SANTA ANA PUEBLO, N.M. — Residents and nurse practitioners are better at spotting anxiety than depression in patients recovering from acute myocardial infarction—but both disorders are underdiagnosed and undertreated, Dr. Felicia A. Smith reported at the annual meeting of the Academy of Psychosomatic Medicine.
In a study conducted at Massachusetts General Hospital in Boston, house staff and nurses identified three (4%) of 74 patients in cardiac units as having a major depressive disorder, Dr. Smith reported.
The researchers flagged 11 depressed patients (15%) in the same population.
The clinical teams treating these patients were better at identifying anxiety, but they still recognized only half as many cases as did the researchers: 8 (11%) vs. 16 (22%).
“The results of this study suggest it may be unrealistic for these busy, front-line clinicians to adequately diagnose depression in the post-MI period in the absence of systematic screening,” said Dr. Smith, a fellow on a psychiatric consultation service at the hospital. She suggested better education of clinical teams and the development of new screening tools for them to use in this setting.
Depression and anxiety are common after myocardial infarction, according to Dr. Smith, and both disorders are associated with higher mortality and complications. “This has clearly been shown to be a major issue,” she said.
To gauge the ability of house staff and nurse practitioners to recognize and treat the two psychiatric disorders in high-risk cardiac patients, Dr. Smith and her colleagues compared assessments of patients being treated in a cardiac intensive care or step-down unit 72 hours after a myocardial infarction.
The average age of the largely male population was about 64 years. Dr. Smith said 22% had had a prior depressive episode.
The investigators used a screening battery that included the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and the DMS-IV Structured Clinical Interview (SCID) for major and minor depression.
The house staff's impressions correlated with the SCID, BAI, and a psychiatric evaluation for anxiety, but did not correlate with the SCID, BDI, and a psychiatric evaluation for depression, Dr. Smith said.
About 26% of the patients had a BDI score higher than 10; the mean BDI was 8, Dr. Smith said. The same proportion, 26%, of patients scored above 10 on the BAI, but the average anxiety score was more than twice as high, at 18.5.
As for treatment, Dr. Smith reported only one patient of the three identified as depressed by the house staff was started on antidepressant medication. “Some patients were started on antidepressants who did not meet criteria for depression and the study team did not identify as depressed,” she said.
Anxiety was more likely to be treated, and seven of the patients flagged by the house staff were started on benzodiazepines.
Dr. Smith said she did not know why residents and nurses were better at spotting anxiety, but offered a theory. “Maybe patients who are anxious call more attention to themselves,” she said, citing more frequent use of the call bell and physical manifestations of anxiety, such as dyspnea and nausea.
“Depressed patients may be anergic and withdrawn, and don't call much attention to themselves,” she continued. “Less interaction with the team makes the diagnosis more difficult.”