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INTRODUCTION
R. M. CARNEY et al.
METHODS
Subjects
Subjects were recruited for this study from a
sequential series of patients with documented acute
myocardial infarction who were admitted to the
Barnes Hospital Coronary Care Unit. Infarction was
documented in all patients by the presence of chest
pain compatible with ischemia, electrocardiographic
changes, and a rising and falling pattern of MBcreatine kinase (MB-CK) characteristic of acute infarction with at least one level above the upper
bound of the reference range (5). Patients admitted
to the study had to be: (1) under 70 years of age; (2)
without history or evidence of a previous MI; (3)
without history of angioplasty or coronary artery
bypass surgery; (4) without severe diabetes or other
chronic medical illnesses; (5) without present diagnosis of congestive heart failure, valvular heart disease (except mitral valve prolapse), or severe mental
impairment; (6) able to complete the psychiatric
diagnostic interview and psychological testing; (7)
permitted by the patient's cardiologist to participate
in the study.
The first 70 patients who met these criteria and
who agreed to participate were enrolled during the
five to seven days immediately following the acute
myocardial infarction.
Procedure
A modified version of the affective disorders section of the Diagnostic Interview Schedule (DIS) (6)
was used to assess the presence of symptoms of
depression and determine the presence and duration
of sleep complaints. The DIS is a structured interview developed by the National Institutes of Mental
Health for epidemiologic studies of psychiatric disorder. It has been shown in previous studies to be
both reliable and valid (7-9). Modifications of the
DIS included the addition of questions to determine
the onset and duration of each symptom and questions regarding the specific type of insomnia (sleep
onset, interval, or terminal) experienced by the patient. Following the DIS, patients were asked questions regarding the presence and time of onset of
symptoms of medical and cardiovascular illnesses,
including angina. Patients were interviewed after
agreeing to be enrolled in the study. The interview
604
was administered by two lay interviewers with extensive training and experience in administering the
DIS. Two senior clinicians independently reviewed
the interview results for each subject and rendered
diagnoses according to DSM-II1-R criteria (10). One
hundred percent agreement was achieved between
the two clinicians. The presence of a depressive
disorder at the time of myocardial infarction was
determined from the patients' retrospective report
of the duration of the relevant symptoms that they
had experienced prior to their myocardial infarction.
All medical and demographic information was obtained from the patients' medical charts.
RESULTS
Nearly half of the patients who complained of insomnia for two weeks or
longer prior to their acute myocardial infarction met criteria for a major depressive episode. Twenty-three percent of the
total sample of patients met the DSM-IIIR criteria for a major depressive episode.
This rate is close to the 18% prevalence
estimate of major depressive disorder reportedly recently by Schleifer et al. (12)
using the Research Diagnostic Criteria
(11), and to the 18% which we reported
for CAD patients without myocardial infarction. Patients with insomnia who did
605
R. M. CARNEY et al.
TABLE 1. Means (Standard Deviations) and Frequencies of Selected Medical and Demographic
Variables for MDE Patients and Non-MDE Patients with and without Insomnia
Variables
Mean age
Mean number of alcoholic
drinks weekly
Mean number of cigarettes
daily (current smokers)
Current smokers
Sex (% females)
History of angina
History of hypertension
History of diabetes
Chronic lung disease
Receiving beta-blockers
Receiving sleep medications
Receiving psychiatric medications
MDE
N= 16
Non-MDE
Insomnia
N = 14
Non-MDE
w/o
Insomnia
N = 37
53.4 (8.2)
2.9 (9)
54.7(7.9)
3.8 (5)
52.1 (10.6)
4.1 (5)'
F =
1.16
NS*
NS
28.8(16.2)
30.0(11.0)
27.8(15.6)
F =
0.96
NS
46%
14%
21%
40%
14%
0%
29%
7%
3%
X ==
x 2 ==
x 2 ==
x 2 ==
x 2 ==
FETt
X 2 ==
FET
FET
56%
50%
38%
38%
25%
6%
25%
6%
6%
43%
21%
23%
58%
14%
0%
19%
3%
0%
F = 0.71
0.7
8.2
4.5
1.3
0.5
0.6
NS
0.02
NS
NS
NS
NS
NS
NS
NS
ever, we were unable to rule out the possibility that some patients had this disorder.
The use of a retrospective self-report
interview to assess the presence of depression and insomnia is a limitation of this
study. Because of the difficulty in accurately predicting myocardial infarction,
even among high risk patients with
known coronary disease, it is difficult to
study this question prospectively. For this
reason, it is also difficult to use more
reliable means, such as sleep EEG, of documenting sleep disturbance. The DIS has
been carefully validated and has been
used in medical as well as psychiatric
populations to assess depressive symptoms. Nevertheless, patients with recent
myocardial infarction may not accurately
recall symptoms that occurred just prior
to their infarction. Our data must therefore be interpreted with caution.
A recent study of insomnia in the general population reported by Ford and Kamerow (14) showed a strong relationship
not only between insomnia and depression, but also between insomnia and anxiety disorders. The interview employed in
this study focused primarily on affective
disorders, so it was not possible to determine whether other psychiatric disorders
were also associated with some of the
cases of insomnia.
Ford and Kamerow (14) also found that
the risk of developing major depression
within one year after the first interview
was over 20 times greater for patients who
continued reporting insomnia, suggesting
that sleep disturbance in many cases may
be an early symptom of depression, or
may reflect an underlying process of affective disturbance. Unfortunately, we
did not obtain a follow-up interview of
subjects in this study and thus have no
information concerning how many of
Psychosomatic Medicine 52:603-609 (1990)
R. M. CARNEY et al.
REFERENCES
1. Falgar P, Schouten E, Appels A: Sleep complaints, vital exhaustion and depression, and myocardial
infarction. Washington DC, Proceedings of the Eighth Annual Scientific Session of The Society of
Behavioral Medicine, March 19-22, 1987, 58-59
2. Kuller L: Prodromata of sudden death and myocardial infarction. Adv Cardiol 2561-72, 1978
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