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Psychosomatics 47:479-485, December 2006
doi: 10.1176/appi.psy.47.6.479
© 2006 Academy of Psychosomatic Medicine
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Prevalence and Correlates of Major Depressive Disorder in Nigerian Outpatients With Heart Failure

Abiodun O. Adewuya, M.D., Bola A. Ola, M.D., Olufemi E. Ajayi, M.D., Adebayo O. Oyedeji, M.D., Michael O. Balogun, M.D., and Steven K. Mosaku, M.D.

Received September 2, 2005; revised December 5, 2005; accepted December 7, 2005. From the Dept. of Mental Health and Dept. of Medicine, Obafemi Awolowo Univ. Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria. Address correspondence and reprint requests to Dr. Adewuya, Dept. of Mental Health, OAUTHC, Wesley Guild Hospital, ILESA 233001, Osun State, Nigeria. e-mail: biodunwuya{at}yahoo.com


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
This study aims to estimate the prevalence and correlates of major depressive disorder (MDD) in Nigerian outpatients with heart failure. Authors assessed patients with heart failure (N=102) for DSM-IV diagnosis of MDD and obtained sociodemographic and clinical data. MDD was found in 28 (27.5%) of the patients. The significant correlates predicting MDD included unemployment and disability due to the illness, more severe illness (NYHA class), age younger than 60 years, and not being married. These factors should be considered in planning further studies and in screening and intervention programs for patients with heart failure.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Heart failure is the most prevalent cardiovascular disease and the leading cause of sudden cardiac death in Nigeria.1,2 Comorbid psychological conditions, particularly depression, often accompany heart failure and add to the complexity of clinical management. Depression in patients with heart failure may be associated with increased medical costs,3 increased risk of hospital admission and mortality,4–7 and decline in health status.8

Most studies on depression in patients with heart failure have focused on hospitalized patients, with a prevalence ranging from 13%–77.5%.4–6,9–11 The existing studies on outpatients have estimated the prevalence of depression to range between 13% and 48%.12–18 These studies have, however, been limited either by reliance exclusively on rating scales like the Center for Epidemiological Studies on Depression scale (CES–D) and the Beck Depression Inventory (BDI),12–17 or focusing only on patients with advanced heart failure.18 The prevalence of depressive disorders defined by DSM-IV criteria has therefore not been firmly established in outpatients with heart failure.

The factors associated with depression in patients with heart failure have been controversial. Freedland et al.10 had found that age, gender, employment status, past history of depression, and functional severity of illness are associated with depression in hospitalized patients with heart failure. In later studies on outpatients, Gottlieb et al.12 had found significant association equally among depression and age, gender, and functional status. In a prospective cohort study of outpatients with heart failure, Havranek et al.14 had found that social factors and health status are predictive of the development of depression.

These studies are few, and they have all been done in western cultures. Searches of the literature, both manual and electronic, reveal no study done on depression in patients with heart failure in sub-Saharan Africa. There is a clear cultural difference between the western countries and Nigeria as regards heart failure and its management. Sub-optimal health services, poverty, illiteracy, and lack of adequate information about cardiovascular diseases make patients with chronic heart failure in Nigeria less well treated than their counterparts in the western world, and this may potentially increase disability and the risk of developing depression. At the same time, studies have suggested that patients in developing countries and those of lower socioeconomic status often report somatic symptoms and deny psychological symptoms more frequently than patients in Western or developed countries.19–22 In Nigeria, the prevalence of depression ranged from 4.1% in the general population22 to 18.2% among geriatric patients.23 It is seen more in women and in patients of lower socioeconomic status.24

With the potential importance of depression in the quality of life of patients with heart failure, a study of prevalence and correlates of depression in Nigerian patients with heart failure is therefore warranted.

