الفهرس 
Psychiatric morbidity in cardiovascular diseaseOnly 14 pages are availabe for public view
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Abstract
SUMMARY
Patients with chronic conditions often have to adjust their aspirations, lifestyle, and employment. Many grieve about their condition before adjusting to it. But others have protracted
distress and may develop psychiatric disorders, most commonly depression or anxiety. Unfortunately, physicians may be well equipped for the biomedical aspects of care but not for the
challenges of understanding the psychological, social, and
cultural dimensions of illness and health. It can be difficult to diagnose psychiatric disorders in the
medically ill. Physical symptoms may already exist as a result of
the disease. Sometimes treatment for a medical condition may
affect the patient’s mood, as may the disease process itself. The
functional limitations imposed by the disease may result in “understandable” distress, and some clinicians find it difficult to conceptualize such distress as a depressive disorder.
Despite these difficulties, it is essential to diagnose and treat psychiatric morbidities in patients with chronic conditions.
Even mild depression may reduce a person’s motivation to gain
access to medical care and to follow treatment plans. Furthermore, the development of apsychiatric disorder in people with a medical illness has been linked to adverse physical
outcomes and substantial increases in disability, in addition to
more impairment in quality of life.
This current study was designed to test our hypothesis that
psychiatric morbidity is frequent among patients with ischemic
heart diseases, heart failure, diabetes mellitus and thyroid
disorders, and compare the frequencies of psychiatric morbidities
between these 4 medical diseases.
Moreover, we also attempted to find out how each of the different sociodemographic data and clinical variables are related
to psychiatric morbidities in these aforementioned medical diseases.
The present study evaluated 400 patients, distributed as
follows: 100 ISHD patients and 100 HF patients enrolled from
the inpatients wards of the cardiology department, and the Coronary Care Unit at Ain Shams University Hospital, as well as 100 DM patients and 100 thyroid patients from the endocrine
outpatients clinics at Ain Shams University Hospital.
After an initial designed interview to collect sociodemographic and clinical data, all the patients were
subjected to the General Health Questionnaire (GHQ) to screen
for mental health. Those patients who scored 7 or higher in GHQ
were further assessed by Structured Clinical Interview for DSMIV
(SCID I) to diagnose axis I psychiatric disorders. Finally, all
the patients were given a score on the Global Assessment of
Functioning Scale (GAF) for assessment of quality of life.
Results:
The main findings of our study were:
I. Evaluation of psychiatric morbidity
The patients diagnosed with ISHD, HF, DM and thyroid
disease experienced psychiatric disorders following the onset of
their medical disease, with the prevalence reaching 25%, 37%,
37%, and 36% respectively. There was no significant difference
between the rates of psychiatric diagnoses in the 4 groups of
medical patients.
Mood disorders were the most frequently encountered
diagnostic category in ISHD, HF, DM and Thyroid patients:
19%, 34%, 29% and 26% respectively, with no significant
difference between them.
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291
Anxiety disorders followed mood disorders in frequency.
Its prevalence in thyroid patients reached 19%, in DM 12%, in
HF 9%, and in ISHD 3% with a significant difference between
them.
There was no statistically significant difference as regards
substance abuse diagnosis between ISHD, HF, DM and Thyroid
patients reaching 6%, 5%, 3% and 2% respectively.
Psychiatric morbidities in ISHD patients are as follows:
14% major depression, 5% dysthymia, 1% agoraphobia without
panic, 1% specific phobia, 1% GAD, and 6% substance abuse.
Psychiatric morbidities in HF patients are as follows: 31%
major depression, 3% dysthymia, 1% panic disorder, 5% social
phobia, 3% GAD, and 5% substance abuse.
Psychiatric morbidities in DM patients are as follows: 19%
major depression, 10% dysthymia, 2% OCD, 2% PTSD, 2%
agoraphobia without panic, 6% social phobia, 1% specific
phobia, 5% GAD, and 3% substance abuse.
