Brief reportQuantifying links between acute myocardial infarction and depression, anxiety and schizophrenia using case register databases
Introduction
Depression and coronary artery disease are some of the most common diseases in the industrialized world, with ischaemic heart disease and stroke followed by depression as the strongest determinants of disability in industrialized countries (Lepine, 2001).
Over the last decade, evidence for an association between depression and acute coronary syndromes has accrued (Dinan, 1999, Glassman and Shapiro, 1998, Lett et al., 2004, Rozanski et al., 1999, Wulsin, 2004, Rugulies, 2002). A recent review article asserts that the presence of depression increases the risk for developing coronary artery disease by a factor ranging from 1.5 to 2.0 (Rugulies, 2002).
Despite growing evidence for such an association, depressive disease is not included in the list of important and independent risk factors for cardiovascular disease published by the American Heart Association (Hunt et al., 2005). Furthermore, it is still not common practice for either general practitioners or cardiologists to screen for depression when examining risk factor status for coronary artery disease, or for depressed patients to be screened for risk factors for coronary heart disease. This may reflect insufficient awareness of the associational strength, and the suggested specificity to depressive illness, and argues the need for quantification from large databases as many of the contributing studies have involved relatively small sample sizes. Population and record linkage studies have the capacity to quantify risk more precisely and thus advance awareness.
The aims of this study were firstly, to quantify the association between depression and AMI in a large register, and secondly, to examine whether it is depressive disease itself – or a broader variable of being mentally ill as a whole – that may provide increased risk for cardiovascular disease. The latter hypothesis was to be explored by comparing the comparative impact of anxiety and schizophrenia on AMI rates.
Section snippets
Methods
The study is a longitudinal, historically-designed register study allowing psychiatric patients to be followed for episodes of AMI. Data were extracted from the Danish Psychiatric Central Research Register (PCR). This register contains person-identifiable information about all admissions to psychiatric inpatient facilities in Denmark since 1969 and outpatient facilities since 1995 (Munk-Jorgensen and Mortensen, 1997). Registration is complete for hospitalized patients as there are no private
Results
Table 1 reports the numbers of subjects in diagnostic and control groups. In Table 2 the IRRs for AMI among the depressive, anxious and the patients with schizophrenia are presented. Among the depressive patients, the IRR for AMI was elevated significantly, being 1.16 (CI: 1.10–1.22). For subjects with anxiety and AMI, the IRR was also significantly elevated, being 1.56 (CI: 1.35–1.79). For the schizophrenic patients, there was a statistically significant lower risk of AMI, with the IRR being
Discussion
The present study quantified a significant positive association between depression and acute myocardial infarction with an IRR of 1.16 (CI: 1.10–1.22). As we excluded persons who, prior to their depression had experienced an episode of AMI, the association is truly prospective, and indicates that depressed caseness is associated with an increased risk of myocardial infarct. This supports findings from previous studies (Glassman and Shapiro, 1998, Rugulies, 2002, Fielding, 1991). In a
Limitations
Being register-based our study has some limitations (Byrne et al., 2005, Parker, 2005). Data including diagnoses were reported from daily clinical practice from all treatment facilities in the whole country of Denmark over a 24-year period, and are therefore heterogeneous, mirroring different diagnostic principles as to time and professional tradition. Furthermore, as a register study it was not possible to correct for all potential confounders, which indeed could have influenced the results.
Conclusion
This study quantifies positive associations linking both depression and anxiety with an increased risk of AMI. As the association was not demonstrated for those with schizophrenia, our findings argue for some diagnostic specificity. Consequently, both depression and anxiety should be included along with other traditional cardiovascular risk factors in identifying those at risk of coronary heart disease morbidity.
Role of funding source
Nothing declared.
Conflict of interest
No conflict declared.
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