Differential impact of physical activity type on depression in adults with congenital heart disease: A multi-center international study

doi:10.1016/j.jpsychores.2019.109762

Journal of Psychosomatic Research

Volume 124, September 2019, 109762

https://doi.org/10.1016/j.jpsychores.2019.109762 Get rights and content

Highlights

•
12% of our international study cohort reported having elevated depressive symptoms.
•
The prevalence of elevated depressive symptoms was lower in physically active ACHD.
•
Sport participation was significantly associated with reduced depressive symptoms.

Abstract

Objective

This study aimed to examine the association between physical activity (PA) and depression in a large international cohort of adults with congenital heart disease (ACHD) as data about the differential impact of PA type on depression in this population are lacking.

Methods

In 2018, we conducted a cross-sectional assessment of 3908 ACHD recruited from 24 ACHD-specialized centers in 15 countries between April 2013 to March 2015. The Hospital Anxiety and Depression Scale was used to assess self-reported depressive symptoms and the Health-Behavior Scale-Congenital Heart Disease was used to collect PA information. Cochran-Armitage tests were performed to assess trends between depressive symptom levels and PA participation. Chi-Square and Wilcoxon Rank Sum tests were utilized to examine relations between depressive symptom levels and patient characteristics. Stepwise multivariable models were then constructed to understand the independent impact of PA on depressive symptoms.

Results

The overall prevalence of elevated depressive symptoms in this sample was 12% with significant differences in rates between countries (p < .001). Physically active individuals were less likely to be depressed than those who were sedentary. Of the 2 PA domains examined, sport participation rather than active commute was significantly associated with reduced symptoms of depression. After adjustment in multivariable analysis, sport participation was still significantly associated with 38% decreased probability of depressive symptoms (p < .001).

Conclusions

Sport participation is independently associated with reduced depressive symptoms. The development and promotion of sport-related exercise prescriptions uniquely designed for ACHD may improve depression status in this unique population.

Introduction

A sedentary lifestyle has been consistently associated with premature death and the development of chronic illness, including cardiovascular disease, osteoporosis, diabetes mellitus, cancer, and depression [1]. Physical inactivity, however, is a modifiable risk factor and existing evidence has shown the protective effect of physical activity (PA) on overall health - both physical and psychological - in multiple patient groups, including adults with congenital heart disease (ACHD) [[1], [2], [3], [4], [5], [6]]. Specifically, depression has been demonstrated to have an adverse impact on the prognosis in patients with chronic heart disease (e.g., poor quality of life, higher rates of hospitalization or mortality, increased healthcare utilization, and shorter event-free survival) [7,8]. We recently demonstrated that depression is a primary driver of patient-reported health status in ACHD [9]. Although existing studies have demonstrated an antidepressant effect of PA in other populations, the effect of PA on depressive symptoms in a large, diverse international cohort of ACHD has not been previously investigated [4,10,11]. Given the importance of both PA and depression on prognosis and health status, identifying the relationship between the two in ACHD has the potential to positively impact patient care. In the present study, we sought to identify independent associations between PA type and depression in a large international cohort of ACHD with the goal of better directing providers as to the impact of PA in ACHD care.

Section snippets

Study design, patients, and patient-reported outcome metrics (PROMs)

In 2018, we performed a cross-sectional multi-institutional analysis of data derived from the Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart Disease – International Study (APPROACH-IS) study, which was conducted from April 2013 to March 2015. This study enrolled 4028 ACHD from 24 centers in 15 countries across 5 continents. A detailed study protocol and a full list of demographic, clinical, and psychological variables have previously been summarized by Apers

Results

The demographic, clinical, and psychological characteristics of 4028 ACHD have been previously described [17]. Detailed information on the significant differences in patient characteristics within each PA domain and the rates of PA participation across countries, have also been reported [2]. Briefly, of 3087 individuals, either employed or attending school, 1084 (35%) actively commuted; the rates of active commute differed significantly by country (p < .001), ranging from 18% (the United

