Brief report
Validation of simple visual-analogue thermometer screen for mood complications of cardiovascular disease: the Emotion Thermometers

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Abstract

Objective

Conventional scales may help with the identification of depression but are generally too lengthy for clinical practice and perform poorly against anxiety and distress. We therefore examined the value of a single item NCCN Distress Thermometer and an enhanced visual-analogue method (Emotion Thermometers, ET) that incorporates four emotion thermometers.

Methods

We examined 228 patients with mixed cardiovascular conditions of whom 200 completed questionnaires. 64.5% suffered from cardiomyopathy/congestive heart failure, 9.5% had coronary artery disease, 4.5% had multiple cardiac diagnoses, 3% suffered from hypertension, 2% had rhythm problem, 2% had valve problems and 1.5% were diagnosed with atrial fibrillation. We used DSM-IV criteria to define current depression, the GAD7 to define current anxiety and the HADS-T to define distress. 13% had DSM-IV MDD and 19.1% had major or minor depression using DSM-IV (any depression). There were also 59 people (29.6%) with clinically significant distress and 46 with clinically significant anxiety (23.1%).

Results

The optimal accuracy for major depression was either the Depression thermometer (DepT) or the Help thermometer (HelpT), as both performed well. They had a sensitivity and specificity of 73.1%, 89.7% and 84.6%, 85.6%, respectively. The DepT was also best for detecting any DSM-IV depression (sensitivity 68.4% and specificity 93.2%) and HAD-T based distress (sensitivity 79.7% and specificity 82.9%). The Anxiety thermometer (AnxT) performed best against the GAD7 (sensitivity 84.8% and specificity 83.7%).

Conclusion

Innovative visual-analogue screening tools for mood appear to perform well in cardiovascular settings.

Introduction

Depression is an important complication of cardiovascular disease and significantly more common in patients who have suffered acute myocardial infarction (AMI) than in the general population (Glassman and Shapiro, 1998). Data from the National Health interview survey showed that the prevalence of major depression was 9.3% of those with cardiac disease, compared with 4.8% of those without medical illness (Edge, 2007). Robust studies suggest 15% to 20% of patients with myocardial infarction (MI) and heart failure meet Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) criteria for major depression, and an even greater proportion show elevated levels of depressive symptoms (Bush et al., 2005, Rutledge et al., 2006). Yet several important emotional complications are not captured by the concept of depression. For example anxiety is also common after an acute cardiac event (Suls and Bunde, 2005) and in patients with coronary heart disease (CHD) (De Jong and Hall, 2006, Suls and Bunde, 2005). Hopelessness and demoralization may also be important symptoms (Rafanelli et al., 2005). The presence of comorbid major depression with chronic heart conditions is associated with greater ambulatory care visits, emergency department visits, days spent in bed because of illness, participation in rehabilitation and degree of functional disability (Kerins et al., 2011, McGrady et al., 2009). In addition to major depression, significant symptoms of anxiety and depression are associated with worse prognosis in patients with coronary heart disease (CHD) (Frasure-Smith and Lespérance, 2008, Roest et al., 2010). Similarly, distress may be significant even when depression is not present (Ferketich and Binkley 2005, Denollet and Brutsaert, 2001). Thus there is considerable clinical significance in emotional complications beyond major depression yet most clinicians do not formally assess patients for major depression, even those patients who are at high risk (Rozanski, 2005).

Recently the American Heart Association (AHA) issued an advisory statement for screening, referral, and treatment in patients with CHD which advised that “Screening tests for depressive symptoms should be applied to identify patients who may require further assessment and treatment.” The AHA also promoted “Routine screening for depression in patients with CHD in various settings…” (Lichtman et al., 2008). AHA advocated a simple screening algorithm using the Patient Health Questionnaire 2 (PHQ2), followed by the PHQ9, although no supportive evidence was presented. Many mood scales are available to assist clinicians, but few are used routinely, largely because they are not practical for a busy clinic. In response, a number of abbreviated versions of screening tools have been developed. These very brief methods typically consist of 1 to 5 items and take less than 2 minutes to administer (Mitchell, 2007). Yet few ultra-short screening methods have been validated in cardiovascular settings, and these are restricted to identification of depression (Denollet et al., 2006, Huffman et al., 2006, McManus et al., 2005, Thombs et al., 2008a, Thombs et al., 2008b).

The primary aim of the current study is to investigate the accuracy of three ultra-short screening instruments in detecting depression, anxiety and distress in patients with cardiac diseases. We will investigate the screening performance of combined items versus single items and verbal versus visual-analogue methods.

Section snippets

Patients and procedure

Patients treated at the Loma Linda International Heart Institute (IHI) at the Loma Linda University Medical Center in Loma Linda, CA, USA were assessed by Nurse Practitioners in the Congestive Heart Failure clinic. Patients were excluded if they were unable to consent or if they were too unwell to participate, as were non-English speaking patients who did not have a family member to translate. Completion of the questionnaires took place in the IHI waiting area. Patients completed a demographic

Patient characteristics

213 questionnaires were distributed in a clinic setting, of which 200 (93.8%) were completed. Of the included respondents, 124 were male (62%), 68 were female (34%) and 8 declined to provide a gender (0.4%). The age range of the sample was 22 to 91, with a mean of 62 (median 65). 110 participants were married (55%), 34 were single (17%), 20 were widowed (10%), 15 were divorced (7.5%) and 16 declined a response (8%), 165 respondents originated from the United States (82.5%). 178 participants

Discussion

In this study of 200 patients with cardiovascular disease examined in a routine cardiac setting, we offer a validation of simple and practical visual-analogue scales that may help identify emotional disorders common in this population. Visual-analogue scales (VAS) are long established in medical settings and from the evidence in oncology settings visual analogue scales appear to have high acceptability (Hawke et al., 2010, Shimizu et al., 2010). The sample included patients with several heart

Role of funding source

Nothing declared.

Conflict of interest

No conflict declared.

Acknowledgements

Many thanks to the staff of the medical library, Leicester General Hospital.

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