October 26, 2022

Association of Depression and PAD Outcomes Evaluated in Systematic Review and Meta-Analysis

October 26, 2022—In a systematic review and meta-analysis conducted to examine the association between depression and peripheral artery disease (PAD) outcomes, Scierka et al found a 24% increased risk of all-cause mortality and a trend toward an association between depression and major adverse limb events (MALE). Results of the study were published online in Journal of Affective Disorders.

KEY FINDINGS

Depression was associated with an increased risk of all-cause mortality in patients with PAD.
There was a positive trend between depression and MALE, but the paucity of studies limited in-depth analysis.

Investigators performed a literature search of Cochrane Library, Google Scholar, Ovid Embase, Ovid MEDLINE, PsycInfo, PubMed, Scopus, and Web of Science Core Collection databases for prospective or retrospective studies to January 2022 including patients aged ≥ 18 years and reporting (1) depression or depressive symptoms, (2) mortality and/or MALE outcomes with at least 12-month follow-up, and (3) effect size (relative risk, odds ratio, or hazard ratio [HR] with 95% CI) and P value on the outcome of mortality or MALE for exposure of comorbid depression in patients with PAD.

Primary outcomes were all-cause mortality and MALE (major amputation, minor amputation, and any amputation or amputation plus repeat peripheral vascular intervention).

The literature search yielded 7,048 articles; duplicates were removed and titles and abstracts were screened. Of 88 articles meeting the criteria for full-text review, five articles (four United States studies and one study from the Netherlands) comprising 119,123 patients met inclusion criteria and were included in the meta-analysis.

Mean ages ranged from 66.7 to 71.3 years, and female representation was low in three of the studies (1.2%, 1.4%, 2.1%, 35%, 38.9%). Most patients were White, but two studies did not report data on race. Overall, 25,622 (16.2%) patients had a diagnosis of depression or depressive symptoms (either ICD diagnosis or self-reported symptoms).

In the all-cause mortality analysis, 158,211 patients were included (mean or median follow-up, 31.83-70.8 months). In the meta-analysis, depression in PAD patients was associated with an increased risk of all-cause mortality (HR, 1.24; 95% CI, 1.07-1.25; P = .005).

A total of 155,904 patients (from only two studies) were included in the MALE analysis (mean or median follow-up, 28.3-70.8 months). The meta-analysis showed a trend toward a positive association between depression and MALE in patients with PAD, but it was not statistically significant (HR, 1.47; 95% CI, 0.78-2.79; P = .23).

Investigators noted several limitations, including the paucity of studies, overrepresentation of White men, the larger sample size of one study as compared with the other included studies, and the absence of information on depression severity or remission.

This study is an important step in bringing awareness to the relationship between depression and PAD, and further studies are warranted, noted the investigators.

ENDOVASCULAR TODAY ASKS…

Study investigators Lindsey E. Scierka, MD, and Kim Smolderen, PhD, with Yale University and Yale School of Medicine in New Haven, Connecticut, were asked to discuss the impact of depression in PAD and what future studies might address.

You noted that your study demonstrates a need for better recognition of depression in vulnerable populations. What are some ways clinicians and study investigators can help integrate assessment of depression in the PAD population and ensure comprehensive care?

Our study highlights that depression is common in individuals with PAD but is likely undermeasured given the paucity of studies. There are a range of validated assessment tools that can be integrated into the clinical workflow to screen for depression during clinic visits. Screening alone, however, is not sufficient. Clinicians need to provide pathways for individuals with positive screens to receive mental health interventions in a way that works with their overall vascular disease management.

Comorbid depression may affect patients’ adherence to recommended treatment, such as medications, exercise, smoking cessation, and lifestyle changes. In what ways can a multidisciplinary approach help reduce this barrier to PAD management, and who should be involved in the overall care plan?

Simply telling people to change their behavior is likely ineffective in producing durable changes in their mood and lifestyle. Integrative care models that utilize a multidisciplinary approach to manage mental health comorbidities are important for addressing the diverse aspects of this disease. Involving psychology for evidence-based behavioral interventions and psychiatry for individuals with treatment resistance, those requiring pharmacotherapy, or individuals with more advanced mental health diseases outside of the scope of psychology are beneficial to promote a change behavior for all domains. In addition, involving social work for assistance with care coordination and management of larger socioeconomic barriers to care is also important as these factors are often drivers of stress and depression.

Because this wasn’t a patient-level analysis, you were unable to look at the potential effect of depression treatment on PAD outcomes. What might future studies evaluating the role of depression interventions in PAD outcomes look like, and how could they inform practice?

The treatment of depression is complex, but comprehensive management should include behavioral interventions. Future studies that pilot integrated care models in the context of a vascular care clinic to address PAD treatment goals in addition to the management of mood disorders and stress would be beneficial. The specific workflows needed to best accomplish this goal will need to be explored. In addition to studying the interventions themselves, we also need to understand the patient’s preferences on how they want to manage their comorbid mental health conditions in the context of their vascular care to ensure the interventions we design are evidence-based and patient-centered.

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