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Review

Prevalence of Depression in Coronary Artery Bypass Surgery: A Systematic Review and Meta-Analysis

1
Faculty of Health Sciences, University of Granada, Avenida de la Ilustración N. 60, 18016 Granada, Spain
2
Instituto de Investigación Biosanitaria, IBS, 18012 Granada, Spain
3
Faculty of Health Sciences, University of Granada, Campus Universitario de Ceuta, C/Cortadura del Valle s/n, 51001 Ceuta, Spain
4
University Hospital of Ceuta. Institute of Health Management. C/Colmenar s/n, 51003 Ceuta, Spain
5
University Hospital Virgen de las Nieves. Andalusian Health Service. Av. de las Fuerzas Armadas 2, 18014 Granada, Spain
*
Author to whom correspondence should be addressed.
These authors contributed equally to this work.
J. Clin. Med. 2020, 9(4), 909; https://doi.org/10.3390/jcm9040909
Submission received: 4 February 2020 / Revised: 20 March 2020 / Accepted: 25 March 2020 / Published: 26 March 2020
(This article belongs to the Section Epidemiology & Public Health)

Abstract

:
Coronary artery bypass graft surgery (CABG) might adversely affect the health status of the patients, producing cognitive deterioration, with depression being the most common symptom. The aim of this study is to analyse the prevalence of depression in patients before and after coronary artery bypass surgery. A systematic review and meta-analysis was carried out, involving a study of the past 10 years of the following databases: CINAHL, LILACS, MEDLINE, PsycINFO, SciELO, Scopus, and Web of Science. The total sample comprised n = 16,501 patients. The total number of items was n = 65, with n = 29 included in the meta-analysis. Based on the different measurement tools used, the prevalence of depression pre-CABG ranges from 19–37%, and post-CABG from 15–33%. There is a considerable presence of depression in this type of patient, but this varies according to the measurement tool used and the quality of the study. Systematically detecting depression prior to cardiac surgery could identify patients at potential risk.

1. Introduction

Coronary artery disease (CAD) is one of the leading causes of death in developed countries, and it is associated with deteriorated quality of life, disability, and premature death [1]. The usual surgical treatment involves coronary artery bypass graft surgery (CABG). This technique is based on revascularisation by diverting blood flow to other arteries to increase the blood supply to the heart muscle [2].
Although CABG surgery increases life expectancy [3], it is associated with multiple physical complications, including myocardial infarction, stroke, and even kidney failure [4]; in addition to psychological consequences, such as mood disorders, fatigue, weakness, stress, anxiety, and depression [5].
Short-term recovery factors include a longer hospital stay, pain, and infection, which may predispose towards cognitive disorders, like anxiety and depression [6]. In the long term, it is estimated that at least 25% of patients will experience deteriorated quality of life after a CABG; and, it even doubles the post-surgery risk of future cardiac events and mortality related to high levels of anxiety and depression [7].
In particular, depression is considered to be one of the main reasons for reduced well-being, having a negative impact on a patient’s quality of life, as well as their social and family life. It is a strong risk factor for mortality, being related to the occurrence of new cardiac events and reduced functionality up to six months post-CABG surgery, increasing the risk of hospital readmission in up to 20% of patients, due to complications including infection, arrhythmia, and volume overload [8].
Diagnosis is sometimes difficult, since symptoms, such as loss of appetite, sleep cycle disturbance, and constant fatigue, may be superimposed over the same symptoms that were derived from surgery. For this reason, determining the degree to which a CABG can affect a patient’s mental, psychological, and social skills, and, specifically, analysing the level of depression, requires the use of multiple tools validated during a clinical interview [9,10].
A number of factors seem to influence the relationship between depression and CABG, including biological alterations (cardiac rhythm alterations, tone of cardiac muscle, hormone levels, and reduced brain perfusion) [11]. However, in many cases, the high prevalence of mood disorders cannot be explained by the severity of the illness, but is instead related to psychosocial factors, such as socioeconomic status, lifestyle (adherence to the recommended diet or prescribed treatment), or the level of social support [12].
Even though the effects of CABG have been studied in terms of morbidity, mortality, and organ function, the effect or influence it has on mood disorders, like depression, remains unclear. It seems that depression predicts how much a patient’s health will deteriorate. Therefore, it is extremely important to assess how the disease affects a patient, as this can influence the therapeutic benefit and, consequently, which interventions and care are prioritised, and which self-care strategies are implemented both before and after surgery [13,14].
Although depression is considered to have a negative impact on patient recovery, few studies have examined the association between CABG and depression. Some systematic reviews have analysed the risk factors [15], and there are also reports regarding the effect of certain interventions [16,17]. However, to our knowledge, no meta-analysis studies that include a prevalence analysis have been exclusively undertaken on CABG patients.
Describing the levels of depression in CABG patients is essential for analysing the importance of this surgery with regard to depression levels. The purpose of this work is, therefore: (1) to analyse the prevalence of depression in patients both before and after CABG surgery; and, (2) to analyse the depression levels over time.

2. Materials and Methods

The data were extracted and analysed based on the recommendations of preferred reporting items for systematic review and meta-analysis (PRISMA) 2015 [18].

