Clinical Practice & Epidemiology in Mental Health




ISSN: 1745-0179 ― Volume 14, 2018
RESEARCH ARTICLE

Takotsubo Syndrome is Associated with Mood Disorders and Antidepressants Use, not with Anxiety and Impairment of Quality of Life Due to the Psychiatric Disorder



F. Sancassiani1, *, Mauro G. Carta1, Roberta Montisci1, Antonio Preti1, Sergio Machado2, 3, Maria F. Moro1, Maria F. Marchetti1, Luigi Meloni1
1 Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
2 Laboratory of Panic and Respiration, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, Brazil
3 Physical Activity Neuroscience, Physical Activity Sciences Postgraduate Program - Salgado de Oliveira University, Niterói, Brazil

Abstract

Background:

The aim was to study the association between mood and anxiety disorders and the Tako-Tsubo Syndrome (TTS) and to determine the role of antidepressants and the impairment of quality of life due the comorbid psychiatric disorder.

Methods:

Case-control study: 19 consecutive patients (17 female) with TTS compared to 76 controls without TTS, were randomly selected from the database of a nationwide epidemiological study after matching (gender, age and residence) by controls. Psychiatric diagnoses were carried out according to the ICD-10 using semi-structured interview tools (ANTAS-SCID) administered by clinical staff. Quality of Life (Qol) was assessed by means of SF-12.

Results:

Only Major Depressive Disorders (MDD) showed higher frequencies in cases with statistical significance difference (p=0.014) as well as at least one Mood Disorder Diagnosis [MDD or BD] (p=0.002). The lifetime prevalence of at least one anxiety disorder with no comorbid mood disorder did not show a higher frequency in cases (p=0.57).

The score at SF-12 in the TTS group was similar to those of controls (p=0.71)In the TTS group, the score at SF-12 in people with one mood or anxiety diagnosis (N=7) was similar to those without mood or anxiety diagnosis (p=0.75). The use of antidepressants was higher in TTS group (15.79% vs 1.31%; p=0.030).

Conclusion:

The study shows an association between TTS with depressive disorders and antidepressants use and does not confirm the association with anxiety syndromes. The study suggests the need to investigate the possible interactions between antidepressants use and mood disorders in studies with appropriate design and sample size.

Keywords: Tako-Tsubo Syndrome, Mood disorders, Anxiety disorders, Post-traumatic stress disorder, Quality of life, Antidepressants, Psychiatric diagnoses.


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 14
First Page: 26
Last Page: 32
Publisher Id: CPEMH-14-26
DOI: 10.2174/1745017901814010026

Article History:

Received Date: 26/09/2017
Revision Received Date: 14/01/2018
Acceptance Date: 06/02/2018
Electronic publication date: 27/02/2018
Collection year: 2018

Article Metrics:

CrossRef Citations:
0

Total Statistics:

Full-Text HTML Views: 1382
Abstract HTML Views: 926
PDF Downloads: 663
ePub Downloads: 597
Total Views/Downloads: 3568

Unique Statistics:

Full-Text HTML Views: 516
Abstract HTML Views: 299
PDF Downloads: 215
ePub Downloads: 165
Total Views/Downloads: 1195
Geographical View

© 2018 Sancassiani et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Medical Science and Public Health, University of Cagliari, SS554, 09042 Monserrato Cagliari, Italy; Tel: +39 349 3119215; E-mail federicasancassiani@yahoo.it




1. BACKGROUND

Tako-Tsubo Syndrome (or stress-induced cardiomyopathy) is a reversible clinical entity that mimics acute myocardial infarction. Peculiar features of this syndrome are the lack of evidence of obstructive coronary artery disease on emergent coronary angiography and the transient left ventricular wall motion abnormalities most often involving the apical region that confers to the left ventricle, the typical shape of the pot used for trapping octopus in Japan named as “Tako-Tsubo Syndrome” [1Sato HT, Uchida T, Dote K, Ishihara M. Tako-tsubo-like left ventricular dysfunc- tion due to multivessel coronary spasm.Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure 1990; 56-64., 2Dote K, Sato H, Tateishi H, Uchida T, Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: A review of 5 cases. J Cardiol 1991; 21(2): 203-14. [abstract].[PMID: 1841907] ].

