Comparing the Effects of Depression, Anxiety, and Comorbidity on Quality-of-Life, Adverse Outcomes, and Medical Expenditure in Chinese Patients with Acute Coronary Syndrome
Introduction
Cardiovascular disease (CVD) remains the leading cause of mortality in China, accounting for a quarter of the country’s medical expenditure. Despite advancements in interventions and preventive strategies, the burden of CVD continues to grow, necessitating a focus on both primary and secondary prevention. While traditional risk factors such as hypertension, hyperlipidemia, diabetes mellitus, and smoking have been well-studied, the role of psychological factors like depression and anxiety in CVD outcomes has gained increasing attention.
Depression has been identified as a significant risk factor for poor prognosis in patients with acute coronary syndrome (ACS), as highlighted by the American Heart Association. However, most of the evidence supporting this association comes from Western populations, with limited data available for Chinese patients. Similarly, anxiety disorders are prevalent among ACS patients, but their impact on outcomes remains unclear, particularly in Chinese populations.
Moreover, while depression and anxiety often co-occur, their combined effect, referred to as comorbidity, has not been thoroughly explored in the context of ACS. Existing studies suggest that comorbidity may have a more severe impact on outcomes than either condition alone, but this hypothesis requires further validation in Chinese patients. Additionally, the effects of depression and anxiety on quality-of-life (QOL) and medical expenditure in ACS patients are underexplored, especially in China.
This study aims to address these gaps by evaluating the dynamic changes of depression and anxiety over 12 months and examining their individual and combined effects on QOL, adverse outcomes, and medical expenditure in Chinese patients with ACS.
Methods
This prospective longitudinal study recruited 647 patients with ACS from five hospitals in North China between January 2013 and June 2015. Patients were included if they were aged 18 or older and had a primary diagnosis of ACS, which included ST-segment elevation myocardial infarction (STEMI), non-STEMI, and unstable angina. Exclusion criteria included cognitive dysfunction, current use of antidepressants, comorbid lethal diseases, active substance abuse, or an anticipated life expectancy of less than one year.
Participants were assessed for depression using the Patient Health Questionnaire (PHQ-9), anxiety using the Generalized Anxiety Disorder (GAD-7) scale, and QOL using the Short-Form Health Survey (SF-12). Follow-up assessments were conducted at 1, 3, 6, and 12 months post-discharge. Adverse outcomes, including all-cause mortality, non-fatal myocardial infarction (MI), and cardiac re-hospitalization, were recorded. Medical expenditure was defined as the number of hospitalizations, outpatient visits, and associated costs within 12 months.
Statistical analyses were performed using JMP software. Patients were stratified into four groups based on their PHQ-9 and GAD-7 scores: depression alone, anxiety alone, comorbid depression and anxiety, and a control group with neither condition. Differences among groups were analyzed using one-way ANOVA and chi-square tests. Multivariate logistic regression models were used to examine the associations between baseline depression, anxiety, and comorbidity with 12-month outcomes, adjusting for covariates such as age, gender, left ventricular ejection fraction (LVEF), and cardiovascular risk factors.
Results
Baseline Characteristics
Of the 647 enrolled patients, 531 (82.1%) completed the 12-month follow-up. The mean age of participants was 63.4 years, and 67.7% were male. No significant differences were observed in baseline demographic characteristics, cardiovascular risk factors, or medications among the four groups. However, patients with comorbidity had the lowest prevalence of regular physical activity and the highest prevalence of hypercholesterolemia.
Dynamic Changes in Depression and Anxiety
Over the 12-month follow-up period, PHQ-9 scores decreased gradually in the depression and comorbidity groups, while GAD-7 scores normalized more rapidly in the anxiety group. The slowest recovery was observed in the comorbidity group, suggesting that comorbid depression and anxiety may persist longer than either condition alone.
Quality of Life
Baseline QOL scores, as measured by the SF-12, were significantly lower in the comorbidity group compared to the other groups. Although QOL improved in all groups over time, the comorbidity group consistently had the lowest scores. Multivariate logistic regression analysis confirmed that baseline comorbidity was a strong predictor of poor 12-month QOL, with an odds ratio (OR) of 1.77.
Adverse Outcomes
During the 12-month follow-up, 7.3% of patients experienced non-fatal MI, and 35.8% were re-hospitalized for cardiac events. Baseline depression, anxiety, and comorbidity were all independent predictors of non-fatal MI and cardiac re-hospitalization. Comorbidity had the highest predictive value, with an OR of 6.33 for non-fatal MI and 14.08 for cardiac re-hospitalization. No significant association was found between depression, anxiety, or comorbidity and all-cause mortality.
Medical Expenditure
Patients with comorbidity had the highest medical expenditure, including the number of hospitalizations, outpatient visits, and associated costs. The number of re-hospitalization days and admission frequency within 12 months were significantly higher in the comorbidity group compared to the other groups.
Discussion
This study provides valuable insights into the effects of depression, anxiety, and comorbidity on QOL, adverse outcomes, and medical expenditure in Chinese patients with ACS. The findings highlight the importance of addressing psychological factors in the management of ACS, particularly comorbid depression and anxiety.
The results indicate that depression and anxiety are independent predictors of non-fatal MI and cardiac re-hospitalization, with comorbidity having the strongest predictive value. This suggests that comorbid depression and anxiety may represent a distinct subtype of psychological distress in ACS patients, warranting targeted interventions.
The study also underscores the significant impact of comorbidity on QOL and medical expenditure. Patients with comorbid depression and anxiety had the lowest QOL scores and the highest healthcare costs, emphasizing the need for early screening and intervention to improve outcomes and reduce financial burdens.
The dynamic changes in PHQ-9 and GAD-7 scores over the 12-month follow-up period suggest that depression and anxiety may have different trajectories in ACS patients. While anxiety symptoms tend to resolve more quickly, depression and comorbid depression and anxiety may persist longer, necessitating prolonged monitoring and support.
Limitations
This study has several limitations. First, the use of self-reported measures for depression, anxiety, and QOL may introduce bias. Second, the sample was drawn from North China, which may limit the generalizability of the findings to other regions or ethnic groups. Third, the study did not explore the mechanisms underlying the observed associations, such as health behaviors or biological pathways.
Conclusions
In conclusion, this study demonstrates that depression, anxiety, and comorbidity significantly impact QOL, adverse outcomes, and medical expenditure in Chinese patients with ACS. Comorbidity, in particular, has the strongest predictive value for poor outcomes and higher healthcare costs. These findings highlight the need for comprehensive psychological assessment and intervention in ACS patients, with a focus on comorbid depression and anxiety as a new target for improving prognosis and reducing healthcare burdens.
doi.org/10.1097/CM9.0000000000000215
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