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292
Psychiatric morbidities in Thyroid patients are as follows:
15% major depression, 11% dysthymia, 2% panic disorder, 1%
PTSD, 3% agoraphobia without panic, 12% social phobia, 1%
specific phobia, 7% GAD, and 2% substance abuse.
The prevalence of major depressive disorder showed
significant difference between the 4 medical groups of patients,
so did the prevalence of social phobia. There was no significant
difference between the 4 groups as regards the prevalence of
dysthymia or any anxiety disorder other than social phobia.
II. Variables associated with psychiatric morbidity in
selected cardiovascular and endocrine disease:
A. Ischemic heart disease patients
Major depression in ISHD patients was significantly higher in
myocardial infarction (14%) than in unstable angina (0%).
Dysthymia in ISHD patients was significantly associated with
presence of pathological Q waves in ECG, which denotes the
presence of previous myocardial infarction (4% compared to
1% in absence of Q wave).
B. Heart failure patients
The frequency of Major Depression appeared to be least in
illiterate HF patients (18%), while reaching its peak among
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293
HF patients with moderate education (60%%), which
represented a statistically significant difference.
Major depression was less frequently diagnosed among
unemployed HF patients (0%), while it reached its peak
among HF employee patients (66.7%), which represented a
significant difference.
Major depression was most frequently diagnosed in middle
social class (75%), while it was less diagnosed among low
social class (13.8%), which represented a significant
difference.
The duration of HF was significantly longer in HF patients
with major depression compared to HF patients without.
Concerning complications, major depression appeared to be
least in HF patients not complicated with hepatic impairment
(25%), reaching its peak among those complicated by hepatic
impairment (57.9%), which represented a significant
difference.
The frequency of major depression was least in HF patients
with no past history if substance abuse (28.4%) while it
reached its peak among HF patients with past history of
substance abuse (80.0%), which represent a significant
difference.
Dysthymia was less frequently diagnosed among HF patients
treated with ACEIS, while it was mostly diagnosed in those
no taking ACEIs, which represented a significant difference.
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294
On the other hand, the frequency of anxiety disorder appeared
to be least in HF employee patients (66.7%), reaching its peak
among unemployed HF patients (100%), which represented a
significant difference.
C. Diabetes Mellitus patients
Major depression is most frequently diagnosed in females DM
patients (75.36%) than in males DM patients (6.45%), which
represented a significant difference.
Major depression in DM patients was most frequently
diagnosed among housewives (32.0%), and lastly encountered
among unemployed patients (0%), which was statistically
significant.
Anxiety disorder was most frequently diagnosed in DM
patients living in rural areas (37.5%) than in those living in
urban areas (9.8%), which was statistically significant.
DM patients with history of diabetic coma were significantly
more diagnosed with major depression (34.6%) than patients
who did not experience diabetic comas before (13.5%).
Patients with a positive family history of neuropsychiatric
disorder were significantly more frequently diagnosed with
major depression (80%), compared to patients with no family
history of neuropsychiatric disorder (15.8%).
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295
DM patients with history of diabetic coma were significantly
more diagnosed with dysthymia (26.9%), than patients who
did not experience diabetic comas before (4.1%).
Dysthymia was more frequently encountered among diabetic
patients complicated with CVS (33.3%) than those not
complicated by CVS (8.5%), which was of significant
difference.
DM patients with a positive family history of neuropsychiatric
disorder were significantly more frequently diagnosed with
dysthymia (40%), compared to patients with no family history
of neuropsychiatric disorder (8.4%).
The prevalence of anxiety disorder among diabetic patients
with past history of substance abuse (66.7%) was significantly
higher than in diabetic patients with no past history of
substance abuse (10.3%).
D. Thyroid patients
Thyroid patients with anxiety disorder were significantly
younger than those not diagnosed with anxiety disorder.