2.1. Search Strategy

A search was conducted of CINAHL, LILACS, MEDLINE, PsychINFO, SciELO, Scopus, and Web of Science in January 2020. MeSH descriptors were used, with the search strategy being: “(depression OR depressive disorder) AND (coronary artery bypass grafting)”.

2.2. Inclusion and Exclusion Criteria

The inclusion criteria were the following: (1) full text of quantitative primary studies; (2) men and women aged over 18; (3) no psychiatric pathology or illness; (4) CABG surgery; (5) study of depression levels prior to or after CABG; (6) the use of a validated scale; (7) written in English, Portuguese, Spanish, or French; and, (8) published in the last 10 years.
The exclusion criteria were the following: (1) paediatric population; (2) a different type of cardiac surgery that was not exclusively CABG (CABG with valve replacement); (3) measurement of depression in relatives; (4) patients with an active treatment deriving from a psychiatric disorder; (5) data from duplicate articles in previous studies; and, (6) no depression data extracted using a validated scale.

2.3. Selection of Articles and Information Analysis

Firstly, two authors checked the title and abstract, and, secondly, the full text of the article. A third author was consulted in the case of discrepancy.
For the meta-analysis, we selected the data from those studies that used the same measurement tool, since the inclusion of several measurement tools would not permit the results to be integrated, due to different scores.

2.4. Data Extraction

The following variables were recorded: (1) data on the study (author, year, country); (2) type of CABG (first time, elective or emergency); (3) study characteristics (sample, type of study, sex, and follow-up time); (4) measurement tool; and, (5) mean, standard deviation, prevalence of depression. For clinical trials or quasi-experimental studies, we selected only the levels of depression prior to the programme intervention (baseline) or those relating to the control group.
We used the intraclass correlation coefficient to analyse coding reliability, obtaining an average value of 0.97 (minimum = 0.93; maximum = 1), and the Cohen’s kappa coefficient with a mean value of 0.94 (minimum = 0.92; maximum = 1).

2.5. Assessment of Quality and Measurement of Bias

Two independently authors assessed the quality of the studies, consulting with a third party in the event of a disagreement.
For observational studies (cohort and cross-sectional), we followed the guidelines in “Strengthening the Reporting of Observational Studies in Epidemiology” (STROBE) [19]. We followed the standards in the Cochrane Collaboration Risk of Bias tool for clinical trials [20].
We used a second quality assessment tool to analyse the level of evidence in accordance with the recommendations of the Oxford Centre for Evidence-Based Medicine [21] (Table 1).

2.6. Data Synthesis and Statistical Analysis

The meta-analysis included those studies that used the same tool for measuring depression. We performed six meta-analyses using a random-effects model and two meta-analyses using a fixed-effect model, for prevalence levels and confidence intervals, through the statistical package StatsDirect (version 3, StatsDirect Ltd., Cambridge, UK).
We used I2 to analyse the heterogeneity, grouping values into low (25%), moderate (50%), or high (75%) heterogeneity [22]. The publication bias was assessed using Egger’s test.

3. Results

The search yielded a total of n = 1874 articles. After reading the title and abstract, 662 were excluded. Figure 1 shows the study selection process.

3.1. Characteristics of Included Studies

The total sample comprised 16,501 patients, predominantly male (n = 54). Most of the studies were cohort studies (n = 34), followed by cross-sectional studies (n = 12). Thirteen studies evaluated the levels prior to surgery, 23 after surgery, and 29 both before and after. Most of the studies were carried out in the USA (n = 17), followed by Germany (n = 7), Iran (n = 7), and Australia (n = 6) (Table 1). The depression follow-up ranged from a month prior to surgery (since the pre-assessment clinic appointment) [23] up to six years after surgery [24,25].

3.2. Measurement of Depression

We used a total of 15 measurement tools. The Hospital Anxiety and Depression Scale (HADS) (n = 18), Beck Depression Inventory (BDI) (n = 17), nine-item Patient Health Questionnaire (PHQ-9) (n = 9), and Centre for Epidemiological Studies Depression Scale (CES-D) (n = 4) were the measurement tools used (Table 1 and Supplementary Table S1).

3.3. Meta-Analysis

A total of 1217 patients were included in the meta-analysis prior to CABG surgery, and 596 patients after the operation. Egger’s test showed no publication bias in any case.
For the HADS tool, the prevalence of depression prior to surgery (n = 144) was 19% (95% CI = 9–31) with a high degree of heterogeneity (I2 = 93.4%), while the prevalence after surgery (n = 394) was 19% (95% CI = 13–26) with I2 = 92.2%, according to the random effects model (Figure 2 and Figure 3).
For the BDI tool, the prevalence of depression prior to surgery (n = 469) was 37% (95% CI = 28–46) with a high degree of heterogeneity (I2 = 89.4%), while the prevalence afterwards (n = 97) was 33% (95% CI = 12–59) with a high degree of heterogeneity (I2 = 96.6%), according to the random effects model (Figure 4 and Figure 5).
According to the PHQ-9 tool, the prevalence prior to surgery (n = 543) was 22% (95% CI = 12–33) with a high degree of heterogeneity (I2 = 97.5%) according to the random effects model; and, the prevalence of depression after surgery (n = 48), using the fixed effects model, was 18% (95% CI = 14–23) (Figure 6 and Figure 7), with a low degree of heterogeneity (I2 = 2%).
Finally, for CES-D, the prevalence of pre-CABG depression (n = 61) using the random effects model was 28% (95% CI = 17–40) with a moderate degree of heterogeneity (I2 = 66.9%); while the prevalence after surgery (n = 57) was 15% (95% CI = 12–19) with a low degree of heterogeneity (I2 = 2%), according to the fixed effects model (Figure 8 and Figure 9)