Discussion

The present study is unique in that it is the first large international study to assess depression symptomatology in ACHD utilizing the same metrics between countries and that it not only examines the relationship between PA and depression in general, but also provides information on the differential impact of active commute versus sport participation on depression. We found that elevated symptoms of depression were more prevalent in patients who were sedentary compared to those who were

Study limitations

There are several limitations to the present study. A recall and response bias is a potential problem in all self-reported PROMs which tend to yield results either higher or lower than objective measures. Depression assessed by HADS not by psychiatric interview might have underestimated the prevalence of depression in this study cohort. Some incomplete or incorrect clinical data may be present as all clinical data were collected by chart review. The results may not be generalizable to all ACHD

Conclusion

Because depression worsens treatment response and prognosis, the prevention of and early treatment for depression is paramount to promoting mental and physical health in ACHD. Participation specifically in sport is strongly associated with reduced symptoms of depression among ACHD. The development and promotion of sport-related exercise prescriptions uniquely designed for ACHD may improve depression and by extension overall health status in ACHD.

Declaration of Competing Interests

None.

Disclosures

No financial disclosures were reported by the authors of this paper.

Acknowledgements

We are grateful to the study participants who made this study possible as well as all individuals at the participating centers who made substantial contributions to this international study. This work was supported by the Research Fund – KU Leuven (Leuven, Belgium) through grant OT/11/033 to K.L. and P.M.; by the Swedish Heart-Lung Foundation (Sweden) through grant number 20130607 to M.D.; by the University of Gothenburg Centre for Person-centred Care (Gothenburg, Sweden) to M.D. and P.M.; and

References (35)

J.M. Ko et al.
Physical activity-related drivers of perceived health status in adults with congenital heart disease: a multi-center international study
Am. J. Cardiol.
(2018)
R.L. White et al.
Domain-specific physical activity and mental health: a meta-analysis
Am. J. Prev. Med.
(2017)
N. Duppen et al.
Systematic review of the effects of physical exercise training programmes in children and young adults with congenital heart disease
Int. J. Cardiol.
(2013)
T. Rutledge et al.
Depression in heart failure a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes
J. Am. Coll. Cardiol.
(2006)
J.M. Ko et al.
Clinical and psychological drivers of perceived health status in adults with congenital heart disease
Am. J. Cardiol.
(2018)
S. Kvam et al.
Exercise as a treatment for depression: a meta-analysis
J. Affect. Disord.
(2016)
F.B. Schuch et al.
Exercise as a treatment for depression: a meta-analysis adjusting for publication bias
J. Psychiatr. Res.
(2016)
S. Apers et al.
Assessment of patterns of patient-reported outcomes in adults with congenital heart disease – international study (APPROACH-IS): rationale, design, and methods
Int. J. Cardiol.
(2015)
J.A. Baecke et al.
Frijters JE. A short questionnaire for the measurement of habitual physical activity in epidemiological studies
Am. J. Clin. Nutr.
(1982)
S. Apers et al.
APPROACH-IS consortium and ISACHD. Quality of life of adults with congenital heart disease in 15 countries: evaluating country-specific characteristics
J. Am. Coll. Cardiol.
(2016)

P.M. Mommersteeg et al.

Health status as a risk factor in cardiovascular disease: a systematic review of current evidence

Am. Heart J.

(2009)

Y. Beniamini et al.

Effects of high-intensity strength training on quality-of-life parameters in cardiac rehabilitation patients

Am. J. Cardiol.

(1997)

E.E. Bernstein et al.

Exercise as a buffer against difficulties with emotion regulation: a pathway to emotional wellbeing

Behav. Res. Ther.

(2018)

S.R. Chekroud et al.

Association between physical exercise and mental health in 1·2 million individuals in the USA between 2011 and 2015: a cross-sectional study

Lancet Psychiatry

(2018)

N. Sutherland et al.

Should we recommend exercise after the Fontan procedure?

Heart Lung Circ.

