 34.5% and rural 23.7. Herva A [36] founded the prevalence of major depressive disorder was 4.7% among urban subjects, and 4.1% among rural subjects.

Family history

All participants (100%) were of negative family history of mental illness. No statistical value obtained.

Heart surgery

Six (2.3%) underwent surgical procedures. No one of them was depressed according to DSM-IV criteria for depression. This finding is statistically significant (P=0.025).

Conclusion

Current study shows high prevalence of depression (45.1%) among out-patient ischemic heart disease patients. Depressed ischemic heart disease patients were of statistically significant correlation with age, sex, marital status, occupation, education, income, and duration of ischemia, comorbidity with other illnesses, cardiac surgery, and stressful life events.

With lack of mental health services, this issue is more important for the general practitioners and cardiologists to understand the importance of risks of untreated depression in ischemic heart disease patients. Complicating this picture is the prevailing social stigma associated with mental illness in Iraq.

Review of studies found that the association between current heart disease and prevalence of major depression was fairly consistent across many countries and cultures in Europe, the Americas, the Middle East, Africa, and Asia.

Recommendations

In the face of high prevalence of depression among ischemic heart disease patients, educate the public and raising awareness of the healthcare providers is recommended.

Important future research directions including the need of Large-scale, prospective studies in patients with ischemic heart disease to improve understanding of the reciprocal effects between depression, ischemic heart disease, and symptom burden, functional impairment, and self-care regimens. Large, randomized, controlled studies are needed in representative populations with ischemic heart disease and major depression to test the effect of enhancing quality of depression care and improving outcomes of depression on symptom burden, function, self-care activities, direct and indirect costs, medical complications, and mortality. Research is needed to determine which treatment is most effective and whether the treatment of depression will improve morbidity and mortality in patients with ischemic heart disease and depression.

References

Citation: Al-Abbudi SJ, Lami FH, Wady ZA (2017) Prevalence and Assessment of Severity of Depression Among Ischemic Heart Disease Patients Attending Outpatient Cardiology Department Baghdad Teaching Hospital, Baghdad, Iraq. J Psychiatry 21: 438. Doi: 10.4172/2378-5756.1000438

Copyright: © 2017 Al-Abbudi SJ, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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