3.4. Levels of Depression Before and After CABG Surgery and Follow Up

Prior to CABG surgery, most of the authors report depression levels within the normal range, although others found mild [36,55,58,83,86] and moderate levels [27,35,66,69] (Table 1).
Post-surgery, most authors report normal levels, while others found mild [28,36,49,53,58,60,66,83,85,88], moderate [27,47,69], and severe [32] levels.
The majority of authors observed a positive impact on depression prevalence and levels after surgery, as well as in the short and medium term, although others found that these levels increased after surgery [28,32,33,48,49,55,57,89].

4. Discussion

The prevalence of depression obtained in this study varied between 19% and 37% prior to surgery, and between 15% and 33% after surgery, depending on the type of measurement tool used. Other studies that combine CABG with valve replacement have reported similar percentages, with depression prevalence ranging from 15% pre-CABG [90] to 37.7% post-CABG [51,91], associated with the development of the disease, worse quality of life, longer hospital stays, and high rates of hospital readmissions [8].
Normal levels of pre-CABG depression are observed, although other studies have indicated higher levels, from moderate to severe [92]. However, more than 25% of patients with normal levels are at risk of worsening, for which reason continuous reassessment can identify patients with transient symptoms of depression [93].
High levels of depression prior to the operation predict a worse quality of life [94,95], worse survival after a CABG [12,96], and more symptoms up to six months after surgery [97].
We have observed that depression levels did not go to remission, but they tend to improve in depressive symptoms, which is probably due to an improvement in the patient’s quality of life [98], and even due to greater optimism that facilitates commitment to adaptation [99]. Some authors have found a positive impact on patients from eight weeks [100], while others report a slight improvement from the first month post-CABG surgery [101]. For the majority of patients, depression persists after the surgery. Recent meta-analyses demonstrated that patients undergoing heart valve surgery are at risk of cognitive dysfunction up to six months after surgery [102,103].
Although there is a relationship between depression and CABG, its temporal onset is not clear. Depression can be a pre-existing condition, which increases the risk of cardiovascular disease that is related to behavioural alterations in diet, physical activity level, toxic habits, or poor adherence to treatment and recommendations [45]; or, can appear as a consequence of multiple postoperative complications, such as longer hospital stays [23], readmissions [104,105], general pain [104], or even when facing a series of lifestyle changes [12].
Without evaluation, it is unlikely that depression is being treated correctly. Some authors report that more than 50% of patients were receiving medical treatment for depression, even though they had no symptoms of depression [106]. For this reason, the use of measurement tools to confirm the presence and levels of depression makes it possible to identify the at-risk patients, and therefore carry out a more in-depth post-CABG follow-up, of at least nine months [93].
The current study highlights the importance of depression measures before and after CABG in assessing clinically meaningful mood disturbance, in order to provide early intervention. Systematic screening for depression in the period both before and after this procedure is crucial. Planned coaching combined with counselling can reduce these levels [36]. Cardiac rehabilitation programmes [107,108] and cognitive-behavioural therapies are also available, which reduce the levels of depression and even decrease the length of hospital stays [109]. However, further studies are needed to understand the potential prognostic implication of depression and investigate the best ways to approach the treatment of depression in this patient group.
Depression counselling prior to surgery can influence the post-surgical depression levels by positively improving a patient’s perception of illness control and management [13]. Planning is therefore an essential part of the healthcare process as it has the potential to promote self-care [36].
From a clinical perspective, these results suggest that strategies that are aimed to improve depression as a disorder, such as the application of policies and depression assessment protocols prior to CABG by health care providers, are essential, because the depression level might help risk stratification in patients undergoing CABG identifying the high-risk groups and the trajectory of recovery experienced [11].
This study has several limitations. Firstly, the heterogeneity in terms of prevalence is due to different estimation methods over time, differences in the timing of assessment and demographic differences between samples, different uses of cut-offs on questionnaire measures, as well as the use of various tools for assessing the symptoms of depression. Secondly, the measuring tools assess the severity of depression symptoms, but they do not replace a formal clinical diagnosis of depression.

5. Conclusions

There is a high presence of depression both before and after CABG surgery. While this study found an overall improvement in depressive symptoms after CABG, depression persists after the surgery for the majority of patients. The depression levels present prior to the operation may affect postoperative recovery.
Given the prevalence of depression and its impact, early detection is crucial, since it enables the identification of at-risk patients, through a clinical interview that uses validated measurement tools. This enables the medical team to implement preventive strategies as well as monitor the development of the depression.

