Clinical Research
Impact of Physical Activity on Depression After Cardiac Surgery

https://doi.org/10.1016/j.cjca.2013.09.015Get rights and content

Abstract

Background

Physical activity is associated with a lower prevalence of depressive symptoms in cardiac patients. However, the benefits of physical activity on depression perioperatively are unknown. We sought to identify independent parameters associated with depression in patients undergoing cardiac surgery.

Methods

Patients awaiting nonemergent cardiac surgery (n = 436) completed the Patient Health Questionnaire-9 (PHQ-9) to quantify depression (PHQ-9 score > 9). Physical activity was assessed with the International Physical Activity Questionnaire (IPAQ-short) and accelerometry. Data collection occurred preoperatively (Q1, n = 436), at hospital discharge (Q2, n = 374), at 3 months (Q3, n = 318), and at 6 months (Q4, n = 342) postoperatively. Patients were categorized as “depression naive”, “at risk” or “depressed” preoperatively. Physical inactivity was defined as < 600 metabolic equivalent min/wk. Independent perioperative variables associated with depression were identified with univariate and multivariate logistic regression.

Results

Depression prevalence from Q1-Q4 was 23%, 37%, 21%, and 23%, respectively. Independent associations with depression were preoperative left ventricular ejection fraction < 50% (Q1, P < 0.05), physical inactivity (Q1, P < 0.05), baseline “at-risk” (Q2, P < 0.05), and baseline “depressed” groups (Q2-Q4, P < 0.05), hospital stay > 7 days (Q2, P < 0.05), postoperative stressful event (Q3 and Q4, P < 0.05), and cardiopulmonary bypass time > 120 minutes (Q4, P = 0.05). Newly depressed patients 6 months postoperatively reported lower IPAQ-short physical activity than depression-free patients (median change, −40 min/wk (interquartile range [IQR], −495 to +255) vs +213 min/wk (IQR, +150 to +830; P < 0.05).

Conclusions

Up to 40% of patients are depressed after cardiac surgery. Preoperative depression and postoperative stressful events were the strongest independent associations postoperatively. Physical inactivity was associated with preoperative depression and new depression 6 months postoperatively.

Résumé

Introduction

L’activité physique est associée à une plus faible prévalence des symptômes de la dépression chez les patients ayant une maladie cardiaque. Cependant, on ne connaît pas les effets positifs de l’activité physique sur la dépression en phase périopératoire. Nous avons a cherché à déterminer les paramètres associés à la dépression chez les patients subissant une chirurgie cardiaque.

Méthodes

Les patients qui attendent une chirurgie cardiaque non urgente (n = 436) ont rempli le Patient Health Questionnaire-9 (PHQ-9) pour quantifier la dépression (score au PHQ-9 > 9). L’activité physique a été évaluée à l’aide du questionnaire international d’activité physique (International Physical Activity Questionnaire; IPAQ court) et de l’accélérométrie. La cueillette de données a eu lieu en phase préopératoire (Q1, n = 436), au congé de l’hôpital (Q2, n = 374), à 3 mois (Q3, n = 318) et à 6 mois (Q4, n = 342) en phase postopératoire. Les patients ont été classifiés comme « dépression isolée », « exposés à un risque » ou « dépressifs » en phase préopératoire. L’inactivité physique a été définie comme un équivalent métabolique < 600 min/sem. Les variables indépendantes en phase périopératoire associées à la dépression ont été déterminées par la régression logistique univariée et multivariée.

Résultats

La prévalence de la dépression aux Q1-Q4 a été de 23 %, 37 %, 21 % et 23 %, respectivement. Les associations indépendantes à la dépression ont été la fraction d’éjection ventriculaire gauche en phase préopératoire < 50 % (Q1, P < 0,05), l’inactivité physique (Q1, P < 0,05) les groupes « exposés à un risque » au début (Q2, P < 0,05) et « dépressifs » au début (Q2-Q4, P < 0,05), le séjour à l’hôpital > 7 jours (Q2, P < 0,05), l’événement stressant en phase postopératoire (Q3 et Q4, P < 0,05) et le temps de pontage cardiopulmonaire > 120 minutes (Q4, P = 0,05). Les patients nouvellement dépressifs 6 mois après l’opération ont déclaré un plus faible niveau d’activité physique à l’IPAQ court que les patients n’ayant pas de dépression (changement médian, −40 min/sem (intervalle interquartile [IIQ], −495 à +255) vs +213 min/sem (IIQ, +150 à +830; P < 0,05).

