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Psychosomatic Medicine 66:645-650 (2004)
© 2004 American Psychosomatic Society

ORIGINAL ARTICLES

The High Prevalence of Multiple Psychiatric Disorders in Stable Outpatients With Coronary Heart Disease

Bettina Bankier, MD, James L. Januzzi, MD and Andrew B. Littman, MD

From the Behavioral Medicine Division of Preventive Cardiology, Department of Psychiatry (B.B., A.B.L.), Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts; and the Cardiology Division (J.L.J.), Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts.

Address correspondence and reprint requests to Bettina Bankier, MD, Department of Psychiatry, Massachusetts General Hospital, 50 Staniford Street, Suite 401, Boston, MA 02114. E-mail: bbankier{at}partners.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
OBJECETIVE: There is accumulating evidence of high prevalence of comorbid psychiatric disorders in patients with coronary heart disease (CHD). However, most of these studies focused on one psychiatric disorder or one set of psychological symptoms and detected psychiatric disorders in acutely ill CHD patients. To date, no systematic comprehensive psychiatric diagnostic evaluation has been performed in a consecutive sample of stable CHD outpatients.

METHODS: One hundred stable CHD outpatients of the Cardiology Division outpatient clinic at the Massachusetts General Hospital were included in the study. Psychiatric diagnoses were established by using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (axes I-V).

RESULTS: Frequent comorbid psychiatric diagnoses were detected, including single past major depressive episode (29%), current dysthymic disorder (15%), recurrent major depressive disorder with current major depressive episode (31%), current alcohol abuse (19%), posttraumatic stress disorder (29%), current generalized anxiety disorder (24%), current binge-eating disorder (10%), and current primary insomnia (13%). The mean number of comorbid clinical psychiatric disorders per subject was 1.7.

CONCLUSION: The findings suggest high prevalence rates of comorbid psychiatric disorders as well as a broad spectrum of psychiatric disorders in stable CHD outpatients. However, larger epidemiological studies are needed in order to determine the true prevalence of these disorders in CHD patients.

Key Words: coronary heart disease • stable outpatients • multiple psychiatric disorders

Abbreviations: CHD = coronary heart disease;; MGH = Massachusetts General Hospital;; IRB = Institutional Review Board;; MI = myocardial infarction;; PCI = percutaneous coronary intervention;; CABG = coronary artery bypass graft surgery;; CHF = congestive heart failure;; SCID = structured clinical interview for DSM;; DSM = Diagnostic and Statistical Manual of Mental Disorders;; PD = personality disorder;; MDE = major depressive episode;; MDD = major depressive disorder;; PTSD = posttraumatic stress disorder;; GAD = generalized anxiety disorder;; BMI = body mass index;; GAF = Global Assessment of Functioning Scale.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
There is accumulating evidence for high prevalence of comorbid psychiatric disorders in patients with coronary heart disease (CHD). In particular, several studies described a high prevalence of depressive as well as anxiety disorders in CHD patients (1–3). Furthermore, several studies have identified psychiatric disorders, eg, depressive disorders, as an independent risk factor for morbidity and mortality in this patient population (4–9).

However, most of these studies focused on one psychiatric disorder or one set of psychological symptoms. In addition, these studies detected psychiatric disorders mostly in acutely ill CHD patients. To our knowledge, to date no systematic comprehensive psychiatric diagnostic evaluation has been performed in a stable CHD outpatient population.

Therefore, we performed a comprehensive diagnostic evaluation in a consecutive sample of stable CHD outpatients. The purpose of this study was to characterize the prevalence of psychiatric disorders among stable CHD outpatients and to determine to what degree a broader spectrum of comorbid psychiatric disorders exists, in addition to previously detected depressive and anxiety disorders.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Design and Setting
This prospective study of a consecutive series of 100 stable CHD outpatients was conducted from April to August 2002 at the Cardiology Division’s outpatient clinic at the Massachusetts General Hospital (MGH). Stable CHD outpatients of one cardiologist (J.L.J.) of the Cardiology Division’s outpatient clinic were included in the study. The research protocol was approved by the Institutional Review Board (IRB) of the MGH. Psychiatric consultation and treatment referral was offered in accordance with psychiatric diagnoses determined by the interview.