Supplementary Materials

The following are available online at https://www.mdpi.com/2077-0383/9/4/909/s1, Table S1: Depression Assessment Instruments Used by the 65 Studies Included in the Systematic Review [110,111,112,113,114,115,116,117,118,119,120,121,122].

Author Contributions

J.S.-R., J.L.G.-U. and M.C.-R. conceived and designed the review and meta-analysis; M.A.E., N.S.-M. and M.J.M.-J. contributed to the selection process and analysis of the risk of bias; N.S.-M. and J.L.G.-U. contributed to the meta-analysis; J.S.-R., M.C.-R. and A.V.-S. contributed to the data extraction; N.S.-M. and M.C.-R. wrote the paper; J.S.-R. and J.L.G.-U. drafted the paper. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Acknowledgments

The results reported in the study are from the doctoral thesis of Moath Abu Ejheisheh and belong to the Clinical Medicine and Health Public Programme (B 12.56.1) of the University of Granada, Spain.

Conflicts of Interest

The authors declare no conflict of interest.

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Figure 1. Preferred reporting items for systematic review and meta-analysis (PRISMA) flow-chart of included studies.
Figure 1. Preferred reporting items for systematic review and meta-analysis (PRISMA) flow-chart of included studies.
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Figure 2. Forest plot for pre-CABG depression using Hospital Anxiety and Depression Scale (HADS).
Figure 2. Forest plot for pre-CABG depression using Hospital Anxiety and Depression Scale (HADS).
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Figure 3. Forest plot for post-CABG depression using HADS.
Figure 3. Forest plot for post-CABG depression using HADS.
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Figure 4. Forest plot for pre-CABG depression using Beck Depression Inventory (BDI).
Figure 4. Forest plot for pre-CABG depression using Beck Depression Inventory (BDI).
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Figure 5. Forest plot for post-CABG depression using BDI.
Figure 5. Forest plot for post-CABG depression using BDI.
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Figure 6. Forest plot for pre-CABG depression using Patient Health Questionnaire (PHQ-9).
Figure 6. Forest plot for pre-CABG depression using Patient Health Questionnaire (PHQ-9).
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Figure 7. Forest plot for post-CABG depression using PHQ-9.
Figure 7. Forest plot for post-CABG depression using PHQ-9.
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Figure 8. Forest plot for pre-CABG depression using Centre for Epidemiological Studies Depression Scale (CES-D).
Figure 8. Forest plot for pre-CABG depression using Centre for Epidemiological Studies Depression Scale (CES-D).
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Figure 9. Forest plot for post-CABG depression using CES-D.
Figure 9. Forest plot for post-CABG depression using CES-D.
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Table 1. Studies reporting prevalence and levels of coronary artery bypass graft surgery (CABG) depression.
Table 1. Studies reporting prevalence and levels of coronary artery bypass graft surgery (CABG) depression.
Study
CABG (First, Elective, Emergency)
Design and SampleDepression
Screening
Instrument
Timing of AssessmentM (SD)/PrevalenceMain Results EL/RG
PrePost
Abbott et al., [26]
USA
Elective CABG
RCT
n = 226
83% male
HADSAfter CABGCluster 1: 5.9 (4.3)
Cluster 2: 8.2 (4.8)
Cluster 3: 11.8 (6.9)
Elderly patients with more symptoms and chronic illnesses are more prone to depression1a/A
Aburuz, [27]
Jordan
Elective CABG
Cohort
n = 227
78% male
HADS2-weeks before, 1-month after12.76 (6.80)
Normal: 57.26%
Mild: 11.90%
Moderate-severe: 30.84%
11.11 (6.78)
Normal: 59.47%
Mild: 13.66%
Moderate-severe: 26.87%
Pre-operative depressive symptoms increased postoperative hospital length of stay2c/B
Açıkel, [28]
Turkey
Elective CABG
Cohort
n = 65
76.9% male
BDI1-day before
3–7 days, 1-month after
8.12 (5.44)
Normal: 61.5%
Mild: 30.8%
Moderate: 7.7%
Severe: 0%
3rd day: 12.43 (6.36)
Normal: 35.4%
Mild: 40.0%
Moderate: 23.1%
Severe: 1.5%
7th day: 11.66 (6.95)
Normal: 40.0%
Mild: 30.8%
Moderate: 27.7%
Severe: 1.5%
1 month: 12.29 (9.08)
Normal: 47.7%
Mild: 26.2%
Moderate: 23.1%
Severe: 3.1%
Depression levels increase during postoperative CABG period2c/B
Afridi et al., [29]
Pakistan
First-time CABG
Cohort
n = 134
84.3% male
HAM-D2 days before, at discharge, 6-months follow-up98.5%
Mild: 71.6%
Moderate: 23.9%
Severe: 1.5%
Very severe: 1.5%
At discharge: 80.6%
Mild: 73.9%
Moderate: 2.23%
Severe: 2.23%
Very severe: 2.23%
6-months: 16.4%
Depression is commonly reported before and after CABG and influences the quality of life of the patients2c/B
Ajtahed et al., [30]
Iran
First-time CABG
RCT
n = 75
67% male
DASSAfter CABGControl group:
Group 1:
Normal: 60%
Mild: 40%
Moderate: 24%
Severe: 12%
Extremely severe: 0%
Group 2:
Normal: 52%
Mild: 8%
Moderate: 32%
Severe: 0%
Extremely severe: 8%
Group 3:
Normal: 45%