Although extensive myocardial dysfunction often resolves rapidly, mortality is comparable with that of patients with coronary acute syndromes [3Templin C, Ghadri JR, Diekmann J, et al. Clinical features and outcomes of takotsubo (stress) cardiomyopathy. N Engl J Med 2015; 373(10): 929-38.[http://dx.doi.org/10.1056/NEJMoa1406761] [PMID: 26332547] ].

The syndrome usually occurs in postmenopausal women and is typically elicited by emotional or physical stress. An acute increase in cathecolamine surge leading to severe coronary microvascular spasm with myocardial dysfunction has been proposed as the main pathogenetic mechanism and a prior history of mood and anxiety symptoms was found to be associated to this syndrome [4Williams R, Arri S, Prasad A. Current concepts in the pathogenesis of takotsubo syndrome. Heart Fail Clin 2016; 12(4): 473-84.[http://dx.doi.org/10.1016/j.hfc.2016.06.002] [PMID: 27638018] ]. The latter has been confirmed by the International Tako-tsubo Registry by showing that lifetime psychiatric affective or anxiety disorders were more frequent in patients with Tako-Tsubo Syndrome than in patients with acute coronary syndrome (55.8% versus with 25.7% of cases) [3Templin C, Ghadri JR, Diekmann J, et al. Clinical features and outcomes of takotsubo (stress) cardiomyopathy. N Engl J Med 2015; 373(10): 929-38.[http://dx.doi.org/10.1056/NEJMoa1406761] [PMID: 26332547] ].

However, whether the vulnerable substrate for Tako-Tsubo Syndrome is the history of a mood or anxiety disorder in itself, due to the chronic distress, or the antidepressant drugs or, as it seems more likely, both psychiatric illness and treatment, remains unclear. In fact, many antidepressants produce a chronic increase in sympathetic nervous drive in cardiovascular circulation as a side effect of the increase of catecholamines in the central nervous system, that might be amplified acutely by a stressful trigger [5Madias JE. Is the association of history of psychiatric disorders with takotsubo syndrome partially mediated by the underlying psychotropic drug therapy? Int J Cardiol 2016; 220: 307-9.[http://dx.doi.org/10.1016/j.ijcard.2016.06.307] [PMID: 27390946] ].

An indisputable fact is the several cases of Tako-Tsubo Syndrome reported in the literarture induced as a consequence of convulsant antidepressant therapy in which the elevated levels of catecholamines subsequent to the convulsant antidepressant therapy may be implicated [6O’Reardon JP, Lott JP, Akhtar UW, Cristancho P, Weiss D, Jones N. Acute coronary syndrome (Takotsubo cardiomyopathy) following electroconvulsive therapy in the absence of significant coronary artery disease: case report and review of the literature. J ECT 2008; 24(4): 277-80.[http://dx.doi.org/10.1097/YCT.0b013e31815fa4ab] [PMID: 18955900] -9Narayanan A, Russell MD, Sundararaman S, Shankar KK, Artman B. Takotsubo cardiomyopathy following electroconvulsive therapy: An increasingly recognised phenomenon 2014.[http://dx.doi.org/10.1136/bcr-2014-206816] ].

A first important step in understanding the meaning of the association between psychiatric disorders and Tako-Tsubo Syndrome is to see if there is a specific association between particular anxiety or mood disorders. Until now, studies have been conducted using methodologies that only allow broad diagnoses of groups of disorders, such as structured clinical brief interviews [10Delmas C, Lairez O, Mulin E, et al. Anxiodepressive disorders and chronic psychological stress are associated with Tako-Tsubo cardiomyopathy- New Physiopathological Hypothesis. Circ J 2013; 77(1): 175-80.[http://dx.doi.org/10.1253/circj.CJ-12-0759] [PMID: 22987076] ], questionnaires [11Christensen TE, Bang LE, Holmvang L, et al. Neuroticism, depression and anxiety in takotsubo cardiomyopathy. BMC Cardiovasc Disord 2016; 16: 118.[http://dx.doi.org/10.1186/s12872-016-0277-4] [PMID: 27246461] ], or rating scales [12Goh AC, Wong S, Zaroff JG, Shafaee N, Lundstrom RJ. Comparing anxiety and depression in patients With takotsubo stress cardiomyopathy to those with acute coronary syndrome. J Cardiopulm Rehabil Prev 2016; 36(2): 106-11.[http://dx.doi.org/10.1097/HCR.0000000000000152] [PMID: 26468629] ], which allow the detection of only anxious or depressive symptoms without a specific diagnosis label.

