Mental disorders among cardiac disease patients in a Palestinian population

Mental disorders and cardiovascular diseases (CVDs) are among the leading contributors to the global burden of disease, making them a major public health problem. Mental disorders and CVDs are common conditions, which very often co-occur, and influence each other’s etiology. Individuals with cardiac diseases experience higher rates of mental disorders such as depression, anxiety and posttraumatic stress disorder (PTSD) than the general population. Likewise, these mental illnesses are associated with both onset and progression of cardiac diseases. A growing body of evidence has documented the independent association between depression and onset of cardiac disease, morbidity and mortality. There is also compelling evidence that the co-occurrence of depression and cardiac disease leads to worse health-related quality of life (HRQL). However, less is known about the influence of anxiety and PTSD on cardiac outcomes and HRQL. The American Heart Association (AHA) has recommended routine depression screening in cardiac patients and guidelines for cardiac rehabilitation (CR) include that attention is paid to the diagnosis and treatment of mental disorders, yet the uptake of these recommendations remains limited. This situation is expected to be aggravated in low-income countries (LICs) like Palestine, which is affected by the political conflict and rates of CVDs and mental disorders are on a rapid rise. However, mental disorders are stigmatized, and thus not recognized nor treated. The evidence base to promote mental health services is currently lacking. This is the first contribution to assess the relationship between mental disorders and cardiac diseases in Palestine.
This PhD project the “CARMEN Study” was carried out in collaboration between Swiss Tropical and Public Health Institute, (Swiss TPH) and An-Najah National University. The following dissertation is based on three interrelated studies and sought to study the epidemiology and contributions of depression, anxiety, PTSD among cardiac diseases in a population-based sample of Palestinian adults. This dissertation provides evidence to fill the knowledge gaps to inform treatment and guide optimum management of these comorbid conditions.
Study I used a cross-sectional design to investigate the prevalence of depression and anxiety symptoms among Palestinian cardiac patients. Among the 1022 patients assessed, 54% were categorized as having severe depressive symptoms, while 19% exhibited severe anxiety symptoms. The study also found PTSD symptoms, low level of self-esteem, high somatic symptoms, low physical and mental health component scores, active smoking, physical inactivity, and longer disease duration to be independently associated factors with both depressive and anxiety symptoms. Patients with depressive and anxiety symptoms also reported poor social support and lower resilience and were more prevalent among females and less educated patients.
Study II revealed that women were more likely to suffer from depression than men (28.7% vs. 18.8%). When assessing which characteristics mediate the effect of gender on depression using structural equation modeling (SEM), our results showed that there was no direct effect of gender on depression; however, indirect effects showed that female gender was associated with lower resilience, self-esteem and quality of life, education, prevalence of smoking and physical activity and higher PTSD symptoms, comorbidities, somatic symptoms and smoking.
Study III found 27% of the overall sample at baseline exhibits moderate-to-high PTSD symptoms and at one year follow-up, patients with PTSD reported an approximate 20% lower HRQL. In addition, when assessing the longitudinal association of PTSD with HRQL after one year, the findings suggest this relationship was largely mediated by depression and anxiety.
The overall conclusions drawn from this thesis support the essential need for integrating mental health care into CR in Palestine from disease onset and onwards, considering the alarming rates of depression and anxiety symptoms in this Palestinian patient population. Depression, anxiety and PTSD should be considered important risk factors for cardiac diseases as much as other traditional cardiac risk factors. To deliver effective treatments for depression, anxiety and PTSD, assessment of the impact of psychological interventions on cardiac outcomes is needed. For clinical practice, future research should apply a more holistic approach in treating both physical and psychological recovery among cardiac patients. Finally, our findings can be considered as first steps to the translational approach of innovation, validation and application, where we can use the current cardiac sample as an entry door to pursue family members of diseased patients whom also could be at risk of onset and progression of cardiac diseases. This could potentially lead to a national mental health program that could be generalizable to similar health care systems in the Middle East region.