Anxiety and depression in patients with pulmonary hypertension: impact and management challenges

Figures & data

Table 1 Prevalence of anxiety and depression prevalence studies

Study	Design and setting	Diagnosis	Patients	Age (years)	Sex	Tools	Results
Löwe et al (2004)^Citation11	Prospective study matched by age and sex	PH	Total 492, 164 patients with PH, two comparison groups	47.8±12.7	70% females	PHQ	35% mental disorders: 15.9% major depressive disorder, 10.4% panic disorder
Shafazand et al (2004)^Citation13	Cross- sectional study	PAH	53 patients (median duration of disease, 559 days)	47±11	83% females	HADS	20.5% moderate/severe levels of anxiety, 7.5% moderate/severe levels of depression
White et al (2006)^Citation14	Prospective study	PAH	46 patients	48.2±11.8	38 (82.6%) females	BDI, BAI	26% moderate/severe depressive symptoms, 19% severe anxiety
Mc Collister et al (2010)^Citation16	Observational study	PAH (idiopathic, or associated with scleroderma, congenital heart disease, or anorexiant use)	50% with idiopathic PAH	≥18	Total 100, 88 females and 12 males	PHQ 8	15% major depressive disorder, 40% mild-to-moderate depressive symptoms, 45% no-to-minimal depressive symptoms
Vanhoof et al (2014)^Citation18	Cross- sectional study	PAH, 42.6% in New York Heart Association (NYHA) class II	101 patients with PAH, 42.6% in NYHA class II	55.4±16.4	73% females	DASS	32.6% depressive symptoms, 48% anxiety symptoms
Somaini et al (2016)^Citation19	Prospective study	PH	131 PH patients (91 PAH, 30 CTEPH, 10 due to lung disease)	51±75	84 females, 47 males	HADS	53% depression (49 incident patients), 51% anxiety (49 incident patients), 21% depression (82 prevalent patients), 24% anxiety (82 prevalent patients)

Note: Data are presented as mean ± standard deviation.

Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; DASS, Depression Anxiety Stress Scale; HADS, Hospital Anxiety Depression Inventory; PHQ, Patient Health Questionnaire; PH, pulmonary hypertension; PAH, pulmonary arterial hypertension; CTEPH, chronic thromboembolic pulmonary hypertension.