The aim of this study is to clarify if there is an association between specific mood and anxiety disorders and the Tako-Tsubo Syndrome by using a semi-structured psychiatric interview conducted by clinical staff that allows diagnosis in accordance with the ICD-10 system [13WHO International Classification of Diseases: eighth revision 1992.] and a case-control design.

A secondary aim is to determine the impairment of quality of life due to the Tako-Tsubo Syndrome and the role of the concomitant psychiatric disorder, as well the role of concomitant life events.

2. METHODS

2.1. Design

It was a case control design.

2.2. Study Sample

The cases were 19 consecutive patients with Tako-Tsubo Syndrome admitted to the Coronary Care Unit of the University Hospital San Giovanni di Dio in Cagliari, Italy between January 2012 and December 2014. The control group included 76 subjects with no diagnosis of Tako-Tsubo Syndrome randomly selected from the databank of an epidemiological survey on health and mental health in Italy [14Carta MG, Moro MF, Pinna I, et al. The impact of Fibromyalgia Syndrome and the role of co-morbidity with Mood an Post-Traumatic Stress Disorder in worsening the Quality of Life. Int J Soc Psychiatry 2018.-16Carta MG, Moro MF, Lorefice L, et al. The risk of bipolar disorders in multiple sclerosis. J Affect Disord 2014; 155: 255-60.[http://dx.doi.org/10.1016/j.jad.2013.11.008] [PMID: 24295600] ]. The selection of sex- age- and residence- matched controls from the 3498 subjects was carried out with a randomized block design. A block that included all eligible age-matched (± 1 year), sex-matched and residence-matched (by Italian region) controls in the databank was built for each case. Four individuals per block were drawn for each case, excluding the selected subjects from the remaining blocks.

2.3. Psychiatric Diagnosis Interview, Tools, and Psychiatric Assessment

Patients were assessed one month after the acute events. The psychiatric interviews were conducted by means of the “Advanced Neuropsychiatric Tools and Assessment Schedule” (ANTAS) [17Carta MG, Aguglia E, Bocchetta A, Balestrieri M, Caraci F, Casacchia M. Dell 'Osso L, Di Sciascio G, Drago F, Faravelli C, Lecca ME, Moro MF, Morosini PL, Nardini M, Palumbo G, Hardoy MC. The use of antidepressant drugs and the lifetime prevalence of major depressive disorders in Italy. Clin Pract Epidemol Ment Health 2010; 6: 94-100.[http://dx.doi.org/10.2174/1745017901006010094] ]. A semi-structured clinical interview derived in part from the SCID-I non-patient version (SCID-I/NP) [18First M, Spitzer R, Gibbon M, Williams J. Structured clinical interview for DSM-IV axis I disorders, research version, non-patient edition (SCID-I/NP) 1997.] was used to assess the presence of psychiatric disorders according to the ICD-10 diagnosis [13WHO International Classification of Diseases: eighth revision 1992.].

The ANTAS tool was administered by clinical staff (physicians, psychologists) with adequate training. A previous study [17Carta MG, Aguglia E, Bocchetta A, Balestrieri M, Caraci F, Casacchia M. Dell 'Osso L, Di Sciascio G, Drago F, Faravelli C, Lecca ME, Moro MF, Morosini PL, Nardini M, Palumbo G, Hardoy MC. The use of antidepressant drugs and the lifetime prevalence of major depressive disorders in Italy. Clin Pract Epidemol Ment Health 2010; 6: 94-100.[http://dx.doi.org/10.2174/1745017901006010094] ] pointed out that diagnoses resulting from the ANTAS interview were comparable and reable to those found with SCID.

A questionnaire on psychotropic drug consumption, prescription circumstances and health services utilization was also adminstered in cases and controls [17Carta MG, Aguglia E, Bocchetta A, Balestrieri M, Caraci F, Casacchia M. Dell 'Osso L, Di Sciascio G, Drago F, Faravelli C, Lecca ME, Moro MF, Morosini PL, Nardini M, Palumbo G, Hardoy MC. The use of antidepressant drugs and the lifetime prevalence of major depressive disorders in Italy. Clin Pract Epidemol Ment Health 2010; 6: 94-100.[http://dx.doi.org/10.2174/1745017901006010094] ].

