1. Cardiovascular disease in a large cohort of depressed and/or anxious patients Results of the Netherlands Study of Depression and Anxiety N Vogelzangs 1, A Seldenrijk 1, HPJ van Hout 2, HWJ van Marwijk 2, M Diamant 3, BWJH Penninx 1 EMGO Institute and Department of 1 Psychiatry, 2 General Practice, 3 Endocrinology, VU University Medical Center, Amsterdam, The Netherlands

2. 2030Disease% DALYs* 1Depression9.6% 2Heart disease5.9% 3Alzheimer, dementia5.8% 4Alcohol problems4.7% 5Diabetes4.5% 6Stroke4.5% 7Hearing problems4.1% 8Cancer3.0% 9Arthritis2.9% 10Lung disease2.5% Burden of disease in Western countries * DALYs = disability-adjusted life years = lost life years + lost quality of life WHO: Mathers et al. Plos Medicine 2006

3. First studies in heart patients End ’80 – start ’90: first studies show a high prevalence of depression among heart patients 1993: Frasure-Smith: first study to show that MI patients with depression have a greater risk of dying

4. “Depression Following Myocardial Infarction” Frasure-Smith et al. JAMA 1993 HR = 5.74 (4.61-6.87) After adjustment for severity of CVD: HR = 4.29 (3.14-5.44)

5. Depression as risk factor for CVD General population Proof from systematic reviews Review# studies # persons RR Rugulies, 20021136 5491.64 Wulsin, 20031028 7371.64 Nicholson, 200621124 5091.81 Van der Kooy, 200728±80 0001.60 Rugulies Am J Prev Med 2002 Wulsin & Singal Psychosom Med 2003 Nicholson et al. Eur Heart J 2006 Van der Kooy et al. Int J Geriatr Psychiatry 2007

6. Review# studies # persons RR Barth, 20042011 0182.24 Van Melle, 2004166 3672.59 Nicholson, 20063417 8421.80 Barth et al. Psychosom Med 2004 Van Melle et al. Psychosom Med 2004 Nicholson et al. Eur Heart J 2006 Depression and CVD prognosis CVD patients Proof from systematic reviews

7. Relatively unknown Prevalence of CVD in population of depressed and anxious persons Association anxiety disorders and CVD Which characteristics of depression and anxiety are linked with CVD

8. Netherlands Study of Depression and Anxiety www.nesda.nl funded through the mental health program of the Netherlands Organization for Health Research (ZonMW) and matching funds from participating institutes

9. Design Naturalistic cohort study Baseline assessment and follow-up assessments after 1, 2, 4, 6, 8 years Sample Depressed and/or anxious patients recruited from community, primary care, and outpatient psychiatric clinics, and healthy controls 2,981 persons; 1979 women (66%), 1002 men (34%) Design & Sample NESDA

10. Psychopathology CIDI psychiatric interview (DSM-IV): Presence & subtype – –Major depressive disorder (MDD; single, recurrent) – –Anxiety disorder (generalized anxiety disorder, social phobia, panic disorder and/or agoraphobia) Recency: – –Current: within last year – –Remitted: lifetime, not current

11. Psychopathology Chronicity: – –affected ≥ 50% of past 48 months, life chart Severity: – –Inventory of Depressive Symptoms (IDS), 0-84 – –Beck Anxiety Inventory (BAI), 0-63 Subthreshold: – –Depression: no MDD + IDS ≥ 14 – –Anxiety: no anxiety disorder + BAI ≥ 10

12. Cardiovascular disease Coronary heart disease and/or stroke based on: Self-report of myocardial infarction or angina pectoris supported by use of beta blockers or vasodilators (nitrates or calcium channel blockers) (n=129) Self-report of coronary angioplasty or coronary artery bypass surgery (n=70) Self-report of cerebrovascular disease (n=56) => Total N=184

13. Baseline characteristics No CVD (n=2746) CVD (n=184) p Age (years) Women Education (years) No MDD (n=650) Subthreshold depression Remitted MDD (n=680) Current MDD (n=1204) No anxiety (n=907) Subthreshold anxiety Remitted anxiety (n=403) Current anxiety (n=1333) IDS BAI 41.2 (13.0) 67.9 12.3 (3.2) 22.8 13.3 23.0 40.8 31.8 9.6 13.8 44.8 21.1 (14.0) 11.8 (10.5) 53.1 (8.9) 48.4 10.8 (3.1) 12.5 16.3 26.1 45.1 17.9 13.0 12.5 56.5 26.4 (14.3) 16.4 (11.2) <.001.01 <.001 (n=396) (n=287)

14. Adjusted OR for CVD OR*95% CIp MDD and anxiety in separate models No MDD Subthreshold depression Remitted MDD Current MDD 1.93 1.84 2.21 REF 1.07-3.49 1.07-3.14 1.33-3.67.03.002 No anxiety Subthreshold anxiety Remitted anxiety Current anxiety 2.11 1.42 2.42 REF 1.18-3.78 0.80-2.52 1.58-3.72.01.23 <.001 * Adjusted for age, sex, education, smoking, alcohol use, and BMI

15. Depression and anxiety characteristics In multivariable regression analyses: Chronicity of depression or anxiety was not associated with CVD prevalence Subtype of depression (single/recurrent) or anxiety (social phobia, GAD, panic) was not associated with CVD prevalence

16. Normal < 14 1027 Mild 14-25 813 V. severe ≥ 49 114 Severe 39-49 273 Moderate 26-38 703 IDS: N= % with CVD p <.001 3.6 7.6 6.4 9.9 11.4 CVD prevalence and severity of depression and anxiety symptoms BAI: N= Normal < 10 1472 Mild 10-18 757 Severe ≥ 30 215 Moderate 19-29 486 p <.001 3.8 7.5 9.9 10.7 % with CVD Depression severity Anxiety severity

17. OR*95% CIp MDD and anxiety in separate models No MDD Subthreshold depression Remitted MDD Current MDD 1.93 1.84 2.21 REF 1.07-3.49 1.07-3.14 1.33-3.67.03.002 No anxiety Subthreshold anxiety Remitted anxiety Current anxiety 2.11 1.42 2.42 REF 1.18-3.78 0.80-2.52 1.58-3.72.01.23 <.001 * Adjusted for age, sex, education, smoking, alcohol use, and BMI Depression or anxiety? Adjusted OR for CVD

18. OR*95% CIp MDD and anxiety in one model No MDD Subthreshold depression Remitted MDD Current MDD No anxiety Subthreshold anxiety Remitted anxiety Current anxiety 1.29 1.36 1.35 1.83 1.28 2.11 REF 0.67-2.49 0.75-2.46 0.74-2.48 REF 0.96-3.49 0.70-2.33 1.27-3.50.46.31.33.07.43.004 * Adjusted for age, sex, education, smoking, alcohol use, and BMI

19. Conclusions Cardiovascular disease is more prevalent among depressed and/or anxious patients This association was most strong for current anxiety The highest CVD prevalence was found among those with the most severe anxiety and depressive symptoms

20. Discussion CVD was largely based on self-report Link between anxiety and cardiovascular disease needs more attention