This study aims to estimate the prevalence of DSM-IV major depressive disorder (MDD) and examine the sociodemographic and clinical factors associated with depression in Nigerian outpatients with heart failure


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
The subjects for the study consisted of a consecutive series of 105 patients with heart failure, recruited from the Cardiovascular section of the consultant outpatient clinics of Ife State Hospital (ISH) and Wesley Guild Hospital (WGH), both units of Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC). This sample can be said to be representative of other health contexts in Nigeria, because, although OAUTHC is a tertiary health center, the two units are located in semi-urban towns. Also, most of the referrals are from the primary and secondary health-care units located in Osun state and two other neighboring states. Most of the patients referred comprise a group of farmers, artisans, and low-level civil servants. The patients were recruited over a period of 3 months. All subjects had been diagnosed with and were being treated for heart failure by attending consultant cardiologists for at least 6 months before the recruitment. Detailed nuclear ventriculography or echocardiography profiles were not possible in an underdeveloped setting like this, but since the patients were diagnosed and managed by consultant cardiologists, the clinical diagnoses were quite reliable. All the patients were stable, and none had had an acute exacerbation of symptoms. None of the patients had ever been referred to the psychiatric team, and none was, at the time of this study, on any treatment for depression.

Procedures
Written informed consents were obtained from the participants after the aims and objectives of the study had been explained. The Ethics and Research Committee of the OAUTHC approved the study protocol.

The subjects first completed a questionnaire, which was used to gather data regarding sociodemographic details like age, sex, marital status, employment status, and socioeconomic status. The socioeconomic status was determined by summing up the answers to questions regarding occupation, educational level, and monthly income of the patient and his or her spouse. The case files were then reviewed to obtain information regarding duration of illness, the New York Heart Association (NYHA) functional classification, medical history and comorbid medical conditions, prescribed medications, and the latest electrocardiography (ECG) findings.

Two trained psychiatrists, blind to the sociodemographic and clinical characteristics of the patients, then used the Mini-International Neuropsychiatric Interview (MINI) to assess the patients for DSM-IV diagnosis of major depressive disorder (MDD). The MINI25 was designed as a brief structured interview for the major Axis I psychiatric disorders in DSM-IV.26 Validation and reliability studies have been done for MINI, with results showing that the MINI has acceptably high validity and reliability scores. Clinicians can use it after a brief training session, but lay interviewers require training that is more extensive. The two psychiatrists independently rated each interview.

Statistical Analysis
The Statistical Package for the Social Sciences-11 (SPSS.11) program was used for statistical analysis. Participants were classified as Cases or Non-Cases of MDD on the basis of their MINI/DSM-IV diagnosis. Results were calculated as frequencies (%), means and standard deviations (SD). Chi-square and t-tests were first used to determine the sociodemographic and clinical factors associated with the diagnosis of MDD. Significance level was computed at p<0.05. The variables that were significantly associated with DSM-IV diagnosis of MDD in this first analysis and those moderately associated (with p values between 0.05 and 0.1) were then entered into a logistic-regression analysis to determine the predictors of MDD. Odds ratios (ORs) and 95% confidence intervals (95% CI) were calculated for the predicting variables.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Sample Characteristics
All the 105 subjects recruited for the study participated, but 3 had incomplete data, leaving a sample size of 102. There were 65 patients (63.7%) age 60 and above. The patients were mostly male (58.8%), married (51.0%), and disabled because of their illness (68.6%). The majority (77.5%) of the patients had NYHA classification II or III. Hypertension (56.9%) was the most common comorbid cardiac condition, and chronic obstructive pulmonary disease (COPD) (14.7%) was the most common comorbid non-cardiac condition. The sociodemographic and clinical characteristics of the participants are shown in Table 1.


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TABLE 1. Sociodemographic and Clinical Characteristics of Heart-Failure Patients



Prevalence of Major Depressive Disorder (MDD)
The interrater reliability between the two psychiatrists’ clinical interviews was 0.86, as measured with Cohen’s kappa. Disagreements were resolved by consensus. A total of 28 patients (27.5%) were identified as cases of DSM-IV MDD.