Study Participants
There was no restriction regarding the age of the participants in the study. The medical inclusion criteria for stable CHD outpatients were the following: CHD diagnosed via a positive stress test (included treadmill stress test, infusion stress test, stress echo as well as thallium or nuclear imaging testing), history of documented myocardial infarction (MI) by electrocardiogram and creatine phosphokinase isoenzymes/troponins, or coronary atherosclerosis documented by coronary angiography with or without revascularization procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). The medical exclusion criteria were unstable angina, active congestive heart failure (CHF), severe comorbid cardiac disease, e.g., cardiomyopathy with an ejection fraction <40%, and comorbid valve replacement therapy. Patients with CHF, cardiomyopathy, or valvular disease were not included in the study, because the study evaluated patients with stable CHD uncomplicated by other comorbid cardiac conditions.

Psychiatric exclusion criteria were active suicidality, psychosis, delirium, and dementia. In particular, actively suicidal and psychotic patients were not included in the study, because the IRB of the MGH discourages recruitment of subjects who are clinically unstable, eg, actively suicidal or psychotic, in studies that offer no direct treatment benefit, unless there is a very compelling reason to include them.

Psychiatric Assessment
Psychiatric diagnoses were established by using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (SCID; DSM-IV) (10). Psychiatric assessment was performed on axis I (clinical disorders), axis II (personality disorders, [PD]), axis III (general medical conditions), axis IV (psychosocial and environmental problems), and axis V (gobal assessment of functioning).

The first author (B.B.) conducted all structured clinical interviews and was blinded to all psychiatric information about the cardiac patients before the study interview. The first author underwent extensive SCID training during the course of the psychiatry residency. In preparation for this study, the first and senior author (A.B.L.), consultation-liaison psychiatrist of the hospital, psychiatrically evaluated 40 CHD patients in cardiac rehabilitation, with both clinicians present. The most prevalent axis I disorders and {kappa} values among these patients included single current major depressive episode (MDE) (0.895), single past MDE (0.844), recurrent major depressive disorder (MDD) with current MDE (0.948), dysthymic disorder (0.857), alcohol abuse (0.908), posttraumatic stress disorder (PTSD) (0.886), generalized anxiety disorder (GAD) (0.844), and binge-eating disorder (0.771).

Multiple axis I diagnoses were given if all clinical criteria were fulfilled for each disorder; e.g., if a patient fulfilled all clinical criteria of GAD as well as all clinical criteria of PTSD, then both diagnoses were given. Although primary insomnia and hypoactive sexual desire disorder are not listed in the SCID, these disorders were documented after being described by patients included in this study. For diagnosis of these disorders, an ad hoc symptom checklist strictly based on the DSM-IV inclusion criteria (10) was used.

Data collection and calculations were performed with the SPSS program (11). The 95% confidence interval of prevalence rates including continuity correction was calculated by using the method of the confidence interval of a proportion (12).

