Screening for symptoms of depression and anxiety in a cardiology department

Material and method

Study design and screening tools

The study consisted of a screening component and subsequent follow-up identification and assessment by a clinical psychologist where this was indicated (Figure 1). PHQ-2 (21) and GAD-2 (22) were used as screening tools for symptoms of depression and anxiety respectively. In addition, the patient answered a yes/no question on panic attacks from the Patient Health Questionnaire – Somatic, Anxiety, and Depressive Symptom Scales (PHQ-SADS) (21) (Table 1). Patients from the outpatient clinic were screened by oral questioning during an appointment at the clinic – mainly by a cardiologist, but in some cases by a nurse. Admitted patients signed a consent form during hospitalisation and were screened over the telephone by a clinical psychologist one month after discharge. A score of ≥ 2 points on the PHQ-2 and/or the GAD-2, and/or an affirmative answer to the question on panic attacks were cut-off values values, aiming to achieve a high sensitivity to symptoms (23).

Figure 1 Flowchart of patients assessed for inclusion, excluded and included patients, and patients who scored above the cut-off value and went on to further assessment and identification. PHQ-2 = Patient Health Questionnaire-2. GAD-2 = Generalized Anxiety Disorder Scale-2. HADS = Hospital Anxiety and Depression Scale.

Table 1

Screening for symptoms of depression, anxiety and panic attacks at the Department of Cardiology, Diakonhjemmet Hospital (n = 232). PHQ-2 = Patient Health Questionnaire-2. PHQ-SADS = Patient Health Questionnaire – Somatic, Anxiety, and Depressive Symptom Scales. GAD-2 = Generalized Anxiety Disorder Scale-2.

	Not at all	Several days	More than half the days	Nearly every day	No	Yes
Little interest or pleasure in doing things? (PHQ-2, n = 232)	172	39	10	11	-	-
Feeling down, depressed or hopeless? (PHQ-2, n = 232)	163	46	7	16	-	-
Feeling nervous, anxious or on edge? (GAD-2, n = 232)	171	42	7	12	-	-
Not being able to stop or control worrying? (GAD-2, n = 231)	193	19	6	13	-	-
In the last four weeks, have you had an anxiety attack (suddenly feeling fear or panic)? (PHQ-SADS, n = 230)	-	-	-	-	218	12

To obtain more information on the severity of the reported symptoms, patients who scored above the cut-off value were also assessed with the Hospital Anxiety and Depression Scale (HADS). If they were screened by a clinical psychologist one month after discharge, they were immediately followed up with the HADS. If they were screened by a cardiologist or a nurse at the outpatient clinic, HADS was completed a few days later by a clinical psychologist over the telephone. HADS omits questions about somatic symptoms of depression and anxiety that may be confused with symptoms of cardiac disease. Two sub-scales target symptoms of depression (HADS-D) and anxiety (HADS-A) respectively. A cut-off value of ≥ 4 for HADS-D and/or HADS-A has been used in studies of different patient groups (24). Patients who scored above this cut-off value were asked supplementary questions about the impact of their symptoms on functioning (Table 2).

Table 2

Supplementary questions for further identification of patients with symptoms of depression and anxiety (n = 41). n corresponds to the patients who scored above the cut-off value on the initial screening and the Hospital Anxiety and Depression Scale (HADS).

	Not difficult at all	A little difficult	Very difficult	Extremely difficult	No	Yes
In case of heart disease, it is normal to receive health advice on physical activity, dietary changes, cutting down on smoking and taking medicines as recommended. Do you feel that the mental symptoms that you have described here have made it more difficult to follow such advice in practice? (n = 36)	19	13	2	2	-	-
To what extent do you feel that the mental symptoms that you have described here have made it difficult for you to perform your work, deal with things at home or get along with others? (n = 36)	9	22	3	2	-	-
Have your next of kin expressed concern about the mental symptoms that you have described here? (n = 34)	-	-	-	-	17	17
Accompanied by someone close to you if relevant, would you like a session with a clinical psychologist on preventing and coping with mental symptoms associated with cardiac disease? (n = 41)	-	-	-	-	21	20

Results

A total of 267 patients were assessed for inclusion, whereof 20 were excluded and 15 did not consent to participation or were excluded for reasons of time constraints (Figure 1). The final sample consisted of 232 patients, of whom 58 had valvular heart disease, 73 had tachyarrhythmia, 52 had myocardial infarction and 49 had heart failure. Altogether 161 (69 %) of the patients who participated in the screening were men, and the average age was 72 years (SD 11.3). A total of 173 (75 %) of the patients were recruited from the outpatient clinic and 59 (25 %) from the hospital ward. Altogether 57 (25 %) patients scored above the cut-off value when screened. Of these, 12 patients answered ‘yes’ to the question on panic attacks, and all of these simultaneously scored above the cut-off value in PHQ-2 and/or GAD-2 (Table 1).

