Prevalence, Risk Factors and Intervention for Depression and Anxiety in Pulmonary Hypertension: A Systematic Review and Meta-analysis

Abstract

BackgroundCurrent guidelines recommend psychological support for patients with pulmonary hypertension suffering from psychological adversity. However, little is known about the prevalence and risk factors of depression and anxiety in patients with pulmonary hypertension (PH).MethodsMedline and Embase were searched from inception to 6 May 2021. Meta-analysis of proportions using the generalized linear mixed model was conducted to analyze the pooled prevalence rates of depression and anxiety in PH patients. Risk factors for depression and anxiety in PH patients were evaluated using meta regression.ResultsA total of 24 studies involving 2,161 PH patients were included. The pooled prevalence of depression in PH was 28.0% (95% CI: 20.5–36.8) and pooled prevalence of anxiety was 37.1% (95% CI: 28.7–46.4). There was a significantly higher prevalence of anxiety (p = 0.0013) amongst PH patients in Asia (61.1%) compared to Europe (40.3%) and North America (22.9%). In terms of risk factors, congenital heart disease-related pulmonary arterial hypertension (PAH-CHD) were significantly associated with both depression (OR: 1.68, 95% CI: 1.27–2.23, p = 0.024) and anxiety (OR: 1.63, 95% CI: 1.45–1.83, p = 0.002). On the other hand, chronic thromboembolic pulmonary hypertension (CTEPH, OR: 1.18, 95% CI: 1.10–1.26, p = 0.004) was significantly associated with depression, whereas worse pulmonary vascular resistance (β: 0.30, 95% CI: 0.09–0.52, p = 0.005) and cardiac index (β: −0.96, 95% CI: −1.58 to −0.35, p = 0.002) were significantly correlated with anxiety.ConclusionThe prevalence of anxiety and depression in PH patients is alarmingly high, with an increased prevalence of anxiety in Asia compared to Europe or North America. Psychological support is warranted for patients with PH, particularly those with underlying congenital heart disease, CTEPH, and severe disease.Systematic Review RegistrationCRD42021251733.

Cognitive and behavioral processes predict anxiety and depression in patients with pulmonary hypertension

“…While there is growing evidence to suggest adults with PH are at a higher risk of experiencing anxiety and depression, 12 very little is known about the potential causes and factors that may make people with PH more vulnerable to developing mood and anxiety disorders—notwithstanding what has been gleaned from qualitative findings. 17 Most investigations in this area have focused on objective factors, 12 whereas in other medical conditions, self‐reported measures have been extensively researched as possible predictors of mood difficulties.…”

“…The GAD-7 and PHQ-9 are the some of the most commonly used measures of anxiety and depression in people with PH. 12 HRQoL was examined using the emPHAsis-10 which is a condition specific measure. 28 Scores range from 0 to 50, with a higher score indicative of lower HRQoL.…”

“…The pooled prevalence of depression was 28% (95% confidence interval [CI]: 20.5–36.8) and anxiety was even higher at 37.1% (95% CI: 28.7–46.4). 12 The picture is more concerning with evidence suggesting only the minority of patients with anxiety and/or depression and PH receive support. 13 , 14 , 15 Anxiety and depression are typically highly comorbid in PH and both conditions have been shown to have a significant impact on HRQoL.…”

“… 17 Most of the research in this area has focused on disease‐related and objective factors, such as pulmonary vascular resistance; PH diagnosis; World Health Organisation functional classification system, which ranges from I to IV; or demographics including age, marital status and financial circumstance. 4 , 12 Of the factors commonly investigated, few have been found to be a significant predictor, with Mai et al examining 20 possible factors identifying only two significant predictors of depression (PAH—congenital heart disease and CTEPH) and three for anxiety (PAH— congenital heart disease, pulmonary vascular resistance, and cardiac index). 12 It is therefore unsurprising that authors have suggested disease severity alone is insufficient to fully explain psychological difficulties such as mood disorders in people with PH.…”

“… 4 , 12 Of the factors commonly investigated, few have been found to be a significant predictor, with Mai et al examining 20 possible factors identifying only two significant predictors of depression (PAH—congenital heart disease and CTEPH) and three for anxiety (PAH— congenital heart disease, pulmonary vascular resistance, and cardiac index). 12 It is therefore unsurprising that authors have suggested disease severity alone is insufficient to fully explain psychological difficulties such as mood disorders in people with PH. 4 In contrast, there is a lack of evidence concerning subjective risk factors, such as measures of psychological functioning or distress.…”