Recruitment Procedure
The study recruitment overture was made at the front desk at the cardiac outpatient unit in the form of a questionnaire, which asked outpatients in an anonymous fashion whether they would be interested in being enrolled in the study. The study was presented as a research study including an interview about mood, psychiatric symptoms, and psychosocial aspects of patients with diagnosed CHD. If patients agreed to participate and met study criteria, the cardiologist requested their inclusion before the cardiac outpatient visit. The interviews were conducted right before or immediately after the cardiac outpatient visit. The first author was continuously present at the cardiac outpatient unit during the days CHD patients were scheduled. The continuous presence of the first author might have contributed to the very high enrollment rate of this study, because there were no waiting or scheduling procedures. Of 101 consecutive cardiac patients who met the inclusion criteria, only 1 refused inclusion. The following 10 patients who met exclusion criteria were not included in the study: 2 patients with unstable angina, 3 patients with CHF, 3 patients with severe comorbid cardiac disease, and 2 patients with comorbid valve replacement therapy. Patients who were included in the study signed a detailed written informed consent. No incentives or reimbursements were given to the patients.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Demographic Characteristics
The demographic characteristics of the study patients are presented in Table 1. Of patients included in the study (N = 100), 69 (69%) were male and 31 (31%) were female. The patients were 30 to 93 years old (mean = 67.1 ± 13.6 years) and had 0 to 12 children (mean = 2.4 ± 1.8). Sixty-seven percent of the patients were married or living with a partner, 17% were widowed, 4% were divorced, and 11% had never married. With respect to educational attainment, 8% of the patients went as far as grade 6, 13% of the patients attended grades 7 to 12, 28% graduated from high school, 8% did partial college, 7% graduated from 2-year college, 15% graduated from 4-year college, 2% did partial graduate/professional school, and 19% completed graduate/professional school. Sixty percent of the patients were retired. Ninety-five percent of the patients were Caucasians, 4% were African Americans, and 1% was Asian American.


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  		TABLE 1. Demographic Characteristics and Medical Background of Stable CHD Outpatients (N = 100)
 
Medical Background
The medical background of the participants is also shown in Table 1. Forty-four percent of the patients had experienced MI, 35% had undergone PCI, and 27% had undergone CABG. Sixty-one percent of the patients confirmed a family history of CHD, 32% had a history of heaviness or obesity (body mass index [BMI] > 25), and 28% of the patients were still overweight or obese. Sixty-three percent of the patients confirmed a smoking history, and 7% of the patients still smoked at the time of the interview. Nineteen percent of patients had type II diabetes, and 28% had hypertension.

Comorbid Psychiatric Diagnoses
Frequent comorbid psychiatric diagnoses are listed in Table 2, and include single past MDE in full remission (29%), current dysthymic disorder (15%), recurrent MDD with current MDE (31%), current alcohol abuse (19%), PTSD (29%), current GAD (24%), current binge-eating disorder (10%), and current primary insomnia (13%). The vast majority of patients with PTSD had chronic PTSD.


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  		TABLE 2. Frequent Comorbid Psychiatric Diagnoses in Stable CHD Outpatients (N = 100), Prevalence and 95% Confidence Intervals With Continuity Correction
 
Two patients (2%) had a single, moderate, current MDE; no patient fulfilled the criteria for bipolar disorder. One patient (1%) fulfilled the clinical criteria for schizoaffective disorder. Six patients (6%) were diagnosed as having current alcohol dependency. No panic disorder with/without agoraphobia, no agoraphobia without history of panic disorder, or social or specific phobia cases were identified. One patient (1%) fulfilled the clinical criteria for current obsessive-compulsive disorder. Among somatoform disorders, current pain disorder was diagnosed in 4 patients (4%). Four patients (4%) fulfilled the clinical criteria for current hypoactive sexual desire disorder.

The mean number of comorbid clinical psychiatric disorders per patient was 1.7, whereas the percentage of patients with any affective disorder was 68%. The numbers of single and combined comorbid axis I and axis II disorders in stable CHD outpatients are presented in Table 3.


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  		TABLE 3. Comorbid Axis I and Axis II Disorders in Stable CHD Outpatients (N = 100)
 
Overlap of Frequent Comorbid Psychiatric Diagnoses
The complete overlap of frequent comorbid psychiatric diagnoses is shown in Table 4. Of 29 patients with a single past MDE, 9 presented a comorbid overlap with dythymic disorder, 5 with alcohol abuse, 11 with PTSD, and 6 with GAD. Of 15 patients diagnosed with dysthymic disorder, 6 showed a comorbid overlap with PTSD. Of patients with recurrent MDD with current MDE (N = 31), 15 also fulfilled the clinical criteria for PTSD, and 14 also fulfilled the criteria for GAD. Of 19 patients with alcohol abuse, 5 had past MDE, 7 had recurrent MDD, 8 had PTSD, and 4 had GAD. Nine patients with PTSD also reported having GAD.