(2015)

L. Samartzis et al.

SSRIs versus exercise training for depression in chronic heart failure: a meta-analysis of randomized controlled trials

Int. J. Cardiol.

(2013)

D.E. Warburton et al.

Health benefits of physical activity: the evidence

CMAJ.

(2006)

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A comprehensive understanding of adult congenital heart disease outcomes must include psychological functioning. Our multisite study offered the opportunity to explore depression and anxiety symptoms within a global sample.
In this substudy of the APPROACH-IS (Assessment of Patterns of Patient-Reported Outcomes in Adults With Congenital Heart Disease–International Study), the authors we investigated the prevalence of elevated depression and anxiety symptoms, explored associated sociodemographic and medical factors, and examined how quality of life (QOL) and health status (HS) differ according to the degree of psychological symptoms.
Participants completed the Hospital Anxiety and Depression Scale, which includes subscales for symptoms of anxiety (HADS-A) and depression (HADS-D). Subscale scores of 8 or higher indicate clinically elevated symptoms and can be further categorized as mild, moderate, or severe. Participants also completed analogue scales on a scale of 0 to 100 for QOL and HS. Analysis of variance was performed to investigate whether QOL and HS differed by symptom category.
Of 3,815 participants from 15 countries (age 34.8 ± 12.9 years; 52.7% female), 1,148 (30.1%) had elevated symptoms in one or both subscales: elevated HADS-A only (18.3%), elevated HADS-D only (2.9%), or elevations on both subscales (8.9%). Percentages varied among countries. Both QOL and HS decreased in accordance with increasing HADS-A and HADS-D symptom categories (P < 0.001).
In this global sample of adults with congenital heart disease, almost one-third reported elevated symptoms of depression and/or anxiety, which in turn were associated with lower QOL and HS. We strongly advocate for the implementation of strategies to recognize and manage psychological distress in clinical settings. (Patient-Reported Outcomes in Adults With Congenital Heart Disease [APPROACH-IS]; NCT02150603)
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This study selecteds relevant indicators to evaluate the equity of UGS patterns in the Harbin area and used linear regression analysis to explore the correlation between attributes of old industrial areas and UGS patterns. Additionally, this study explored the spatial correlation of UGSs using Moran's index and hotspot analysis. Finally, a report on residents' health was generated through a questionnaire survey, using linear regression analysis to explore the factors affecting residents' self-rated health and the significance of their correlation.
The results showed that there is an excess supply around the core industrial zone in the west, while the rural areas in the south face a serious shortage of supply. The significance between the factors representing age and income in industrial attributes and UGS pattern was less than 0.05. We observed that residents' self-rated health was positively affected by the intensity of physical activity (low intensity B = 2.073, medium intensity B = 2.359, high intensity B = 2.512) and the frequency of physical activity (B = 1.174). Ages (B = −0.597) and three generations living together (B = −3.191), which represent the industrial attributes, had a negative impact on residents' self-rated health.
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Quality of Life and Other Patient-Reported Outcomes Across the Life Span Among People With Fontan Palliation
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Citation Excerpt :
On the basis of North American, German, and French studies in which clinical interviews were administered to adults with CHD, the lifetime risk of mood or anxiety disorders might be as high as 50%.2,95,96 Patients at greater risk of psychological distress include those with neurocognitive impairment, loneliness or less social support, sedentary lifestyle, and lower physical health status.2,97-99 Within the general adult CHD population, there is also emerging concern about the possibility of elevated rates of traumatic stress symptoms and post-traumatic stress disorder.100,101
