Depression in patients who have suffered myocardial infarction at the stages of rehabilitation

The dissertation is devoted to the study of depressive and anxiety-depressive disorders in patients who have suffered myocardial infarction at different stages of rehabilitation. The work examines the frequency and severity of psychoemotional disorders during the inpatient and the initial sanatorium periods, as well as their relationship with the clinical course of the disease, its complications, and social factors, including the patients' professional affiliation. Particular attention is paid to the analysis of vasoregulatory endothelial function in the subacute period of myocardial infarction and its association with the presence of depressive symptoms. On the basis of a comprehensive clinical-instrumental and psychological examination, the author singles out a risk group for the development of anxiety-depressive disorders and substantiates a differentiated approach to the psychological rehabilitation of patients who have suffered myocardial infarction.

The practical significance of the work is related to the substantiation of the inclusion of psychotherapeutic and psychopharmacological methods in rehabilitation programs, as well as to the development of recommendations for the timely diagnosis and treatment of anxiety-depressive states in this category of patients, taking into account the severity of the disease course, the nature of work activity, and the state of endothelial function.

Relevance of the problem. At present, coronary artery disease (CAD) continues to be the main cause of mortality and disability in the population of Russia. One of the most serious manifestations of CAD is myocardial infarction (MI). The high prevalence and severity of coronary disease, its manifestations and complications, which, according to WHO data, account for up to 39-56% of mortality cases from these causes, determine the relevance of scientific research in this field. A considerable number of studies are devoted to the pathogenesis of MI, the features of its clinical course, and the issues of diagnosis and treatment of MI. At the same time, increasing interest has recently been attracted to mental changes of the personality, arising on the one hand as a reaction to the disease, and on the other hand acting as a provoking factor of this disease [1, 12, 13, 56, 61, 74-76, 78, 81, 82, 86-90, 95, 102, 104, 108, 111, 115-117, 119-121, 126, 127, 138, 140, 142, 150].

Studies of recent years indicate that depression and certain other psychological factors are independent risk factors for CAD and independent predictors of cardiovascular mortality [119, 136, 139, 154-156, 205].

However, not only does depression lead to the development of CAD, but the presence of CAD in turn contributes to the development of psychogenic disorders as a result of the personality's reaction to the disease and the associated damage to the socio-psychological position [56]. According to foreign researchers, in the post-infarction period depression is detected in 16-45% of cases, and in 16-18% so-called major depression is noted, substantially worsening the prognosis of the disease [154-156]. According to A. B. Smulevich (2001), no less than 39% of patients who have suffered MI in the acute period suffer from depression. And if we take all mental disorders developing in patients with CAD, then 84% of psychogenias occur in MI [86, 88, 89].

The presence of depression in patients with cardiovascular diseases complicates the course and therapy of these disorders [75-76] and shortens the life expectancy of patients. Depression developing immediately after myocardial infarction increases the risk of death from the disease by 3.5-6 times [154]. Studies show that depression is an independent predictor of cardiovascular mortality and in significance is not inferior to two others — left ventricular dysfunction and severity of MI. The significance of depression as a predictor of coronary death is more accentuated in patients with arrhythmias. It has been established that the influence of depression on the prognosis in MI patients does not depend on the severity of depressive symptoms: even mild depression exerts a negative influence on the prognosis [150, 154].

Despite the wide prevalence of various mental disorders in MI and their serious influence on the clinical course and prognosis, their detection rate is very low. This is due on the one hand to the fact that MI patients often dissimulate depression, and on the other hand a limiting factor is the insufficient awareness of physicians about the clinical picture and diagnosis of depression. Moreover, in a number of cases a significant role is played by the physician's attitude — a "shift" of diagnosis aimed exclusively at identifying somatic disease. Mental disorders are also often underestimated in those cases when depressive symptoms may be interpreted as psychologically understandable. In such "traps" the physician may fall, for example, in cases of depression regarded as an "adequate" answer to somatic suffering [86, 87, 89].