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  		TABLE 4. Overlap of Frequent Comorbid Psychiatric Diagnoses in Stable CHD Outpatients (N = 100)
 
Psychopharmacological and Psychotherapeutic Treatment
The past and present psychopharmacological treatments of the participants are summarized in Table 5. All participants of the study were asked about past and present psychopharmacological as well as psychotherapeutic treatment. Of course, prescription of past and present psychopharmacological medication was not directly related to the psychiatric diagnoses derived from the study’s diagnostic interview. Thirty-two percent of the patients confirmed psychopharmacological treatment (one or more medications) at the time of the assessment. In particular, 13% of the patients took antidepressants, 23% took benzodiazepines, and 2% took neuroleptics. Past psychopharmacological treatment of any duration was mentioned by 36% of the patients; antidepressants have been taken by 19%, benzodiazepines by 22%, and neuroleptics by 2%.


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  		TABLE 5. Frequent Comorbid Psychiatric Diagnoses and Psychopharmacological Treatment (One or More Medication) in Stable CHD Outpatients (N = 100)
 
Of 29 CHD patients with a single past MDE, 8 (27%) mentioned a past psychopharmacological medication, with 6 of these patients having received antidepressant drugs. Of 15 patients with dysthymic disorder, 5 (33%) patients mentioned past and 3 (20%) patients mentioned present psychopharmacological medications. Of 3 dysthymic patients currently taking psychopharmacological medication, 1 reported current antidepressant drug treatment. Of 31 patients with recurrent MDD with current MDE, 19 (61%) patients were treated with psychotropic drugs at the time of the interview, and 11 (58%) of these treated patients were on antidepressant drugs. Ten of 29 (34%) patients with PTSD were treated with psychotropic medication at the time of the interview, and 5 of these patients received antidepressants. Of 24 patients with GAD, 14 (58%) received psychopharmacological treatment at the time of the interview. Four of 10 patients (40%) with binge-eating disorder reported current psychopharmacological treatment. One patient out of 13 with primary insomnia was on psychopharmacological treatment at the time of the interview.

The percentage of stable CHD patients with current comorbid psychiatric disorders taking psychopharmacological medication was 29%, whereas the percentage with current affective disorders taking antidepressants was 12%. Lastly, of all CHD patients included in the study, 4 patients (4%) reported past and/or present psychotherapeutic treatment.

PDs, General Medical Conditions, Psychosocial and Environmental Problems, and Global Assessment of Functioning
With regard to the presence of PDs (axis II), no patient fulfilled the clinical criteria for paranoid, schizoid, schizotypal, antisocial, borderline, or histrionic PD. Three patients (3%) fulfilled the criteria for narcissistic PD. One patient (1%) presented avoidant, 4 patients (4%) presented dependent, and 1 patient (1%) presented obsessive-compulsive PD.

Besides CHD, obesity, type II diabetes (19%), and hypertension (28%), 64 patients (64%) mentioned an additional current general medical condition (axis III). Among these 64 patients, 41% had 1, 15% had 2, 4% had 3, and 4% had 4 additional current general medical conditions.

In assessing psychosocial and environmental problems (axis IV), 20 patients (20%) described severe problems with their primary support group. In particular, patients told of highly dysfunctional marriages or relationships, isolation after the loss of their partner, and/or dysfunctional relationships with one or more children, who represented in several cases the only close family member. Seven patients (7%) cited problems related to the social environment. Educational problems were mentioned by 4% of patients. Occupational as well as economic problems were named by 12% of patients. In addition to problems with the primary support group, these two categories (occupational/economic problems) were described as of utmost importance for the patients concerned.