Mild: 9.1%
Moderate: 13.6%
Severe: 13.6%
Extremely severe: 18.2%
Training cognitive rehabilitation can improve cognitive functions and quality of life in patients after CABG surgery1a/A
Ammouri et al., [31]
Jordan
First-time CABG
Cross-sectional
n = 100
80% male
CSS2-weeks after discharge3%Pain, leg swelling, poor appetite and trouble sleeping are the most frequent symptoms after CABG2c/B
Amouzeshi et al., [32]
Iran
Elective CABG
Cross-sectional
n = 54
68% male
BDI1 day before and after ICU11.7 (7)
Minimal: 55.4%
Mild: 28.6%
Moderate: 16.1%
Severe: 0%
Male: 31.5 (10.60)
Female: 29.3 (10.55)
Minimal: 0%
Mild: 17.9%
Moderate: 32.1%
Severe: 46.4%
No relationship between age, sex, marital status, and education level with post-operative depression2c/B
Azzopardi & Lee, [33]
Australia
Elective CABG
Cohort
n = 48
85.4% male
BDIBefore, 6-weeks after, 1–2 years follow-up7.31 (4.1)2 years: 7.90 (7.1)Depression levels 2 years after CABG were not severe2b/B
Bay et al., [34]
USA
Elective CABG
RCT
n = 170
75% male
HADSBaseline,1–6 months afterControl group:
7.3 (3.7)
Control group:
1-month: 3.0 (3.1)
6-months: 3.0 (3.1)
A coping religious intervention can reduce depression levels up to 6 months after surgery1a/A
Beresnevaite et al., [35]
Lithuania
Elective CABG
Cross-sectional
n = 109
100% male
SCL-90R1-day before after63.13 (8.22)
High level: 23%
Preoperative depression score is related with a length stay hospital (p < 0.001) and perioperative complications (p < 0.05)2b/B
Cebeci & Çelik, [36]
Turkey
First-time CABG
Quasi-experimental
n = 52
80.8% male
HADS1-day before, 1-day,1-week, 1-month after8.3 (3.6)At discharge: 7.9 (4.2)
1-week: 8.2 (4.5)
1-month: 7.7 (4.3)
At the time of admission, patients had a higher level of depression than at the time of discharge1b/A
Chocron et al., [37]
France
First-time CABG
RCT
n = 361
BDIBefore CABG39%Antidepressant treatment did not affect the morbidity and mortality events after CABG surgery1a/A
Colella et al., [38]
Canada
First-time CABG
RCT
n = 124
100% male
BDIAt discharge, 6–12 weeks afterControl group:
After: 8.87 (4.74)
6-weeks: 5.84 (5.30)
12-weeks: 4.43 (5.26)
Physiological and psychological challenges after CABG increases the depression risk1a/A
Dal Boni et al., [39]
Brazil
Elective CABG
Cross-sectional
n = 78
67% male
BDIBefore, 2-months after8.49 (6.87)5.01 (6.61)CABG had a positive impact on the patient’s quality of life2b/B
Doering et al., [40]
USA
First-time CABG
Cohort
n = 67
100% female
HAM-DAt discharge, 1 month after41.79%Six months after CABG, women with major depression have at increased risk for infections2b/B
Donohue et al., [41]
USA
Elective CABG
RCT
n = 2485
PHQ-2At discharge56%A nurse-guided intervention in the mental health area reduces the level of depression and health costs post-CABG1a/A
Dunkel et al., [42]
Germany
Elective CABG
Cross-sectional
n = 1238
72% male
PHQ-9Before CABG21.6%Lower age, female gender, less than 10 years of education and living alone are related to depression symptoms2b/B
Dunkel et al., [43]
Germany
Elective CABG
Cross-sectional
n = 971
80.1% male
PHQ-91–3 days
before, 1 year after
5.61 (4.31)Female gender is related to depression symptoms Attributions to stress, personality and destiny are associated with higher depression scores2b/B
El-Baz et al., [44]
Netherlands and Slovakia
Elective CABG
Observational multicentre
n total = 226
n1 = 114 Slovakia
n2 = 112 Netherlands 80% male
HADSBefore CABGn1 = 5.01 (3.73)
n2 = 4.96 (3.16)
Female gender, smoking, lower education, and lower social support are risks factors of depression2b/B
Elliott et al., [45]
Australia
Elective CABG
Cohort
n = 174
80% male
POMS-DBefore, 2–6 months after10.50 (11.76)2-months: 7.38 (9.41)
6-months: 8.32 (10.52)
The young, male and smoking are the main risk factors of depression2b/B
Feuchtinger et al., [46]
Germany
First-time CABG
Cross-sectional
n = 24
37.5% male
HADS1-day before6.7 (5.1)
Low: 54.17%
Moderate: 20.83%
Severe: 25%
Interventions such as information, spiritual support or cognitive behavioral therapy are the key to reduce the feeling of fear before CABG surgery2b/B
Freedland et al., [47]
USA
Elective CABG
RCT
n = 123
50% male
BDI
HAM-D
1 year afterBDI = 22.26 (1.3)
HAM-D = 19.53 (1)
Improvement in perceived cognitive impairment correlated with improvement in depression1a/A
Gallagher & McKinley, [48]
Australia
Elective CABG
Cohort
n = 155
74% male
HADSBefore, after surgery, 2-weeks after4.10 (3.22)
16%
After: 18.2%
4.67 (3.49)
2-weeks: 45%
6.58 (4.03)
26.5% of patients reported low perceptions of control before CABG, 22% after surgery and 10.3% at discharge2b/B
Gelogahi et al., [49]
Iran
Elective CABG
RCT
n = 40
37.5% male
DASSBefore, after6.67 (4.7)12.1 (8.1)Nurses interventions can reduce depression levels after surgery1a/A
Hazavei et al., [50]
Iran
First-time CABG
Quasi-experimental
n = 27
77.8% male
CDSBefore, 4-8 weeks after104.5 (30.4)2-months after: 89.2 (27.8)Most patients lacked the skills in health education and lifestyle-related with coronary artery disease1b/A
Horne et al., [51]
Canada