The problem of anxiety and depressive disorders in MI patients in Russia remains insufficiently studied. The number of studies devoted to identifying the frequency and severity of depression, as well as to analyzing the influence of various factors on the formation of psychoemotional disorders in general and depression in particular in MI patients depending on the stages of the disease course in Russia is small. In the domestic literature there are practically no data devoted to studying the mutual influence of endothelial dysfunction and depression in MI patients. All of the above determines the relevance of scientific research in this field.

Aim of the study. To identify the frequency and severity of psychoemotional disorders in patients with myocardial infarction and to assess the nature of the influence of various factors on the features of the formation of anxiety and depressive states in MI patients at different stages of rehabilitation.

Objectives of the study:

1. To identify the frequency and severity of anxiety and depressive states in patients who have suffered MI at the inpatient stage and in the initial period of sanatorium rehabilitation.

2. To assess the state of vasoregulatory endothelial function in patients with myocardial infarction in the subacute period depending on the presence of depressive symptoms.

3. To determine the influence of various factors, such as the severity of MI course, the presence of complications, and the professional category of patients, on the psychoemotional status. Among patients who have suffered MI, to single out a possible risk group for the development of anxiety and depressive disorders.

4. To assess the quality of life in patients who have suffered MI at the stage of rehabilitation.

Scientific novelty. For the first time, the frequency and severity of depression in patients who have suffered MI at the inpatient stage of treatment of acute MI and in the initial period of sanatorium rehabilitation have been studied. The relationship between psychoemotional disorders and the features of the clinical course, severity, and complications of MI depending on the stages of rehabilitation has been established. An analysis of the influence of social factors on the formation of changes in the mental state depending on the stages of rehabilitation has been carried out. The differing significance of the influence of these factors on the psychoemotional state of MI patients at the inpatient treatment stage and in the initial period of sanatorium rehabilitation has been revealed. It has been established that as the time from the onset of the disease lengthens, the influence of the clinical course on the formation of psychological changes of the personality weakens and the influence of social factors increases. The relationship between endothelial dysfunction and depression in MI patients has been revealed. Among MI patients, a risk group for the development of anxiety and depressive disorders has been singled out. Changes in the level of the quality of life indicator of patients and their relationship with the features of the clinical course, severity, and complications of the disease, as well as with the features of the psychoemotional state of patients and their professional category, have been determined.

Scientific and practical significance. The obtained data on changes in the psychoemotional status of MI patients, characterized by an increase in the level of anxiety-depressive-hypochondriacal states, make it possible to clarify the severity of the disease and substantiate the use of psychotherapeutic and psychopharmacological methods of treatment in the comprehensive rehabilitation program for patients after MI. The data on the different factorial influence of the clinical course of the disease and social categories on the psychoemotional status of MI patients depending on the duration of the disease should be used when developing a program of differentiated psychological rehabilitation at different stages of rehabilitation. According to the results of the study, patients with a severe clinical course of MI, engaged in physical labor and having endothelial dysfunction, constitute a possible risk group for the development of anxiety and depressive disorders and an unfavorable prognosis of the disease course. Therefore, these patients require closer attention for the timely diagnosis and treatment of anxiety and depressive states with the use of modern antidepressants.

Approval of the work. The main results of the work were reported at the scientific and practical conference of young scientists of the Republic of Bashkortostan in the specialty of medicine "MEDICAL SCIENCE - 2004" (Ufa, 2004), "SCIENTIFIC BREAKTHROUGH - 2004" (Ufa, 2004), the Russian National Congress of Cardiologists (Tomsk, 2004), and the interregional scientific and practical conference "Current Issues of Internal Medicine and Lipidology" (Chelyabinsk, 2005). The dissertation was approved at a meeting of the problem commission on cardiology of the Bashkir State Medical University (Ufa, May, 2006).

On the topic of the dissertation, 8 works have been published.

Structure and scope of the work. The dissertation is presented on 147 pages of text and includes an introduction, a literature review, a description of materials and methods of the study, the results of the author's own studies, a conclusion, findings, practical recommendations, and a list of references. The work contains 15 tables and 33 figures. The bibliography includes 211 sources, of which 111 are domestic and 100 are foreign.