NIHR Signal Depression and anxiety common in people with heart disease

Published on 28 June 2016

This multi-part NIHR study found that depression and anxiety were more common in people with coronary heart disease, than the general population. Anxiety increased people’s risk of a future heart attack. The people included in the study were generally older, white males, so the findings may not apply to everyone.

Patients considered a nurse-led intervention to personalise care was acceptable. The intervention included optimising medicines and facilitating referrals for psychological support. When asked, people with depression and coronary heart disease generally favoured non-medical treatments. These findings provide an insight into the scale of depression and anxiety amongst people with coronary heart disease. Overall costs of NHS care were increased in people with coronary heart disease and depression, compare with those who were not depressed. This was mainly due to coronary heart disease related inpatient care. The link between mental and physical health indicates the necessity of addressing both.

The insights into why people feel depressed provide a framework for starting conversations with potentially depressed people.

Share your views on the research.

Why was this study needed?

Coronary heart disease is when the heart’s blood supply is interrupted or blocked, causing chest pain (angina), heart attacks and heart failure. Coronary heart disease is the UK’s biggest killer and 2.3 million people are living with the condition.

Depression is two to three times more common in people with such chronic physical health problems than people with good physical health. Around 20% of people with a chronic physical health problem experience depression, so in the case of coronary heart disease this could be as many as 460,000 people.

The relationship between chronic physical health problems and depression is two way. Chronic physical health problems can cause depression, for example, no longer being able to do things you enjoy and experiencing pain. Depression is also a risk factor for some physical health conditions, including coronary heart disease.

This study was designed to establish the scale of depression in people with coronary heart disease and to understand the course of depression in these individuals.

What did this study do?

The UPBEAT-UK study was made up of four components, some of which involved 33 GP surgeries in South London. The first part was to assess current practice, consisting of a literature review and qualitative study of GP and practice nurse views. The second part was a qualitative study to understand the psychological and physical needs of patients with coronary heart disease.

The third part was a pilot study of a nurse-led personalised care intervention for people with chest pain and depression, informed by the first two parts of the project. The nurse-led intervention included helping the individual to “break down” the problem into manageable chunks that could be addressed through personalised advice, support for self-management and goal-setting with regular review. The pilot trial aimed to estimate the feasibility and cost-effectiveness of this new approach. The final component was a three year study of people with coronary heart disease on a GP registry to gather data on rates of depression, understand the course of their depression and the relationship between their physical and mental health.

What did it find?

  • The pilot study randomised 81 participants from 17 GP practices to a personalised care intervention compared to usual care by the GP. The intervention was designed to monitor patients’ outcomes and provide additional support, such as emotional support and information about services they could access (including psychological services). The pilot study was not powered to show whether the intervention was effective. Depression was similar over time in those receiving personalised care and those receiving usual care. However, 37% of people in the personalised care intervention reported no chest pain at 6 months, compared with 18% in usual care. Total costs were lower amongst personalised care intervention participants, but this was not statistically significant. The pilot study did not calculate the cost of the nurse-led intervention.
  • The cohort study consisted of 803 people with coronary heart disease across sixteen GP practices. Participants were predominantly older (70 years or more), male (70%) and white (87%). Depression occurred in 7% of participants, with men twice as likely to develop depression. Anxiety was more frequent than depression, at 12% and a further 25% had some anxiety symptoms. People with anxiety were four times more likely to have a heart attack or cardiovascular death (relative risk ratio 3.93, 95% confidence interval 1.95 to 7.90).
  • Overall NHS costs were doubled over the course of 36 months in people with depressive symptoms at baseline, mostly due to inpatient services.
  • Interviews with 30 people with coronary heart disease and depression symptoms revealed an overarching theme of “loss”, which primary care professionals should acknowledge. Where help was offered, talking therapies and interventions such as support groups and exercise were preferred over antidepressants.

What does current guidance say on this issue?

NICE guidance from 2009 recommends screening people with chronic health problems for depression in primary care. The individual is treated using “stepped care”, where interventions are more or less intensive depending on the severity of the condition and their response to treatment. For example, people with mild depression might initially be given details of a local support group and be closely monitored by their GP. If their depression does not improve, options include a referral for more formal psychological therapy or commencing antidepressants or both.

In their 2011 guidance on managing anxiety, NICE recommends that primary care professionals are aware of the potential signs of anxiety in people with chronic health problems.

What are the implications?

This multi-component study found that people with coronary heart disease were likely to experience depression and anxiety, reinforcing the need for primary care professionals to look out for these conditions in their patients.

When discussing treatment, primary care professionals should consider that people with depression and coronary heart disease favoured interventions other than antidepressants.

The pilot study of a nurse-led personalised care intervention found that it was acceptable to patients, showed promise in improving some clinical outcomes and was cost-effective. The NIHR has funded a number of studies recently addressing problems of multimorbidity. One is a nationwide trial of nurse case management  in general practice for people with long term physical problems and anxiety/depression to improve the quality of care and the patients’ quality of life. This study will provide evidence of clinical and cost effectiveness in a larger number of people.