Elective CABG
Cohort
n = 104
PHQ-9Before60.6%Length of stay (more than 7 days) is associated with a higher risk of depression2b/B
Hweidi et al., [52]
Jordan
Elective CABG
Cross-sectional
n = 143
53.1% male
SDS 2 days afterMild: 32.2%
Moderate: 60.1%
Severe: 5.6%
Depression is related to female, unmarried and unemployed patients 2b/B
Kendel et al., [53]
Germany
Elective CABG
Cohort
n = 351
77% male
PHQ-92 months, 2 years afterMale: 5.38 (4.2)
Female: 6.84 (4.8)
Females have a higher level of depressive symptoms2b/B
Kendel et al., [54]
Germany
Elective CABG
Cohort
n = 883
80.2% male
PHQ-91–3 days before5.38 (4.09)
8.5%
Depression is related to a deterioration of physical condition in patients undergoing CABG surgery2b/B
Khoueiry et al., [55]
USA
Elective CABG
Cohort
n = 50
56% male
BDIBefore, 1–3–6–9 months follow-up8%After: 60%
3-months: 44%
6-months: 40%
9-months: 44%
Age and gender are not correlated with depression levels2b/B
King et al., [56]
Canada
First-time CABG
Cohort
n = 120
100% male
BDI
CDS
At discharge, 6–12–36 weeks follow-upBDI
At discharge:
8.08 (4.76) 4.3%
6-weeks:
5.82 (5.36) 1.9%
12-weeks:
4.81 (4.73) 1.9%
36-weeks:
4.31 (5.81) 2.1%
CDS
At discharge:
74.46 (24.29) 17.2%
6-weeks:
59.58 (25.19) 7.6%
12-weeks:
54.56 (23.06) 6.7%
36 weeks:
51.22 (23.17) 4.3%
Family reduces the risk of depression2b/B
Korbmacher et al., [57]
Germany
Elective CABG
Cohort
n = 135
77% male
HADS1–2 days before,1-week, 6-months after4.3 (3.1)
20.7%
1-week:
5 (3.9) 24%
6-months: 4.7 (4.3) 28%
Hight levels of depression are not associated with mortality. A 24.2% of patients with normal scores before surgery suffers depression 6-months latter2b/B
Kozora et al., [58]
USA
Elective CABG
Cohort
n = 1156
99.2% male
BDIAfter, 1-year follow-up9.9 (7.65)8.9 (7.85)Older age and lower education are related to depression levels2b/B
Macken et al., [59]
USA
Elective CABG
Quasi-experimental
n = 34
76.5% male
PHQ-9After CABGControl group: 18%An intervention cardiac program can reduce depressive symptoms1b/A
McGrady et al., [60]
USA
Elective CABG
Quasi-experimental
n = 91
BDIAfter CABG9.2 (7.5)The symptoms can affect adherence to prescribed treatment and may also affect morbidity and mortality1b/A
McKenzie et al., [61]
UK
Elective or emergency CABG
Cross-sectional
n = 111
82.9% male
HADSAfter CABG3.16 (3.61)13.5%Post-operative depression predicts activities of daily living functioning2b/B
McKhann et al., [24]
USA
Elective CABG
Cohort
n = 220
73.6% male
CES-DAfter, 3 months, 1–3–6 years afterBaseline: 13.2 (9.8) 32.4%
3-months: 10.2 (9.9) 24.1%
1 year: 9.1 (9.8) 17.3%
3 year: 8.9 (9.5) 11.8%
6 year: 10.1 (9.4) 16.8%
Depressed patients tended to have more memory complaints2b/B
Modica et al., [62]
Italy
Elective CABG
Cross-sectional
n = 1179
80% male
HADSAfter CABGModerate-severe: 10.4%
Male: 9.2%
Female: 15.4%
Female gender is related to a higher depression score2b/B
Moser et al., [63]
USA
Elective CABG
Observational multicentre
n = 131
94% male
MAACLAfter CABG13.0 (5.5)
53%
Factors such as being a woman and have lower educational attainment are related to depression2b/B
Murphy et al., [64]
Australia
Elective CABG
Cohort
n = 184
79% male
HADSBefore, 2–6 months follow-up5.35 (4.01)2-months: 4.16 (3.71)
6-months: 3.87 (3.51)
Over 6-months follow-up patients show a minor score of depression2b/B
Nair et al., [65]
India
Elective CABG
Quasi-experimental
n = 500
20.2% male
HADS6 months after20.2%11.6% of patients after CABG adhered to healthy lifestyle practices1b/A
Nemati & Astaneh, [66]
Iran
Elective CABG
Cohort
n = 71
73% male
HADSBefore, 4-weeks afterMale: 13.58 (8.54)
Female: 17.88 (7.54)
Male: 9.51 (6.00)
Female: 15.05 (8.63)
CABG surgery can decrease the level of depression in a short-term follow-up2b/B
Nunes et al., [67]
Brazil
Elective CABG
Cohort
n = 57
68.42% male
BDIBefore, 6-months afterMinimal: 56.14%
Mild: 26.32%
Moderate: 12.28%
Severe: 5.26%
Minimal: 49.12%
Mild: 29.82%
Moderate: 17.54%
Severe: 3.51%
Improvement the quality of life with CABG surgery reducing depressive symptoms2b/B
Okamoto et al., [68]
Japan
Elective or emergency CABG
Cross-sectional
n = 79
75.9% male
HADS1–5 years afterMild: 10.1%
Moderate-severe: 10.1%
Depression in CABG patients is related to a decrease in functional status or activities of daily living2b/B
Oldham et al., [69]
USA
First-time CABG
Cohort
n = 131
73% male
HAM-D
PHQ-9
GDS
BeforeHAM-D: 9.9%
16.3 (5.4)
PHQ-9: 56.2%
13.4 (3.9)
GDS: 6.9 (3.6)
Preoperative depression predicts post-CABG cognitive health2b/B
Perrotti et al., [70]
France
Elective CABG
RCT
n = 359
85% male
BDIBefore,1 year after39.6%In the first year after CABG, depressed patients have a lower improvement and quality of life1a/A
Perrotti et al., [71]
France
Elective CABG
Cohort
n = 272
78% male
HADS2-weeks before6%CABG surgery improve the functional mobility, quality of life and maintenance of an independent status2b/B
Phillips-Bute et al., [72]
USA
Elective CABG
Cohort
n = 427
70% male
CES-DBefore, 6 months, 1 year afterMild-Severe
Male: 28%
Female: 57%
Mild-severe:
Male:
