Original articleA Cardiac Depression Visual Analogue Scale for the brief and rapid assessment of depression following acute coronary syndromes
Introduction
Acute coronary syndromes (ACS) are disorders caused by impaired perfusion of cardiac muscle secondary to atherosclerotic plaque instability. They include non-ST elevation acute myocardial infarction (AMI), ST elevation AMI, and unstable angina [1], [2]. It has been observed that the recovery, specifically the prognosis and treatment outcomes from ACS, is affected by the psychological state of the patient [3], [4], [5], [6]. In particular, patients with even minor symptoms of depression after an AMI have a worse prognosis than do those with no symptoms of depression [7], [8]. A dose-dependent relationship relating initial severity of depression to subsequent mortality has been reported [6]. Additionally, these patients have a worse quality of life [9]. Depression is common following an AMI. The prevalence of minor or major depression observed in the immediate months after AMI can vary from 16% to 65% of patients, depending on the measurement tool and the depression criteria [5], [10], [11], [12], [13], [14], [15]. Moreover, it can been argued that depression in a cardiac population is best viewed as a continuum rather than a discrete entity [16], [17], [18].
From the few longitudinal studies that have been published, it appears that depression is not a transitory phenomenon following an AMI. Up to half of those depressed shortly after an AMI remain depressed 12 months later, especially if initial levels of depression were high. Depression was reported in 20% of males patients 10 days following hospital discharge, and in 26% at 2 and 6 months post-AMI [14]. Likewise, Schleifer et al. [19] found that major depression persisted in the months following an AMI; they suggested that it might not remit unless treated. Half of the participants who had a BDI greater than 10 at 7 days post-AMI were still depressed 12 months later, and a further 15% were depressed, who had not been depressed at baseline [20]. Similarly, Mayou et al. [21] reported that 35% of those with elevated levels of psychological distress, measured with the Hospital Anxiety and Depression Scale (HADS; [22]), remained distressed at 12 months post-AMI.
Major depression, as defined by the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), is typically a chronic disease, which fluctuates over time [23]. However, the natural course of depression following ACS has rarely been measured. Moreover, a single measurement of depressed mood at only one time point might not be representative of the overall mood of the patient because of day to day fluctuations. To better understand depression following ACS, it might be informative to monitor depressive symptoms on a daily basis. Visual analogue scales (VASs), first described by Aitken [24], have been used for the rapid, sensitive, and reliable subjective measurement of various states. For example, they have been used to measure mood [24], [25], pain [26], depression [27], [28], and distress and anxiety [27]. They are reportedly simple to use and interpret and allow numerous repeated measures [27], [28]. VASs have been shown to have good reproducibility and sensitivity when compared with Likert scales [29].
Given the detrimental effects of depressed mood following ACS, there may be value in having a measurement tool that can quickly record valid data for use in a clinical or research setting. Of the few longitudinal studies of depression in cardiac populations, the assessment has used standard depression scales at one to three time points only and usually months apart, without any indication of the natural fluctuation of depression over shorter time intervals between assessments [14], [20], [21]. These fluctuations might have implications for the management or treatment of depression following ACS. Therefore, the aim of the current study was to develop a multi-item instrument that used self-rated VASs to conveniently and rapidly measure depressed mood in a post-ACS population on a daily basis for a 2-week period.
Section snippets
Participants
Participants were 13 female and 45 male patients (a subset of 81 participants who were recruited for a larger longitudinal study) who had been admitted to the coronary care unit of two Australian hospitals for the treatment of an ACS. Initial recruitment took place 1–14 days post-ACS. Utilizing hospital administration records, any patient diagnosed with an AMI, unstable angina, or nonspecific ACS met the primary eligibility criteria for the study. Based on clinical notes, patients typically
Results
Of 406 consecutive patients admitted to the coronary care unit of the participating hospitals, 202 did not meet criteria for the study (18 patients were too ill; 84 were non-English speaking; 60 were greater than 80 years old; 12 had cognitive impairment; 26 were from rural areas; and 2 had alcohol abuse). Another 80 patients declined and 36 were not contactable by the interview date, resulting in a final sample of 81 patients. Of these, 58 (72%) completed the mood diary for the 14-day period.
Discussion
The current findings indicated that the CD-VAS appears to be a valid, reliable, and sensitive disease-specific measure of the depressive symptomalogy that is often present post-ACS. It has been argued that scales with fewer items should have a lower internal reliability than do scales with more items [33]; however, the internal reliability of the six-item CD-VAS of Day 1 scores was high. Moreover, this increased when mean scores were used for Weeks 1 and 2 and resulted in stronger internal
Acknowledgments
The authors would like to thank the Austin and Northern Hospitals, without whose permission this study was not possible. We would also like to sincerely thank the coronary care unit nursing staff for their support. Finally, we gratefully acknowledge Professor Bruce Jackson, Northern Hospital, for his assistance with the research protocol.
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