Anxiety disorder was diagnosed most frequently in divorced
thyroid patients (60%), while lastly diagnosed among
widow/widower group (0%).
Major depression was most commonly diagnosed among
patients with low T4 levels (35%), and least in patients with
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296
normal T4 levels (4.5%), which represented a statistically
significant difference.
Anxiety disorders were most commonly diagnosed among
patients with low T4 levels (40%), and least in patients with
normal T4 levels (6.8%), which represented a statistically
significant difference.
III. Assessment of Quality of life:
In the four medical conditions studied, patients with
psychiatric morbidities (whether generally speaking or
specifically speaking of major depression, dysthymia and anxiety
disorder) had a significantly lower GAF score than had patients
without psychiatric morbidities. The only exceptions were the HF
patients with dysthymia. No significant difference was found
between GAF scores of HF patients with dysthymia and HF
patients without dysthymia.
On comparing GAF scores obtained by the patients with
psychiatric morbidities in ISHD, HF, DM, and Thyroid groups
against each other, a significant difference was found, mean GAF
score being lowest in HF patients with psychiatric morbidity,
followed by ISHD patients, then Thyroid patients, and finally
DM patients had the highest mean GAF score.
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297
On the other hand, no significant difference was found
between GAF scores of depressed patients with different medical
disease, or in dysthymic patients, or in patients with anxiety
disorder.
We also compared the quality of life of the patients with
the same medical condition diagnosed with different psychiatric
disorders. The statistically significant differences were found
among the HF group and the Thyroid group. In both groups,
patients with major depression had the lowest mean GAF score,
followed by patients with anxiety disorders, and finally by
patients with dysthymia, which represented statistically
significant difference.
IV. Variables associated with GAF scores:
A. Ischemic heart disease patients
In ISHD, the only significant association with the GAF score
found was with the gender of the patients. Quality of life was
significantly poorest among ISHD female patients.
B. Heart failure patients
Educational level, occupation, social class, and hepatic
impairment as a complication of HF were found to have
significant association with GAF score.
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HF patients who could read and write had significantly the
poorest quality of life, while the highest GAF score was found
in illiterate HF patients.
As regards occupation, employee HF patients significantly had
the lowest GAF score, while the highest was found in
unemployed HF patients.
Concerning the relation of social class with quality of life, HF
patients classified as middle social class had the lowest GAF
score, while the highest was for the patients with low social
class.
HF patients complicated with hepatic impairment had a
significantly lower GAF score than those who weren’t
complicated.
C. Diabetes Mellitus patients
Gender, educational level, occupation, social class,
complications, post prandial blood glucose, treatment, and
neuropsychiatric family history were found to have a significant
association with quality of life in DM patients.
Female DM patients had significantly lower GAF scores than
male DM patients.
Lowest GAF score was found in DM patients who can only
read and write, while the highest was found in DM patients
with high educational level.
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299
Housewives had the lowest GAF score, while the highest was
found in employee.
Finally, DM patients of low social class had the lowest GAF
score, while high social class had the highest GAF score.
Both diabetic comas and neuropathy as complications had a
significant relation with quality of life, as patients with either
complication had significant poorer quality of life compared to
those without.
Patients with high post prandial blood glucose had
significantly lower GAF scores than patients with normal post
prandial blood glucose level.
Patients treated with oral hypoglycemic drugs had significantly
higher GAF score than those not on OHG, while patients
treated with insulin had significantly lower GAF score than
those not on insulin.
Patients with neuropsychiatric family history had significantly
lower GAF score than those without neuropsychiatric family
history.
D. Thyroid patients
Finally, in the thyroid group, T4 levels and treatment were
found to be significantly associated with quality of life.
Patients with low T4 levels had the lowest GAF score, while
highest GAF score was found in normal T4 levels.
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300
Patients treated with carbimazole had significantly lower GAF
scores compared to thyroid patients not taking it