6-months: 17%
1-year: 17%
Female:
6-months: 33%
1-year: 32%
Depressed patients are more prone than nondepressed patients to have a new cardiac event within 2 years of CABG2b/B
Poole et al., [23]
UK
First-time CABG
Cohort
n = 310
86% male
BDI29 days before, after surgery8.68 (6.61)
30.3%
Minimal: 69.7%
Mild: 25.5%
Moderate-severe: 4.8%
8.33Pre-operative depression is associated with longer postoperative hospital stays. The young, female gender, overweight, smoking and hypertension variables are related to depression symptoms2b/B
Pourafkari et al., [73]
Iran
Elective CABG
Quasi-experimental
n = 40
82% male
BDIAfter CABG25%
Minimal: 75%
Mild: 12%
Moderate: 8%
Severe: 5%
The emergence of new-onset depression after CABG is associated with a poor outcome1b/A
Rezaei et al., [74]
Iran
Elective CABG
Cohort
n = 135
75% male
SCL-90R6 months after1.17 (0.75)
44.22%
The prevalent mental disorder after CABG is depression followed by sensitivity, paranoia, hostility, anxiety, obsession, somatization, phobia, and psychosis2b/B
Sandau et al., [75]
USA
Elective CABG
Cohort
n = 54
78% male
CES-DBefore, 3-months after14.2 (8.6)
20%
10.4 (7.5)Depressive symptoms remain constant from pre- to postoperatively at 3 months2b/B
Schwarz et al., [76]
Germany
Elective CABG
Cohort
n = 47
89% male
HADSBefore, 3-months after5.0 (3.4)3.8 (3.1)Depression and health-related quality of life are not associated with cognitive dysfunction after CABG2b/B
Selnes et al., [25]
USA
Elective or emergency CABG
Cohort
n = 152
76% male
CES-DBefore, 12–72 months follow-up13.2 (9.6)
33%
9.5 (9.2)
13%
CABG patients had a decline of score 72-months after2b/B
Sorensen & Wang, [77]
USA
First-time CABG
Cohort
n = 70
66% male
GDSBefore, 6-weeks after3.1 (2.5)
24.2%
2.4 (2.3)
15.9%
Women had greater depression pre-operative and post-operative. Length of stay and age are not related to depression2b/B
Spezzaferri et al., [78]
Italy
Elective CABG
Cohort
n = 118
100% male
CBA 2.0-DAt discharge,
1 year after
At discharge: 12.7%
1 year: 5.9%
1 year after CABG depression level decreased2b/B
Stenman & Sartipy, [79]
Sweden
Elective and emergency CABG
Cohort
n = 302
PHQ-9Before29% Depressive symptoms are twice as frequent in women as in men2b/B
Thomas et al., [80]
India
First-time CABG
Quasi-experimental
n = 100
85% male
HADSBefore, 1-week, 1 month after4.10 (3.30)1-week: 2.03 (2.60)
1-month: 1.26 (1.82)
Medical adherence behavior is related to depression six weeks after surgery1b/A
Tsai et al., [81]
Taiwan
First-time CABG
Cohort
n = 198
81% male
CSSBefore, 1–6 weeks, 3 months follow-up2.42 (2.64)1-week: 1.41 (2.00)
6-weeks: 1.24 (1.86)
3-months: 0.96 (1.70)
Age, a longer stay in ICU, smoking, and lack of exercise are related to worse symptoms. 88% of patients have a trajectory of depression levels that decrease over time2b/B
Tully et al., [82]
Australia
First-time CABG
Cohort
n = 226
83% male
DASSBefore, 4 days after20.1%23.5%Readmission is related to a higher depression score. Depression symptoms are associated with morbidity2b/B
Tully et al., [83]
Australia
First-time CABG
Cohort
n = 226
83% male
BDIBefore, after surgery8.62 (6.23)9.05 (6.40)Pessimism, past failure, self-criticalness and, worthlessness are associated with cardiac morbidity and mortality2b/B
Yang et al., [84]
China
First-time CABG
Cohort
n = 232
81% male
PHQ-93-days before, 6-months after4.8 (5.0)
18.1%
4.2 (5.0)
18.1%
Preoperative depression is associated with women gender2b/B
Yang et al., [85] Taiwan
Elective and emergency CABG
Cross-sectional
n = 87
74.7% male
HADS1 week, 1 month after1 week:
Mild: 17.2%
Moderate-severe: 60.9%
1 month: 8.75 (4.63)
Mild: 24.1%
Moderate-severe: 35.6%
Depression is related to sleep quality after CABG surgery2b/B
Yüksel et al., [86]
Turkey
Elective and first-CABG
Cohort
n = 63
G1: diagnosed after
experiencing an ACS
G2: diagnosed without
an ACS
BDIBeforeG1:14.9 (9.5)
G2: 12.1 (7.4)
66.6%
Mild: 22.2%
Moderate-severe: 44.4%
Patients in both groups were found to be depressed and hopeless about the future2b/B
Zimmerman et al., [87]
USA
Elective CABG
RCT
n = 226
83% male
CSSAt discharge19%Health care providers must assist the patients before hospital discharge to identify the risks and difficulties in patients after CABG up to 6 months after surgery1a/A
ACS = Acute Coronary Syndrome; BDI = Beck Depression Inventory; CABG = Coronary Artery Bypass Graft; CBA 2.0-D = Depression scales of the Cognitive Behavioural Assessment; CDS = Cardiac Depression Scale; CES-D = Center for Epidemiological Studies Depression Scale; CSS = Cardiac Symptom Survey; DASS = Depression, Anxiety, Stress scale; GDS = Geriatric Depression Scale; HADS = Hospital Anxiety and Depression Scale; HAM-D = Hamilton Rating Scale for Depression; ICU = Intensive care unit; MAACL = Multiple Affect Adjective Checklist; PHQ-2 = Patient Health Questionnaire 2-item; PHQ-9 = Patient Health Questionnaire 9-item; POMS-D = Profile of Mood State Depression Scale; RCT = Randomized Clinical Trial; SDS = Self-rating Depression Scale; SCL-90R = Symptom Checklist-90 Revised.