Psychological, social, and occupational functioning recorded by the Global Assessment of Functioning Scale (GAF; axis V) showed a mean of 64 (±15).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
ACKNOWLEDGMENTS
 REFERENCES
 
In accordance with previous findings of a high prevalence of psychiatric disorders among mostly acutely ill CHD patients, we found a high prevalence of psychiatric comorbidity in stable CHD outpatients. In addition, we detected a broad spectrum of psychiatric comorbidity in these patients, besides previously described depressive and anxiety disorders. In particular, besides the expected high prevalence of depressive disorders and GAD, we found a high prevalence of alcohol abuse and PTSD among the patients included in the study. Additionally, we recorded a notable prevalence of dysthymic disorder, binge-eating disorder, and primary insomnia.

Our findings are in line with previous research showing a high prevalence of MDE and MDD in CHD patients (1,2). In particular, Freedland et al. (13) found recurrent MDD in up to 44% of recently diagnosed CHD patients. Accordingly, Barefoot et al. (9) described persistence and recurrence of MDE in CHD patients after a follow-up of nearly 20 years. In addition to current and past MDE and recurrent MDD, we found notable prevalence of dysthymic disorder in this patient population.

With regard to anxiety disorders, we identified a high prevalence of GAD and PTSD in our sample of stable CHD outpatients. Furthermore, in accordance with previous findings (14), we found considerable comorbid overlap of GAD and PTSD with depressive disorders in CHD patients. With regard to a potential impact of anxiety disorders on the development and course of CHD, previous data (14,15) showed significant associations between PTSD and the development and recurrence of CHD in war veterans. On the other hand, the experience of CHD itself, eg, a myocardial infarction, was found to potentially traumatize or re-traumatize subjects with PTSD (16).

We did not identify panic disorder with/without agoraphobia, agoraphobia without history of panic disorder, or social or specific phobia cases among stable CHD outpatients included in our study. In contrast, high prevalence rates of panic disorder (25–34%) with/without agoraphobia were previously described in patients with acute chest pain admitted to coronary care and emergency units (3,17,18), and the presence of panic disorder did not exclude an acute cardiac event. The discrepancy between these findings may be partly explained by differences in the samples, particularly chest pain patients versus diagnosed CHD patients and acutely symptomatic versus stable outpatients. With regard to lifetime prevalence rates for panic disorder in community samples, most studies have found between 1% and 2%, and for social phobia, 3% or more (10). Specific phobias are common in the general population, but they rarely result in sufficient impairment to warrant a diagnosis (10). Our findings suggest that panic disorder, social phobia, and specific phobia are not common in stable CHD outpatients, but future epidemiological research is needed to shed light on the true prevalence rates of these disorders in this population.

We found a high prevalence of alcohol abuse among stable CHD outpatients and a notable overlap of alcohol abuse with recurrent MDD and PTSD in patients included in the study. Previous research underlined disparate relations between alcohol use disorders and cardiovascular conditions. Klatsky et al. (19) described higher cardiovascular mortality rates among ex-drinkers due to confounding traits such as hypertension, hemorrhagic but not occlusive stroke, and cardiomyopathy. Accordingly, previous findings have highlighted the relationship between alcohol use disorders and cardiac problems such as arrhythmias and heart failure (20).

To our knowledge, no previous research focused on eating disorders among CHD patients. However, we found notable prevalence of binge-eating disorder among patients included in the study. Future research seems needed to assess the prevalence of eating disorders, in particular binge-eating disorder, in CHD patients. This may be especially relevant for a fruitful treatment approach, given the impact of binge-eating disorder on specific CHD risk factors.

In evaluating sleeping disorders in stable CHD outpatients, we recorded a notable prevalence of primary insomnia. Accordingly, previous findings underlined significant associations between sleep disturbances and the development and recurrence of CHD (21–24).

With regard to PDs, our findings suggest that narcissistic PD (3%) might be more common in CHD patients compared with the general population (1%) (10). Furthermore, our results suggest similar prevalence rates of avoidant (1%) and obsessive-compulsive PD (1%) compared with findings in the general population (10). Dependent PD is among the most frequently reported PDs encountered in mental health clinics (10) and was the most prevalent PD (4%) in our sample.