Correlates of MDD
The patients were dichotomized into two groups on the basis of their DSM-IV diagnosis of MDD. Univariate analyses were done by t-tests and chi-square tests (Table 1), with the t-tests performed on the proportion of patients in each category. The result showed that the only variables significantly associated with DSM-IV diagnosis of MDD were younger age (t = –3.439, df=100, p=0.001), female sex ({chi}2=8.509, df=1, p=0.004), unemployed due to illness ({chi}2=10.524, df=1, p=0.001) and higher NYHA classification ({chi}2=9.643, df=3, p=0.022).

When these significant variables and those moderately associated with MDD (e.g., socioeconomic status and marital status, with p values between 0.05 and 0.1) were then entered into a regression model to determine the independent predictors of MDD, sex and socioeconomic status dropped out of the analysis. It should be noted that sex was significantly associated with age (p<0.001), employment status (p<0.001), and NYHA classification (p<0.001). The result of the regression analysis is presented in Table 2. The ORs and 95% CIs for the predicting variables are shown in Table 3.


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TABLE 2. Regression Analysis to Determine Predictors of Major Depressive Disorder (MDD) in Heart-Failure Patients




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TABLE 3. Predicting Variables for Major Depressive Disorder (MDD) in Patients With Heart Failure




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
To our knowledge, this is the first African study to examine depression in patients with heart failure. It is also among the few to have assessed depression in patients with heart failure by use of a structured diagnostic instrument. The 27.5% prevalence of MDD in our study is in line with the range of 13%–48% found by rating scales from studies in western cultures.12–17 When compared with studies using DSM-IV criteria through standardized interviews, our prevalence rate for MDD is higher than the 19% found by Sullivan et al.’s 2004 study,18 which had examined only outpatients with advanced heart failure. Our finding is also comparable to those found with hospitalized patients. Stotzko et al.,17 assessing a small number of hospitalized patients age 70 and above, found a prevalence of 17% for MDD. Koenig11 also examined hospitalized patients age 60 years or older and found a prevalence of 37%, whereas Freedland et al.10 found a rate of 20% in a recent study of hospitalized patients.

Disability due to heart failure had the strongest association with MDD in our study. This is in agreement with other studies finding that depression is associated with poor physical and role functioning and unemployment.5,10,18,27 We also found depression in patients with heart failure to be more commonly associated with younger age (less than 60 years) in this study. Some other studies have found similar results,10,12 whereas some found no age difference.4,14 Although it is expected that loneliness, diminished health and strength, and loss of friends to death might lead to a higher rate of depression in normal populations, younger patients with heart failure might perceive that their heart failure interferes with their functional status and expectations. Coping with these limitations caused by heart failure may be more difficult for younger individuals.12

We found higher NYHA classification to be independently associated with MDD in our study. This is in agreement with most studies in western culture that had found strong associations between NYHA class and depression.10,12,16 and in disagreement with the study that did not find any association between severity of illness and depression.17 Heart failure may be a precursor of depression, particularly at a stage at which the patient is experiencing functional impairment and severe dyspnea and other exertional symptoms. Likewise, depression might exacerbate the symptoms of heart failure and increase the severity of functional impairment.

Although marital status was not significant in the univariate analysis (p=0.089), multivariate analysis showed that it was independently associated with MDD. Not being married may be a causal factor in poor social support. On the other hand, although univariate analysis found gender to be significantly associated with depression in our patients with heart failure, it could not independently predict MDD, as noted in other studies.10,12 In our study, this could be due to its significant association with other predictor variables, such as age, employment status, and NYHA classification.

