1. CoRPS Center of Research on Psychology in Somatic diseases Depression is associated with a 2-fold independent risk of mortality in implantable cardioverter defibrillator patients Susanne S. Pedersen 1,2,3, Professor of Cardiac Psychology 1 Medical Psychology, Tilburg University, The Netherlands 2 Thoraxcenter, Erasmus Medical Center, The Netherlands 3 Department of Cardiology, Odense University Hospital, Denmark

2. CoRPS Disclosures Cameron Health Medtronic Sanofi-Aventis St. Jude Medical Moderate speaker or consultancy fees, or independent research grants:

3. CoRPS Prevalence of distress in ICD patients Psychological morbidity: Anxiety/depression ≈ 25% Posttraumatic stress ≈ 12% Chronic anxiety ≈ 50% Versteeg et al. Int J Cardiol 2011;146:438-9; Pedersen et al. Int J Cardiol 2011;147:420-3; von Känel et al. J Affect Disord 2011;131:344-52 Subset of patients (1 in 4) Depression: 11% to 28% Anxiety: 11% to 26%

4. CoRPS Should we take distress in ICD patients seriously? Braunschweig, Boriani,... Pedersen et al. Europace 2010;12:1673-90 Stressed out - ME???!!!

5. CoRPS Down in the dumps Feeling blue Angry Worried Bad mood Unhappy Type D ? Type D personality - burden of increased negative emotions and inhibition No!! I do not want to share my emotions with others… No!! I do not want to share my emotions with others…

6. CoRPS Type D personality: An important risk marker for poor prognosis Denollet et al. Circ Cardiovasc Qual Outcomes 2010;3:546-57 Mean OR across 9 studies: 3.7 [95% CI 2.7-5.1]

7. CoRPS Pedersen, Jordaens, Theuns et al. Europace 2010;12:1446-52 Type D personality, pre-implantation ICD concerns and mortality HR: 2.38 [95% CI:1.08-5.23]; p = 0.03 11.0% 4.5% HR: 2.74 [95% CI:1.24-6.03]; p = 0.01 13.3% 4.9% (N = 371)

8. CoRPS Posttraumatic stress symptoms and mortality Ladwig et al. Arch Gen Psychiatry 2008;65:1325-30 HR: 3.45 [95% CI:1.57-7.60]; p = 0.02 (N = 211)

9. CoRPS What about depression?

10. CoRPS Study objectives To examine: (i)the influence of depression on mortality (ii)whether specific depressive symptoms drive the relationship between depression and mortality

11. CoRPS Methods: Participants Consecutive patients (N = 430; 79% men; mean age = 58 ± 12) with a first-time ICD or CRT-D Implanted between August 2003 to March 2010 in the Erasmus Medical Center, Rotterdam Participating in Mood and personality as precipitants of arrhythmia in patients with an Implantable cardioverter Defibrillator: A prospective Study (MIDAS)

12. CoRPS Methods: Design and measures Prospective follow-up study – 2 ½ years (range 47 days to 3 years) Demographic and clinical characteristics (incl. device therapy) obtained from medical chart abstraction and purpose-designed questions Patients completed: o 7-item depression scale at baseline – Hospital Anxiety and Depression Scale (HADS) Statistical analysis: Univariable and multivariable Cox’s proportional hazard regression analysis

13. CoRPS Results: Mortality stratified by depression (cut-off ≥8) 11% died (47/430) during the follow-up period HR: 2.31 [95% CI:1.30-4.12]; p = 0.005 8.4% 18.5% * HR: 2.16 [95% CI:1.20-3.89]; p = 0.01 * Adjusted for gender, age, indication for ICD implantation, symptomatic heart failure, beta-blocker therapy, appropriate shocks HR: 1.12 [95% CI:1.05-1.20]; p < 0.001 Percentage

14. CoRPS Results: Mortality stratified by specific depressive symptoms HADS-D (item)HR[95% CI]p “Do not enjoy the things I used to” (#2)1.57[1.15-2.13]0.004 “Cannot laugh and see funny side” (#4)1.44[0.98-2.11]0.06 “Do not feel cheerful” (#6)1.33[0.96-1.84]0.09 “Feel as if I am slowed down” (#8)1.33[0.97-1.83]0.08 “Lost interest in my appearance” (#10)1.85[1.33-0.97]<0.0001 “Hardly ever look forward with enjoyment to things” (#12) 1.70[1.27-2.29]<0.0001 “Cannot enjoy a good book radio or TV program” (#14) 1.30[0.98-1.72]0.07

15. CoRPS Take home message Depression was associated with a 2-fold risk for mortality – independent of demographic and clinical risk factors including shocks Cardio-toxic symptoms of depression – tapping into feelings of anhedonia (i.e., lack of positive affect) but also depression Depression in ICD patients should be taken seriously – hampers patient survival despite state- of-the-art treatment

16. CoRPS Acknowledgements Funding VENI grant (451-05-001) from the Netherlands Organization for Scientific Research (NWO) VIDI grant (91710393) from the Netherlands Organization for Health Research and Development (ZonMw) FUNDING Center of Research on Psychology in Somatic diseases, Tilburg University, The Netherlands Research team Co-authors Dominic Theuns (PhD), Erasmus MC Luc Jordaens (MD, PhD), Erasmus MC Ruud AM Erdman (PhD), Erasmus MC