We found surprisingly high current psychopharmacological treatment, in up to 61% of patients with recurrent MDD with current MDE, which was the most prevalent diagnosis in our sample. Furthermore, more than half of these patients were on current antidepressant drug treatment. Of all CHD patients included in our study with current psychiatric comorbidity, 29% were currently taking psychotropics, whereas 12% with a current affective disorder were currently taking antidepressants. Only 4 patients (4%) included in our study reported past and/or present psychotherapeutic treatment.

In line with previous findings (25,26) stressing lack of social support as a core element in CHD patients, we found a notable prevalence of psychosocial and environmental problems in this patient population. However, the psychological, social, and occupational functioning of patients appeared high, with a mean of 64 on the GAF Scale (1–100). In particular, the range of 61 to 70 on the GAF scale describes an individual with mild symptoms or mild difficulties in social, occupational, or school functioning, and with meaningful interpersonal relationships. The scores may reflect the nature of the clinical practice from which these patients were enrolled.

This study’s strength was the use of the DSM-IV clinical nomenclature rather than a questionnaire cutoff or a construct such as, e.g., psychological distress that is not easily translated into the DSM code. However, our findings should be tempered by the methodological limitations of this study. First, the inclusion of stable CHD outpatients of one cardiologist of the MGH Cardiology Division’s outpatient clinic represents a selection bias. Second, CHD patients with psychiatric disorders are higher users of clinics, and hence they are more likely to be represented in this study. Third, 10 patients were not included in the study because they met exclusion criteria, and this represents an additional selection bias. These data suggest a high prevalence of psychiatric disorders in this patient population, but larger epidemiological studies are needed in order to evaluate the true prevalence of these disorders in all these patients. Finally, the value of the results is limited by the fact that the material of this study represents stable CHD outpatients, and therefore the results cannot be generalized for all CHD patients. In addition, the small number of racial and ethnic minority participants also limits the generalizability of these findings.

In considering the range of available psychiatric assessment procedures for CHD patient populations, e.g., in cardiac rehabilitation programs, the adoption of a systematic comprehensive psychiatric assessment (27) seems unlikely. The use of broad-based psychiatric screening instruments, e.g., the Psychiatric Diagnostic Screening Questionnaire (28) or the Patient Health Questionnaire (29), seems more practical for a large-scale use.

In conclusion, our findings suggest high prevalence rates of depressive and anxiety disorders (particularly GAD and PTSD) in stable CHD outpatients, but also suggest a notably high prevalence of a broad range of other psychiatric disorders in these patients. Hence, it might be clinically useful to address psychiatric comorbidity in these patients instead of relying on a single entity or symptom domain. In particular, assessments of CHD patients should not miss recognition of comorbid disorders such as PTSD, alcohol use disorders, binge-eating disorder, and primary insomnia, which are currently not routinely evaluated. Furthermore, additional research is needed to determine whether an early recognition of these disorders could lead to better outcomes through more specific provision of care.


   ACKNOWLEDGMENTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
REFERENCES
 
This research was supported in part by a grant from the Charles A. Dana Foundation, New York, New York.

Received for publication October 14, 2003.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 

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L. D. Kubzansky, K. C. Koenen, A. Spiro III, P. S. Vokonas, and D. Sparrow
Prospective Study of Posttraumatic Stress Disorder Symptoms and Coronary Heart Disease in the Normative Aging Study
Arch Gen Psychiatry, January 1, 2007; 64(1): 109 - 116.
[Abstract] [Full Text] [PDF]

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 FocusHome page
J. K. Schulman, P. R. Muskin, and P. A. Shapiro
Psychiatry and Cardiovascular Disease
Focus, April 1, 2005; 3(2): 208 - 224.
[Abstract] [Full Text] [PDF]

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