The perceived quality of life was measured by means of the Short Form Health Survey (SF-12) [19Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996; 34(3): 220-33.[http://dx.doi.org/10.1097/00005650-199603000-00003] [PMID: 8628042] ] in the Italian version [20Apolone G, Mosconi P, Quattrociocchi L, Gianicolo EA, Groth N, Ware JE. Questionario sullo stato di salute SF-12 versione italiana 2001.]. The SF-12 components are the seven dimensions: activity, limitations due to health conditions, emotional state, physical pain, perception of general health, vitality, social relationship and psychosocial disability. The tool measures the month prior to evaluation and higher scores correspond to a better quality of life.

2.4. Diagnosis of Tako-Tsubo Syndrome

The Mayo Clinic criteria were followed in diagnosing Tako-Tsubo Syndrome [21Bybee KA, Kara T, Prasad A, et al. Systematic review: Transient left ventricular apical ballooning: A syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 2004; 141(11): 858-65.[http://dx.doi.org/10.7326/0003-4819-141-11-200412070-00010] [PMID: 15583228] , 22Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction. Am Heart J 2008; 155(3): 408-17.[http://dx.doi.org/10.1016/j.ahj.2007.11.008] [PMID: 18294473] ], including:

  1. Transient regional left ventricular systolic dysfunction;
  2. Absence of obstructive coronary disease or acute plaque rupture (on angiography);
  3. New mild or moderate ECG abnormalities (such as ST elevation or T inversion) or elevation in cardiac troponin;
  4. Exclusion of pheochromocytoma or myocarditis.

2.5. Screening Controls for Tako-Tsubo Syndrome

During the interviews of the controls, each was asked about general wellbeing, consultation with physicians and diagnosis of illness, and medical tests they underwent routinely (e.g., work/education periodical controls or driver’s license or hunter’s license eligibility tests). Diagnosis of physical illness was reported on a structured form. People with acute or chronic myocardiopathy were excluded.

3. DATA ANALYSIS

Lifetime prevalence of ICD-10 [13WHO International Classification of Diseases: eighth revision 1992.], Major Depressive Disorder (MDD), Bipolar Disorder (BD) (including Bipolar I and Bipolar II), Post-Traumatic Stress Disorder (PTSD), Panic Disorder (PD) and Generalized Anxiety Disorder (GAD) were calculated in cases and controls. The odds ratio for each ICD-10 diagnosis, as well as for all mood disorders, for all anxiety disorders without comorbidity with mood disorders and for all mood or anxiety disorders (dependent variables) were calculated using the control group as a “pivot” with univariate analysis (owing to the matching method, the groups were balanced by age and gender). The analysis of variance (ANOVA one-way) was used for measuring the parametric variables; the χ2 test was used for nonparametric variables. The odds ratio and 95% confidence intervals (OR 95% CI) were calculated with Miettinen’s simplified method.

4. RESULTS

The study samples were represented by 19 cases (17 female) with a diagnosis of Tako-Tsubo Syndrome and by a control group of 76 subjects (68 females) without a diagnosis of Tako-Tsubo Syndrome; the matching method allowed controls to be perfectly homogeneous with cases by age and gender. The characteristics of cases and controls are reported in Table 1.

Table 1
Demographic characteristics of cases and controls.


Table 2 shows the lifetime prevalence and the measure of association of psychiatric disorders (MDD, BD, PTSD, PD and GAD) as well as all people with at least one mood disorder and all people with at least one anxiety disorder without comorbidity with mood disorders; all people with at least one mood or anxiety disorder in cases and controls. All psychiatric disorders evaluated in this study showed a higher prevalence in cases, but only in MDD, the difference reached statistical significance (26.3%)% vs 6.57%; χ2= 6.27, p=0.014) as well as the association of people with at least one mood disorder diagnosis and Tako-Tsubo Syndrome (31.5% vs 6.57%; χ2= 9.27, p=0.002). On the contrary, the lifetime prevalence of people with at least one anxiety disorder without mood disorder showed a low frequency in patients with Tako-Tsubo Syndrome. The difference versus controls did not reach statistical significance (10.52% vs 3.95%; χ2 with Yates correction 0.33, p=0.57).

