Symptoms of depression and anxiety predict mortality in patients undergoing oral anticoagulation: Results from the thrombEVAL study program

  • Matthias Michal
    Correspondence
    Corresponding author at: Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Mainz, Untere Zahlbacher Str. 8, 55131 Mainz, Germany.
    Affiliations
    Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany

    DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Mainz, Germany
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  • Jürgen H. Prochaska
    Affiliations
    Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany

    Department of Medicine II, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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  • Karsten Keller
    Affiliations
    Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany

    Department of Medicine II, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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  • Sebastian Göbel
    Affiliations
    Department of Medicine II, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany

    DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Mainz, Germany
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  • Meike Coldewey
    Affiliations
    Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany

    Department of Medicine II, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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  • Alexander Ullmann
    Affiliations
    Preventive Cardiology and Preventive Medicine, Department of Medicine II, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany

    Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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  • Andreas Schulz
    Affiliations
    Preventive Cardiology and Preventive Medicine, Department of Medicine II, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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  • Heidrun Lamparter
    Affiliations
    Preventive Cardiology and Preventive Medicine, Department of Medicine II, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany

    Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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  • Thomas Münzel
    Affiliations
    Department of Medicine II, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany

    DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Mainz, Germany
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  • Iris Reiner
    Affiliations
    Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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  • Manfred E. Beutel
    Affiliations
    Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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  • Philipp S. Wild
    Affiliations
    Preventive Cardiology and Preventive Medicine, Department of Medicine II, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany

    Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany

    DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Mainz, Germany
    Search for articles by this author

      Abstract

      Background/objectives

      Depression and anxiety are highly prevalent in cardiovascular patients. Therefore, we examined whether the 4-item Patient Health Questionnaire (PHQ-4, measuring symptoms of depression and anxiety) predicts all-cause mortality in outpatients with long-term oral anticoagulation (OAC).

      Methods

      The sample comprised n = 1384 outpatients from a regular medical care setting receiving long-term OAC with vitamin K antagonists. At baseline, symptoms of anxiety and depression were assessed with the PHQ-4 and the past medical history was taken. The outcome was all-cause mortality in the 24 month observation period. The median follow-up time was 13.3 months.

      Results

      N = 191 patients from n = 1384 died (death rate 13.8%). Each point increase in the PHQ-4 score was associated with a 10% increase in mortality (hazard ratio [HR] 1.10, 95% confidence interval [95% CI] 1.05–1.16) after adjustment for age, sex, high school graduation, partnership, smoking, obesity, frailty according to the Barthel Index, Charlson Comorbidity Index and CHA2DS2-VASc score. The depression component (PHQ-2) increased mortality by 22% and anxiety (GAD-2) by 11% respectively. Neither medical history of any mental disorder, nor intake of antidepressants, anxiolytics or hypnotics predicted excess mortality.

      Conclusions

      Elevated symptoms of depression and, to a lesser degree, symptoms of anxiety are independently associated with all-cause mortality in OAC outpatients. The PHQ-4 questionnaire provides valuable prognostic information. These findings emphasize the need for implementing regular screening procedures and the development and evaluation of appropriate psychosocial treatment approaches for OAC patients.

      Keywords

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