Traditional congenital heart disease (CHD) outcomes include mortality (survival to adulthood and life expectancy) as well as cardiac and noncardiac morbidity. Strategies to identify and manage sequelae have primarily focused on objective data obtained though invasive and noninvasive diagnostic approaches. In contrast, patient-reported outcomes (PROs) provide subjective information, using standardized measures, about patients’ health and well-being as reported directly by patients, without interpretation, interference, or assumptions made by clinicians or others. Selection of PRO measures entails thoughtful consideration of who the individuals being surveyed are, why assessment is occurring (eg, what are the domains of interest; clinical vs research), and what processes are in place for acquisition, administration, interpretation, and response. In this review, we focus on 3 domains of PROs for pediatric and adult patients with Fontan physiology: physical health status, psychological functioning, and quality of life. Infants, children, adolescents, and adults with CHD face a spectrum of challenges that might influence PROs across the life span. In general, patients with Fontan palliation tend to have lower physical health status, experience more psychological distress, and have equivalent or reduced quality of life compared with healthy peers. Herein, we provide an overview of PROs among people with Fontan circulation as a group, yet simultaneously emphasize that the optimal way to understand the experiences of any individual patient is to ask and listen. We also offer clinical and research initiatives to improve the adoption and utility of PROs in CHD settings, which show commitment to capturing, understanding, and responding to the patient voice.
L’issue classique des cardiopathies congénitales comprend le décès (survie jusqu’à l’âge adulte et espérance de vie écourtées) ainsi que la morbidité cardiaque et non cardiaque. Les stratégies de dépistage et de prise en charge des séquelles s’articulent essentiellement autour de données objectives obtenues par le biais d’approches diagnostiques invasives et non invasives. En revanche, les données d’autodéclaration des patients fournissent des informations subjectives sur la santé et le bien-être de ces derniers, au moyen de mesures normalisées, de façon directe et sans interprétation, intervention ni hypothèses de la part de cliniciens ou d’autres personnes. La sélection des paramètres d’autodéclaration des patients doit être mûrie et nécessite que l’on sache qui sont les répondants, pourquoi l’évaluation est effectuée (notamment en ce qui concerne la nature des domaines abordés, dans une optique clinique ou de recherche) et quels processus sont en place en matière de collecte, d’administration, d’interprétation et de réaction. Dans le présent article de synthèse, nous nous concentrons sur trois domaines d’autodéclaration des patients pédiatriques et adultes ayant subi l’intervention de Fontan : état de santé physique, bien-être psychologique et qualité de vie. Les nourrissons, les enfants, les adolescents et les adultes atteints de cardiopathies congénitales doivent composer avec un large éventail d’enjeux susceptibles d’influer sur les données d’autodéclaration tout au long de leur vie. Généralement, les patients qui ont subi l’intervention de Fontan tendent à présenter un moins bon état de santé physique, à éprouver plus de détresse psychologique et à avoir une qualité de vie équivalente ou inférieure comparativement à des pairs en bonne santé. Nous donnons ici un aperçu des données d’autodéclaration de personnes ayant subi l’intervention de Fontan, tous cas confondus. Nous soulignons également que la façon optimale de comprendre ce que vit un patient consiste à interroger et à écouter ce dernier. Nous proposons aussi des initiatives à l’intention des cliniciens et des chercheurs en vue d’accroître l’adoption et l’utilité des méthodes d’autodéclaration touchant les cardiopathies congénitales, dans l’optique d’une volonté affichée d’écoute, de compréhension et de réactivité à l’endroit du patient.
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View full text

Differential impact of physical activity type on depression in adults with congenital heart disease: A multi-center international study

Highlights

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Study design, patients, and patient-reported outcome metrics (PROMs)

Results

Discussion

Study limitations

Conclusion

Declaration of Competing Interests

Disclosures

Acknowledgements

Am. J. Cardiol.

Am. J. Prev. Med.

Int. J. Cardiol.

J. Am. Coll. Cardiol.

Am. J. Cardiol.

J. Affect. Disord.

J. Psychiatr. Res.

Int. J. Cardiol.

Am. J. Clin. Nutr.

J. Am. Coll. Cardiol.

Am. Heart J.

Am. J. Cardiol.

Behav. Res. Ther.

Lancet Psychiatry

Heart Lung Circ.

Int. J. Cardiol.

Health benefits of physical activity: the evidence

CMAJ.