Patients' understanding of heart disease: relationships with decisions to seek help with acute symptoms, and with adherence to treatment.

Pre-hospital delay in seeking help for acute chest pain in patients with coronary heart disease is a major impediment to prompt thrombolysis. Failure to adhere to medication, attend cardiac rehabilitation where appropriate, and change lifestyle, all impair secondary prevention. This thesis examined psychological factors related to these problems, and the psychological models of illness held by patients diagnosed with acute coronary syndromes (ACS). Two main issues were investigated firstly, what factors were associated with shorter pre-hospital delays following symptom onset and secondly, whether cognitive models of illness predicted adherence to advice, psychological and emotional adjustment, and quality of life at 3 months and 13 months post-discharge. Data were collected from 269 patients diagnosed with ACS within five days of hospital admission. Analyses were focussed on the total time between symptom onset and admission to hospital (pre-hospital delay). This interval was divided into two phases time between symptom onset and decision to call for medical help (patient decision time), and time from call for help to admission (home to hospital delay). Patients were followed up 3 and 13 months later. Adherence to medical advice (lifestyle changes, adherence to medication, attendance at cardiac rehabilitation programmes), psychological distress and quality of life were measured by telephone interview and questionnaire. A number of sociodemographic, social, clinical and psychological factors were associated with pre-hospital delay. Beliefs about the causes of heart disease made an important contribution. Cognitive representations of heart disease measured during hospital admission did not predict adherence to treatment regimens after discharge, but significantly predicted later psychological and emotional adjustment, and quality of life. Theses findings have implications for understanding the contribution of psychological factors to the experience of acute heart disease, and point to methods of more effective patient care and management

Effects of Brief Mindfulness-Based Interventions on Health-Related Outcomes: a Systematic Review

Objectives Traditional mindfulness-based interventions (MBIs) have been applied successfully across many populations. The time commitment for these programs is often a barrier, and while brief MBIs have become popular, the impact of these on health-related outcomes is unclear as they have not yet been reviewed. Methods A search of databases, including Medline, Embase, and PsycINFO, was conducted with qualitative and case studies being excluded. Findings were summarized using a narrative approach for all studies that met the inclusion criteria. Results With one exception, all 85 studies that were included were randomized controlled trials and were relatively robust methodologically. Seventy-nine reported significant positive effects on at least one health-related outcome and over a quarter targeted a clinical population. The majority of studies focused on psychological outcomes, such as anxiety and depression, as well as emotion regulation, stress, and cognitive outcomes. Conclusions Despite heterogeneity of outcomes across studies, there is evidence that brief MBIs can impact numerous health-related outcomes, after only one session and with interventions as brief as 5 min. These interventions have the potential to be the initial steps leading to sustainable and positive health outcomes

Cortisol levels and history of depression in acute coronary syndrome patients

Background Depressed mood following an acute coronary syndrome (ACS) is a risk factor for future cardiac morbidity. Hypothalamic-pituitary-adrenal (HPA) axis dysregulation is associated with depression, and may be a process through which depressive symptoms influence later cardiac health. Additionally, a history of depression predicts depressive symptoms in the weeks following ACS. The purpose of this study was to determine whether a history of depression and/or current depression are associated with the HPA axis dysregulation following ACS. Method A total of 152 cardiac patients completed a structured diagnostic interview, a standardized depression questionnaire and a cortisol profile over the day, 3 weeks after an ACS. Cortisol was analysed using: the cortisol awakening response (CAR), total cortisol output estimated using the area under the curve method, and the slope of cortisol decline over the day. Results Total cortisol output was positively associated with history of depression, after adjustment for age, gender, marital status, ethnicity, smoking status, body mass index (BMI), Global Registry of Acute Cardiac Events (GRACE) risk score, days in hospital, medication with statins and antiplatelet compounds, and current depression score. Men with clinically diagnosed depression after ACS showed a blunted CAR, but the CAR was not related to a history of depression. Conclusions Patients with a history of depression showed increased total cortisol output, but this is unlikely to be responsible for associations between depression after ACS and later cardiac morbidity. However, the blunted CAR in patients with severe depression following ACS indicates that HPA dysregulation is presen

Emotional triggering and low socio-economic status as determinants of depression following acute coronary syndrome

Background The determinants of depression following acute coronary syndrome (ACS) are poorly understood. Triggering of ACS by emotional stress and low socio-economic status (SES) are predictors of adverse outcomes. We therefore investigated whether emotional triggering and low SES predict depression and anxiety following ACS. Method This prospective observational clinical cohort study involved 298 patients with clinically verified ACS. Emotional stress was assessed for the 2 h before symptom onset and compared with the equivalent period 24 h earlier using case-crossover methods. SES was defined by household income and education. Depression was measured with the Beck Depression Inventory and the Hamilton Rating Scale for Depression and anxiety with the Hospital Anxiety and Depression Scale 3 weeks after ACS and again at 6 and 12 months. Age, gender, ethnicity, marital status, the Global Registry of Acute Coronary Events risk score, duration of hospital stay and history of depression were included as covariates. Results Emotional stress during the 2-h hazard period was associated with increased risk of ACS (odds ratio 1.88, 95% confidence interval 1.01-3.61). Both low income and emotional triggering predicted depression and anxiety at 3 weeks and 6/12 months independently of covariates. The two factors interacted, with the greatest depression and anxiety in lower income patients who experienced acute emotional stress. Education was not related to depression. Conclusions Patients who experience acute emotional stress during their ACS and are lower SES as defined by current affluence and access to resources are particularly vulnerable to subsequent depression and anxiet

Cortisol levels and history of depression in acute coronary syndrome patients

BACKGROUND: Depressed mood following an acute coronary syndrome (ACS) is a risk factor for future cardiac morbidity. Hypothalamic-pituitary-adrenal (HPA) axis dysregulation is associated with depression, and may be a process through which depressive symptoms influence later cardiac health. Additionally, a history of depression predicts depressive symptoms in the weeks following ACS. The purpose of this study was to determine whether a history of depression and/or current depression are associated with the HPA axis dysregulation following ACS. METHOD: A total of 152 cardiac patients completed a structured diagnostic interview, a standardized depression questionnaire and a cortisol profile over the day, 3 weeks after an ACS. Cortisol was analysed using: the cortisol awakening response (CAR), total cortisol output estimated using the area under the curve method, and the slope of cortisol decline over the day. RESULTS: Total cortisol output was positively associated with history of depression, after adjustment for age, gender, marital status, ethnicity, smoking status, body mass index (BMI), Global Registry of Acute Cardiac Events (GRACE) risk score, days in hospital, medication with statins and antiplatelet compounds, and current depression score. Men with clinically diagnosed depression after ACS showed a blunted CAR, but the CAR was not related to a history of depression. CONCLUSIONS: Patients with a history of depression showed increased total cortisol output, but this is unlikely to be responsible for associations between depression after ACS and later cardiac morbidity. However, the blunted CAR in patients with severe depression following ACS indicates that HPA dysregulation is present