The links between higher risk of depression and heart failure are uncertain.28 Postulated factors include genetics, shared pathophysiology, and psychodynamic influences. Genetic studies have suggested shared genetic substrates29 and a shared association with the G-protein beta3 825T allele.30,31 Physiological studies have found increased level of circulating catecholamines in both illnesses,32,33 and the high levels of cytokines found in patients with heart failure have been implicated in depressive symptoms.34 Neurohormonal changes in both depression and heart failure suggest that depression could speed the development of heart failure in vulnerable patients, or speed the progression of heart failure in established disease, via the HPA axis and sympathetic hyperactivity.28 Findings also suggest that depression and heart failure share attributes of rhythm disturbances that could predispose to arrhythmias and may, in part, account for the deleterious effect of depression on prognosis in heart failure.28 Psychodynamically, the threat of death and loss of functioning capacity accompanying heart failure may constitute stressful life events that had been known to precipitate depression.35

Psychosocial factors, such as poor drug compliance, lack of social support, and low socioeconomic status, many of which are independently correlated with depression, have also been implicated in the development and progression of heart failure, and are essential to consider when evaluating the impact of depression on heart failure. Although the finding was not at statistically significant levels, our patients were more often of lower socioeconomic status. Poverty may make it difficult for these patients to procure drug treatment, and lack of social support (indicated by not been married) may make drug compliance more difficult. This can mean poor management of the heart failure, with subsequent worsening of NYHA class and its attendant disability, which may precipitate depression in these patients. The distribution of socioeconomic status in our patients is comparable to that of the national distribution in Nigerian communities and other non-western countries. Studies on depression from western countries have had slightly higher percentages of patients of high socioeconomic status. This cannot, however, be said to affect the prevalence of depression in our study, since it was not statistically significant.

The clinical implications of our study are that screening for depression may be warranted for all patients with heart failure in this community. It may be most important to screen for depression among those with associated factors identified in this study, such as younger age, disability due to illness, and higher NYHA classification. Since psychiatric diagnosis may be quite expensive and time-consuming, there is a need to use a short and well-validated depression-screening instrument in these patients so that patients with significant depressive symptoms can be rapidly identified and referred for prompt treatment. Also, psychosocial and preventive interventions should be targeted at patients at risk for depression, as identified in this study.

This study has some limitations. First, our sample size was moderate. We did not extend our measurement of depression to minor depressive disorder, and so did not account for clinically significant depressive symptoms not meeting the strict DSM-IV diagnosis of MDD. We used only relatively stable outpatients and did not compare our patients with any control group. Also, some of the patients had other comorbid conditions (both cardiac and non-cardiac), and this could serve as a confounding factor, and, because of the part of the world in which this study was done, we could not include detailed nuclear ventriculography or echocardiography profiles. However, the symptom-based assessment of the patients’ NYHA classifications was done by experienced consultant cardiologists. We did not assess the patients’ level of social support. The available evidence, although sparse, suggests that a lack of social support may have a deleterious influence on the course of both heart failure and depression. Although this observation does not explain the high prevalence of depression in heart failure, it may contribute to the negative impact of depression on prognosis in heart failure.36,37 We did find, however, an association with marital status, which may be a measure of social support. We did not include a self-report measure of depression to provide information about depression as a continuum and to measure subclinical symptoms of depression, which had previously been shown to be associated with reduced longevity in patients with coronary artery disease.38 Another limitation is the difficulty inherent in diagnosing depression in the context of medical illness, particularly in older population samples.39,40 It is hard to diagnose depression in the setting of a disease with symptoms that mimic depression. Heart failure is often associated with fatigue, malaise, and insomnia, and these may be misattributed to depression. Finally, we did not inquire about previous history of depression in the patients.

The strength of our study lies in its being the first in Africa to examine depression in patients with heart failure. We used a standardized diagnostic instrument for DSM-IV criteria for MDD; we covered a wider age range, and we have included patients with various grades of illness. The patients in this study diagnosed as having MDD were promptly referred to the psychiatric team.

In conclusion, we have shown that major depressive disorder is very common in outpatients with heart failure in Nigeria, as it is in their counterparts from western cultures. Younger patients with more severe symptoms and who are incapacitated by the illness are mostly affected. These factors should be considered in planning further studies and in screening and intervention programs for patients with heart failure.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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