Citation and Funding

Tylee A, Barley EA, Walters P, et al. UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients. Programme Grants Appl Res. 2016;4(8).

This project was funded by the National Institute for Health Research Programme Grants for Applied Research (PGfAR) (project number RP-PG-0606-1048).

Bibliography

NICE. Depression in adults with a chronic physical health problem: recognition and management. CG91. London: National Institute for Health and Care Excellence; 2009.

NICE. Generalised anxiety disorder and panic disorder in adults: management. CG113. London: National Institute for Health and Care Excellence; 2011.

MIND.  Mental health facts and statistics. London; accessed 2016.

Salisbury C. Improving the management of patients with multimorbidity in general practice (trial protocol). London: NIHR Health Services and Delivery Research Programme; 2016.

Why was this study needed?

Coronary heart disease is when the heart’s blood supply is interrupted or blocked, causing chest pain (angina), heart attacks and heart failure. Coronary heart disease is the UK’s biggest killer and 2.3 million people are living with the condition.

Depression is two to three times more common in people with such chronic physical health problems than people with good physical health. Around 20% of people with a chronic physical health problem experience depression, so in the case of coronary heart disease this could be as many as 460,000 people.

The relationship between chronic physical health problems and depression is two way. Chronic physical health problems can cause depression, for example, no longer being able to do things you enjoy and experiencing pain. Depression is also a risk factor for some physical health conditions, including coronary heart disease.

This study was designed to establish the scale of depression in people with coronary heart disease and to understand the course of depression in these individuals.

What did this study do?

The UPBEAT-UK study was made up of four components, some of which involved 33 GP surgeries in South London. The first part was to assess current practice, consisting of a literature review and qualitative study of GP and practice nurse views. The second part was a qualitative study to understand the psychological and physical needs of patients with coronary heart disease.

The third part was a pilot study of a nurse-led personalised care intervention for people with chest pain and depression, informed by the first two parts of the project. The nurse-led intervention included helping the individual to “break down” the problem into manageable chunks that could be addressed through personalised advice, support for self-management and goal-setting with regular review. The pilot trial aimed to estimate the feasibility and cost-effectiveness of this new approach. The final component was a three year study of people with coronary heart disease on a GP registry to gather data on rates of depression, understand the course of their depression and the relationship between their physical and mental health.

What did it find?

  • The pilot study randomised 81 participants from 17 GP practices to a personalised care intervention compared to usual care by the GP. The intervention was designed to monitor patients’ outcomes and provide additional support, such as emotional support and information about services they could access (including psychological services). The pilot study was not powered to show whether the intervention was effective. Depression was similar over time in those receiving personalised care and those receiving usual care. However, 37% of people in the personalised care intervention reported no chest pain at 6 months, compared with 18% in usual care. Total costs were lower amongst personalised care intervention participants, but this was not statistically significant. The pilot study did not calculate the cost of the nurse-led intervention.
  • The cohort study consisted of 803 people with coronary heart disease across sixteen GP practices. Participants were predominantly older (70 years or more), male (70%) and white (87%). Depression occurred in 7% of participants, with men twice as likely to develop depression. Anxiety was more frequent than depression, at 12% and a further 25% had some anxiety symptoms. People with anxiety were four times more likely to have a heart attack or cardiovascular death (relative risk ratio 3.93, 95% confidence interval 1.95 to 7.90).
  • Overall NHS costs were doubled over the course of 36 months in people with depressive symptoms at baseline, mostly due to inpatient services.
  • Interviews with 30 people with coronary heart disease and depression symptoms revealed an overarching theme of “loss”, which primary care professionals should acknowledge. Where help was offered, talking therapies and interventions such as support groups and exercise were preferred over antidepressants.

What does current guidance say on this issue?

NICE guidance from 2009 recommends screening people with chronic health problems for depression in primary care. The individual is treated using “stepped care”, where interventions are more or less intensive depending on the severity of the condition and their response to treatment. For example, people with mild depression might initially be given details of a local support group and be closely monitored by their GP. If their depression does not improve, options include a referral for more formal psychological therapy or commencing antidepressants or both.

In their 2011 guidance on managing anxiety, NICE recommends that primary care professionals are aware of the potential signs of anxiety in people with chronic health problems.

What are the implications?

This multi-component study found that people with coronary heart disease were likely to experience depression and anxiety, reinforcing the need for primary care professionals to look out for these conditions in their patients.

When discussing treatment, primary care professionals should consider that people with depression and coronary heart disease favoured interventions other than antidepressants.

The pilot study of a nurse-led personalised care intervention found that it was acceptable to patients, showed promise in improving some clinical outcomes and was cost-effective. The NIHR has funded a number of studies recently addressing problems of multimorbidity. One is a nationwide trial of nurse case management  in general practice for people with long term physical problems and anxiety/depression to improve the quality of care and the patients’ quality of life. This study will provide evidence of clinical and cost effectiveness in a larger number of people.

