1. CoRPS Center of Research on Psychology in Somatic diseases Brief Depression Screening with the PHQ-2 Predicts Poor Prognosis following PCI with Drug-Eluting Stenting Susanne S. Pedersen (PhD), Tilburg University, The Netherlands

2. CoRPS Background Depression is a common co-morbid disorder of coronary artery disease (CAD), with a prevalence of around 25% Associated with increased morbidity, mortality, impaired quality of life, poor adherence, and rehospitalizations Depression as a prognostic marker in CAD has primarily been studied in patients post myocardial infarction A recent science advisory from the American Heart Association advocates routine screening for depression in clinical practice, using a two-stepped approach (PHQ-2 and PHQ-9) Nicholson et al. Eur Heart J. 2006; 27:2763-74 Lichtman et al. Circulation. 2008;118:1768-75

3. CoRPS Background The prognostic value of the PHQ-2 has not yet been examined in cardiac patients, nor its differential prognostic effect in men versus women The PHQ-2 may be a superior measure to the PHQ-9 in cardiac patients due to no somatic items  ongoing debate Feasible to use the PHQ-2 as screening in clinical practice due to brevity Faller et al. Eur J Heart Fail. 2007;9:1018-23 Thombs et al. J Gen Intern Med 2008;12:2014-7

4. CoRPS Objectives 1)Examine the prognostic value of the PHQ-2 in a consecutive series of patients treated with PCI, comparing the prognostic power of a continuous score versus different cut-off scores 2)Investigate whether the PHQ-2 has differential prognostic power in men versus women

5. CoRPS Methods Consecutive cohort of PCI patients treated between 15 February 2005 to 14 February 2006 in the Erasmus Medical Center, Rotterdam, The Netherlands Paclitaxel-eluting stent used as default strategy N=796; 72.1% men; mean age=62.5  11.5 74.2% response rate Information on demographic and clinical variables obtained from medical records Endpoint: Death or non-fatal myocardial infarction (MI) at 1 year

6. CoRPS Patient Health Questionnaire 2 (PHQ-2) A 2-item measure of depressive symptoms → cardinal symptoms of a clinical diagnosis of depression: o“Little interest or pleasure in doing things” o“Feeling down, depressed, or hopeless” Rated on a 4-point Likert scale from 0 (not at all) to 3 (nearly every day) – range 0-6 Cronbach’s alpha of.83 A cut-off ≥3 optimal balance between sensitivity and specificity for major depressive disorder In cardiac patients, a cut-off ≥2 exhibits an optimal balance between sensitivity and specificity Kroenke et al. Med Care 2003;41:1284-1292 Thombs et al. J Gen Intern Med. 2008;12:2014-2017

7. CoRPS Results Prevalence of depressive symptoms: Mean depression score = 1.01 ±1.42 at baseline Cut ≥1 = 45.9% (365/796) Cut-off ≥2 = 30.2% (240/796) Cut-off ≥3 = 11.9% (95/796)

8. CoRPS Impact on death/MI* - univariable analysis Continuous PHQ-2 depression – not significant (HR: 1.15; 95% CI: 0.97-1.36; p =.12) Cut-off ≥1 – a trend (HR: 1.76; 95% CI: 0.98-3.15; p =.057) Cut-off ≥3 – not significant (HR: 1.27; 95% CI: 0.57-2.83; p =.57) Cut-off ≥2 – significant; incidence of adverse clinical events was significantly higher in depressed versus non- depressed patients (8.8% versus 4.7%; p =.031) * (47 events: deaths = 35; MIs = 12)

9. CoRPS Incidence of death/MI stratified by depressive symptomatology (PHQ-2 cut-off ≥2)* 21/240 26/556 % HR: 1.89 [95% CI: 1.06-3.35] * The number of depressed versus non-depressed patients who had an event during the follow-up period is listed on top of bars

10. CoRPS Impact of depressive symptoms (cut-off ≥2) and other factors on death/MI* HR [95% CI]p Depressive symptoms1.90[1.05-3.42].03 Male gender1.07[0.56-2.04].83 Age1.05[1.02-1.08].001 Multi-vessel disease1.36[0.75-2.48].31 Cardiac history 1 0.81[0.43-1.53].52 Hypertension 2 0.82[0.43-1.55].54 Hypercholesterolemia 3 0.48[0.24-0.97].04 Diabetes 4 1.98[0.98-4.00].06 Smoking 5 2.42[1.27-4.61].007 * Multivariable logistic regression analysis; 1 Previous MI, PCI or CABG; 2 140/90 mmHg or being treated for hypertension; 3  240 mg/dL or being treated for hypercholesterolemia; 4 Being treated for diabete; 5 Based on the patient’s self-report

11. CoRPS Impact of depressive symptoms (cut-off ≥2) and other factors on death/MI, stratified by gender* * Multivariable logistic regression analysis; 1 Previous MI, PCI or CABG; 2 140/90 mmHg or being treated for hypertension; 3  240 mg/dL or being treated for hypercholesterolemia; 4 Being treated for diabetes; 5 Based on the patient’s self-report 10.4% vs. 3.9% 5.3% vs. 6.8%

12. CoRPS Limitations Potential selection bias – asked to complete PHQ- 2 30 days post PCI 47 events – risk of over fitted regression models No information on renal failure, angina, NYHA class, heart failure, participation in cardiac rehabilitation, education, the use of psychotropic medication and prior depression status

13. CoRPS Take home message... 2-item PHQ predicted adverse clinical events at follow-up when using a cut-off ≥2 on the scale  (2- fold independent risk) Neither a continuous score on the PHQ-2 nor other cut-offs were predictive of death/MI Depressive symptoms may exert a more deleterious effect in men than in women  should be confirmed in future studies The brief PHQ-2 can be used as a marker of poor prognosis in PCI/CAD patients

14. CoRPS Acknowledgements Erasmus Medical Center, Rotterdam: Patrick Serruys, MD, PhD Ron T van Domburg, PhD Cihan Simsek, MSc CoRPS, Tilburg University: Johan Denollet, PhD Peter de Jonge, PhD E-mail: s.s.pedersen@uvt.nl