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MDPI and ACS Style

Correa-Rodríguez, M.; Abu Ejheisheh, M.; Suleiman-Martos, N.; Membrive-Jiménez, M.J.; Velando-Soriano, A.; Schmidt-RioValle, J.; Gómez-Urquiza, J.L. Prevalence of Depression in Coronary Artery Bypass Surgery: A Systematic Review and Meta-Analysis. J. Clin. Med. 2020, 9, 909. https://doi.org/10.3390/jcm9040909

AMA Style

Correa-Rodríguez M, Abu Ejheisheh M, Suleiman-Martos N, Membrive-Jiménez MJ, Velando-Soriano A, Schmidt-RioValle J, Gómez-Urquiza JL. Prevalence of Depression in Coronary Artery Bypass Surgery: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine. 2020; 9(4):909. https://doi.org/10.3390/jcm9040909

Chicago/Turabian Style

Correa-Rodríguez, María, Moath Abu Ejheisheh, Nora Suleiman-Martos, María José Membrive-Jiménez, Almudena Velando-Soriano, Jacqueline Schmidt-RioValle, and José Luis Gómez-Urquiza. 2020. "Prevalence of Depression in Coronary Artery Bypass Surgery: A Systematic Review and Meta-Analysis" Journal of Clinical Medicine 9, no. 4: 909. https://doi.org/10.3390/jcm9040909

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