Conclusions

Jusqu′à 40 % des patients sont dépressifs aprés une chirurgie cardiaque. Les événements stressants de la dépression en phases préopératoire et postopératoire ont été les associations indépendantes les plus importantes en phase postopératoire. L’inactivité physique a été associée à la dépression en phase préopératoire et à la nouvelle dépression 6 mois après la chirurgie.

Section snippets

Methods

From May 2010-August 2011, 436 consecutively consenting patients undergoing elective cardiac surgery or awaiting in-hospital cardiac surgery requiring cardiopulmonary bypass (CPB) were recruited. Enrolled patients were assessed for short-term depression and physical activity behaviour preoperatively (Q1), at hospital discharge (Q2), and 3 months (Q3) and 6 months (Q4) postoperatively (Fig. 1). The study was approved by the University of Manitoba Research Ethics Board and the St. Boniface

Depression

The prevalence of depression increased significantly preoperatively to the time of discharge (Fig. 2), which resulted from an incidence of new depression of 29%,12 whereas 58% and 28% of the “at risk” and “naive” subgroups became depressed at discharge, respectively (Fig. 2). Although the prevalence of depression in the whole study population decreased to baseline levels (Fig. 2), 20% and 23% of the “at risk” group, and 10% and 11% of the “naive” subgroup (similar to the noncardiac general

Depression

Previous studies have been performed examining the prevalence of preoperative depression in the patient undergoing cardiac surgery.6, 7, 18, 19 There has been, however, ambiguity as to whether depression increases or decreases postoperatively.6, 20, 21 A unique feature of this study was the preoperative classification of patients into depression subgroups in conjunction with a serial assessment of depression and physical activity to 6 months postoperatively, thus providing insight into the

Conclusions

Depression in the patient undergoing cardiac surgery appears complex. We have identified that although 7 independent factors are associated with depression before and after cardiac surgery, different mood responses in different subsets of patients exist. Furthermore, patients “at risk” for depression represent a new high-risk subset. Preoperative physical inactivity independently poses a 2-fold risk for depression before surgery and is associated with the development of new depression

Disclosures

The authors have no conflicts to disclose.

References (42)

  • T.K. Dao et al.

    Randomized controlled trial of brief cognitive behavioral intervention for depression and anxiety symptoms preoperatively in patients undergoing coronary artery bypass graft surgery

    J Thorac Cardiovasc Surg

    (2011)
  • P.H. Lee et al.

    Validity of the International Physical Activity Questionnaire Short Form (IPAQ-SF): a systematic review

    Int J Behav Nutr Phys Act

    (2011)
  • B. Roshanaei-Moghaddam et al.

    The longitudinal effects of depression on physical activity

    Gen Hosp Psychiatry

    (2009)
  • A.M. Maclullich et al.

    Unravelling the pathophysiology of delirium: a focus on the role of aberrant stress responses

    J Psychosom Res

    (2008)
  • B.G. Arenson et al.

    Effect of intensive care unit environment on in-hospital delirium after cardiac surgery

    J Thorac Cardiovasc Surg

    (2013)
  • X.S. Wang et al.

    Depression before and after operation in patients undergoing coronary artery bypass grafting and the effect thereof on quality of life

    Zhonghua Yi Xue Za Zhi

    (2008)
  • L. Andrade et al.

    The epidemiology of major depressive episodes: results from the International Consortium of Psychiatric Epidemiology (ICPE) surveys

    Int J Methods Psychiatr Res

    (2003)
  • J.P. van Melle et al.

    Effects of antidepressant treatment following myocardial infarction

    Br J Psychiatry

    (2007)
  • A.H. Glassman et al.

    Sertraline treatment of major depression in patients with acute MI or unstable angina

    JAMA

    (2002)
  • J.A. Blumenthal et al.

    Effects of exercise training on depressive symptoms in patients with chronic heart failure: The HF-ACTION randomized trial

    JAMA

    (2012)
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text rev. ed....
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    These authors contributed equally to this work.

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