Citation and Funding

Tylee A, Barley EA, Walters P, et al. UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients. Programme Grants Appl Res. 2016;4(8).

This project was funded by the National Institute for Health Research Programme Grants for Applied Research (PGfAR) (project number RP-PG-0606-1048).

Bibliography

NICE. Depression in adults with a chronic physical health problem: recognition and management. CG91. London: National Institute for Health and Care Excellence; 2009.

NICE. Generalised anxiety disorder and panic disorder in adults: management. CG113. London: National Institute for Health and Care Excellence; 2011.

MIND.  Mental health facts and statistics. London; accessed 2016.

Salisbury C. Improving the management of patients with multimorbidity in general practice (trial protocol). London: NIHR Health Services and Delivery Research Programme; 2016.

UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients

Published on 1 May 2016

Tylee A, Barley EA, Walters P, Achilla E, Borschmann R, Leese M, McCrone P, Palacios J, Smith A, Simmonds R, Rose D, Murray J, van Marwijk H, Williams P, Mann A on behalf of the UPBEAT-UK team

Patient Grants for Applied Research Volume 4 Issue 8 , 2016

Background Depression is common in patients with coronary heart disease (CHD) but the relationship is uncertain. In the UK, general practitioners (GPs) have been remunerated for finding depression in CHD patients; however, it is unclear how to manage these patients. Objectives Our aim was to explore the relationship between CHD and depression in a GP population and to develop nurse-led personalised care (PC) for patients with CHD and depression. Design The UPBEAT-UK study consisted of four related studies. A cohort study of patients from CHD registers to explore the relationship between CHD and depression. A metasynthesis of relevant literature and two qualitative studies [patients’ perspectives and GP/practice nurse (PN) views on management of CHD and depression] helped develop an intervention. A pilot randomised controlled trial (RCT) of PC was conducted. Setting Thirty-three GP surgeries in south London. Participants Adult patients on GP CHD registers. Interventions From the qualitative studies, we developed nurse-led PC, combining case management and self-management theory. Following biopsychosocial assessment, a PC plan was devised for each patient with chest pain and depressive symptoms. Nurses helped patients address their most important related problems. Use of existing resources was promoted. Nurse time was conserved through telephone follow-up. Main outcome measures The main outcome of the pilot study of our newly developed PC for people with depression and CHD was to assess the acceptability and feasibility of the intervention and to decide on the best outcome measures. Depression, measured by the Hospital Anxiety and Depression Scale – depression subscale, and chest pain, measured by the Rose angina questionnaire, were the main outcome measures for the feasibility and cohort studies. Cardiac outcomes in the cohort study included: attendance at rapid access chest pain clinics, stent insertion, bypass graft surgery, myocardial infarction and cardiovascular death. Service use and costs were measured and linked to quality-adjusted life-years (QALYs). Data for the pilot RCT were obtained by research assistants from patient interviews at baseline, 1, 6 and 12 months for the pilot RCT and at baseline and 6-monthly interviews for up to 36 months for the cohort study, using standard questionnaires. Results Personalised care was acceptable to patients and proved feasible. The reporting of chest pain in the intervention group was half that of the control group at 6 months, and this reduction was maintained at 1 year. There was also a small improvement in self-efficacy measures in the intervention group at 12 months. Anxiety was more prevalent than depression in our CHD cohort over the 3 years. Nearly half of the cohort complained of chest pain at outset, with two-thirds of these being suggestive of angina. Baseline exertional chest pain (suggestive of angina), anxiety and depression were independent predictors of adverse cardiac outcome. Psychosocial factors predicted the continued reporting of exertional chest pain across the 3 years of follow-up. Costs were slightly lower for the PC group but QALYs were also lower. Neither difference was statistically significant. Conclusions Chest pain, anxiety, depression and social problems are common in patients on CHD registers in primary care and predict adverse cardiac outcomes. Together they pose a complex management problem for GPs and PNs. Our pilot trial of PC suggests a promising approach for treatment of these patients. Generalisation is limited because of the selection bias in recruitment of the practices and the subsequent participation rate of the CHD register patients, and the fact that the research took place in south London boroughs. Future work should explicitly explore methods for effective implementation of the intervention, including staff training needs and changes to practice. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 4, No. 8. See the NIHR Journals Library website for further project information.

Expert commentary

In recent years, there has been increasing recognition of the importance of the effects of mental health problems on the outcomes of long-term conditions such as coronary heart disease. The UPBEAT-UK study confirms that conditions such as anxiety, depression and social problems are common in patients with coronary heart disease in primary care and that they are associated with adverse clinical outcomes. The findings of this study shows the importance of taking a holistic approach to the management of patients with coronary heart disease. Management of these patients should encompass all their health needs, not just their coronary heart disease, including addressing their mental health problems.

Azeem Majeed, Professor of Primary Care and Head of the Department of Primary Care & Public Health at Imperial College London