Of the 57 patients who scored above the cut-off value in the screening, altogether 56 continued to further identification and assessment by a clinical psychologist (Figure 1). A total of 41 (73 %) of these also scored ≥ 4 on HADS-A and/or HADS-D. For 17 (47 %) patients, the mental symptoms had made it more difficult to comply with health advice in practice. For 27 (75 %) patients, the mental symptoms had made it more difficult for them to perform their work, deal with things at home or get along with others, and a total of 17 (50 %) of those asked had experienced that their next of kin had expressed concern for their mental state (Table 2).

Altogether 20 (49 %) of those 41 patients who scored above the cut-off value on the initial screening and HADS wanted counselling sessions with a clinical psychologist, and 9 (43 %) of those who did not want counselling sessions reported that they would like an opportunity for counselling at a later time (Table 2).

Discussion

The main conclusion is that we have suitable screening tools for symptoms of depression and anxiety in patients with cardiac disease. The gap between the recommendations for routine screening on the one hand and what actually happens in clinical practice on the other is likely to have other causes. One such cause could be uncertainty as to whether the treatment of symptoms of depression and anxiety also contributes to increased survival for patients with cardiac disease (17).

Altogether 73 % of those who scored above the cut-off value on the screening questions also scored above the cut-off value on HADS. Other studies have found that a score of ≥ 2 points on PHQ-2 and/or GAD-2 is a suitable cut-off value for further assessment (25). Raising the cut-off value to ≥ 3 points may increase the risk of failing to identify patients in need of follow-up. No more than twelve patients answered ‘yes’ to the question on panic attacks, and all of them scored above the cut-off value in PHQ-2 and/or GAD-2, which may be an argument in favour of omitting this question (Table 1).

One limitation of this study is that we could not ascertain the number of patients who were not assessed for screening. Not all of the doctors in the department participated, and during periods of high workload screenings could sometimes not be performed. Measures to increase the proportion might be to include all relevant health personnel and ensure that patients who are not screened can be included at a later time. The proportion will increase even further if GPs also perform screening of those patients who receive such follow-up.

One advantage of having the specialist health services perform the screening is that it helps direct attention to the barriers to compliance that symptoms of depression and anxiety entail. Many of the patients in the study reported difficulties in complying with health advice (47 %) or performing work, dealing with things at home or getting along with others (75 %) (Table 2). A Norwegian study showed that few patients achieve an adequate reduction in their cardiovascular risk factors after a myocardial infarction (26). In case of a positive screening, health personnel can follow up with questions about the extent to which the symptoms hinder compliance.

It is important to ascertain when in the disease course screening should be performed, if at all, and whether it should be done by the specialist and/or primary health services. Attempting to perform screening at both levels would increase the likelihood of identifying relevant patients, and for coordinated treatment between service levels and between different primary health agencies (‘collaborative care’) (27). Screening can be performed on a routine basis while taking patient history and can also be carried out by nurses. Moreover, many cardiologists find it natural to ask questions about the mental burden associated with cardiac disease, and to view the person in a holistic way.

By asking questions about mental symptoms one opens up a topic that may require further follow-up. It is thus essential to have a strategy for what to do if the patient answers in the affirmative. Internal referral in the hospital or communicating this information to the patient’s GP may represent such strategies. In addition, the patient may be asked the same questions again in a later consultation, especially in case of problems with compliance. Here, one might provide information that measures recommended for heart disease also can prevent mental symptoms. These include regular physical exercise, avoiding isolation and passivity, freeing oneself from depressing thoughts and establishing a daily routine of meaningful activities. Systematic screening may thus provide a good basis for beneficial support measures.