Table 2 Clinical importance of psychological symptoms studies

Study	Design and setting	Diagnosis	Patients	Age (years)	Sex	Variables measured	Tools	Follow- up	Results
Löwe et al (2004)^Citation11	Prospective study matched by age and sex	Pulmonary hypertension (PH)	Total 492, 164 patients with PH, two comparison groups	47.8±12.7	70% females	Depression, panic	PHQ		The prevalence of mental disorders in patients with PH increased significantly with functional impairment, from 17.7% (NYHA class I) to 61.9% (NYHA class IV)
Shafazand et al (2004)^Citation13	Cross- sectional study	PAH	53 patients (median duration of disease, 559 days).	47±11	83% females	QoL, anxiety, depression	HADS, NHP, CHFQ		Compared with population norms, participants reported moderate-to-severe impairment in multiple domains of HRQoL, including physical mobility, emotional reaction, pain, energy, sleep, and social isolation
Harzheim et al (2013)^Citation17	Prospective study	PH invasively diagnosed, with PAH (n=138) and inoperable CTEPH (n=20)	158 patients, two groups: 1) with moderate to severe mental disorder (n =36, 22.8%), and 2) with mild or no mental disorder (n=122)	56±16	133 females	QoL, anxiety, depression	SF-36, PHQ 9, GAD 7	2.7 years	Patients with moderate to severe mental disorder (group 1) had a significantly lower QoL shown in all subscales of SF-36 (P<0.002) QoL impairment significantly correlated with the severity of depression (P<0.001) and anxiety (P<0.05) During follow-up period, 32 patients died and three were lost to follow-up There was no significant difference between groups regarding survival
Vanhoof et al (2014)^Citation18	Cross- sectional study	PAH, 42.6% in NYHA class II	101 patients with PAH, 42.6% in NYHA class II	55.4±16.4	73% females	Depression, anxiety, stress	DASS, MLHFQ, SF-36		HRQoL was 41 SDs below population norms for the SF-36 physical component summary Depressive symptoms, NYHA class, and being disabled explained 46% of the total variance of the MLHFQ. Emotional problems did not contribute to the SF-36 physical component summary but explained part of the variance of the physical sub-scales of the SF-36 role limitations due to physical problems, bodily pain, and general health
Somaini et al (2016)^Citation19	Prospective study	PH	131 PH patients (91 PAH, 30 CTEPH, ten with lung disease)	51±75	64% females	Anxiety, depression, QoL	HADS, MLHFQ, CAMPHOR	16±12 months	The HADS score was improved at the second assessment in incident patients. The HADS score correlated with HRQoL at all consecutive assessments and with functional class until the third assessment, but not with baseline hemodynamics, age or, gender
Pfeuffer et al (2017)^Citation20	Retrospective analysis	70 PAH and 23 CTEPH	93 patients	70.11±11.62 (PAH) 67.65±10.05 (CTEPH)	48 (69%) PAH females 15 (65%) CTEPH females	Anxiety, depression, QoL	HADS SF-36		Although HRQoL was reduced in both cohorts of patients, individuals diagnosed with CTEPH scored lower in nearly all SF-36 parameters. Significance was noted in both “mental health” (P=0.01) and “mental component summary score” (MCS) (P=0.02). Depression was also more frequent in patients with CTEPH (56%) than in patients with PAH (30%), (P=0.03). Overall, depression and anxiety correlated with most SF-36 scales in both PAH and CTEPH. In CTEPH, depression also correlated with the Borg Dyspnea Scale (r=0.44, P=0.01). These patients also had significantly lower pCO2 levels than the PAH cohort, reflecting more severe ventilation/perfusion mismatch. All other hemodynamic and functional parameters did not differ across the groups
Muntingh et al (2017)^Citation21	Qualitative– quantitative study	PAH 0–16 years ago	24 patients	Range of 26–69 years	20 females, three males, and one transgender	Mental problems, distress, preference for support of PAH patients	Qualitative interviews: problem list, need for mental support, distress thermometer		The results from the survey highlight the need for professional support, as 50.8% of the 67 patients who completed the survey would consider support when offered. Younger age (odds ratio = 0.97, P=0.04), depression (odds ratio =11.435, P=0.001) and possibly anxiety (odds ratio =3.831, P=0.069) were related to need for support.
Halimi et al (2018)^Citation22	Consecutive patients	PAH	55 patients	mean age: 57.8±15.3 years;	64% female	HRQoL, anxiety, depression coping strategies	SF-36, HADS, STAI-Y, CHIP, and WCC		The HRQoL of PAH patients was poor with altered results on several scales. Anxiety and depression were high and coping was focused on medical information strategies Multivariate analysis indicated a positive relationship between 6MWD and the physical composite score for QoL (P=0.004), as well as a negative relationship between delta SPO2 and the mental composite score (P=0.02), irrespective of other known prognostic factors (such as hemodynamics at right heart catheterization). Depression and trait-anxiety were associated with a lower physical (P=0.001) and mental (P<0.001) QoL, respectively.

Abbreviations: CAMPHOR, Cambridge Pulmonary Hypertension Outcome Review; CHFQ, Congestive Heart Failure Questionnaire; CHIP, Coping with Health Injuries and Problems scale; CTEPH, chronic thromboembolic pulmonary hypertension; DASS, Depression Anxiety Stress Scale; GAD-7, Generalized Health Anxiety Disorder; MLHFQ, Minnesota Living With Heart Failure Questionnaire; NHP, Nottingham Health Profile; PHQ, Patient Health Questionnaire; SF-36, Medical Outcomes Study Short-Form 36-Item; STAY-Y, State-Trait Anxiety Inventory; NYHA, New York Heart Association; PAH, pulmonary arterial hypertension; QoL, quality of life; HRQoL, health-related quality of life; HADS, Hospital Anxiety Depression Inventory; WCC, Ways of Coping Check List.

Figure 1 Complexity of PAH disease and its management.

Abbreviation: PAH, pulmonary arterial hypertension.

Figure 2 PAH psychological assessment and intervention.

Abbreviation: PAH, pulmonary arterial hypertension.

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