Table 2
Lifetime prevalence of ICD-10 psychiatric disorders in cases and controls.


The SF-12 mean score±sd in the Tako-tsubo group was 34.76±6.92, versus 35.35±6.23 in the control group (ANOVA 1 way: df 1,93,94; F=0.4; p=0.71); the SF-12 mean score±sd in people with one mood or anxiety diagnosis in the Tako-tsubo group (N=7) was 34.00±2.92, versus 35.17±9.25 in people of the Tako-tsubo group without anxiety or mood diagnosis (ANOVA 1 way: df 1,17,10; F=0.104; p=0.75). In 17 out of 19 (84.47%) patients with Tako-Tsubo Syndrome, at least one relevant life event (such as death or severe illness of a relative, job loss, serious bickering in family or with friends) was found one month prior to hospitalization. The two cases without relevant life events showed no association with psychiatric disorders, and the frequency of prior life events in people with Tako-tsubo and psychiatric disorders compared to those with Tako-tsubo but without them (Fisher exact test = 0.508) showed no statistical significance.

The use of antidepressants in the month prior the interview, was found in 3 (15.79%) out of patients with Tako-Tsubo Syndrome and in 1 (1.31%) out of subjects in the control group (χ2 with Yates correcrion =4.71; p=0.030; OR=14.06; CI95% 1.17-376.14). Out of 3 cases using antidepressants in Tako-tsubo group, 1 was diagnosed of MDD, 1 of BD and 1 had no diagnosis of mood disorders at ANTAS-SCID; the control using antidepressants diagnosed MD. After direct standardization considering the freqeuency of mood disorder in the control group, the association with the use of antidepressants and Tako-Tsubo Syndrome became weak, and it was found at the limit of the statistical significance (9.3% vs 1.3%; χ2=0.064).

5. DISCUSSION

Our work has confirmed the association of the Tako-Tsubo Syndrome with mood disorders, and with depressive disorders in particular. Our data do not appear to confirm the association between Tako-tsubo and anxious syndromes previously reported in literature [10Delmas C, Lairez O, Mulin E, et al. Anxiodepressive disorders and chronic psychological stress are associated with Tako-Tsubo cardiomyopathy- New Physiopathological Hypothesis. Circ J 2013; 77(1): 175-80.[http://dx.doi.org/10.1253/circj.CJ-12-0759] [PMID: 22987076] , 12Goh AC, Wong S, Zaroff JG, Shafaee N, Lundstrom RJ. Comparing anxiety and depression in patients With takotsubo stress cardiomyopathy to those with acute coronary syndrome. J Cardiopulm Rehabil Prev 2016; 36(2): 106-11.[http://dx.doi.org/10.1097/HCR.0000000000000152] [PMID: 26468629] , 23Carta MG, Angermeyer MC, Sancassiani F, et al. A follow-up on patients with severe mental disorders in Sardinia after two changes in regional policies: Poor resources still correlate with poor outcomes. BMC Psychiatry 2013; 13: 333.[http://dx.doi.org/10.1186/1471-244X-13-333] [PMID: 24313930] ].

The study highlighted an association between Tako-Tsubo Syndrome and the use of antidepressants, but the sample is too small to perform a multivariate analysis to study the interaction of the two factors. The standardization of the case sample based on the frequency of mood disorders in the controls reduces the strength of the association between Tako-Tsubo Syndrome and the use of antidepressant drugs (in this way irrespective of the presence of mood disorders) at the limits of the statistical significance.

The divergence in the association with Tako-tsubo e Anxiety Disorders shown in literature data may be because this is the first study to have used diagnoses according to international criteria based on semi-structured clinical interviews conducted by the clinical staff [17Carta MG, Aguglia E, Bocchetta A, Balestrieri M, Caraci F, Casacchia M. Dell 'Osso L, Di Sciascio G, Drago F, Faravelli C, Lecca ME, Moro MF, Morosini PL, Nardini M, Palumbo G, Hardoy MC. The use of antidepressant drugs and the lifetime prevalence of major depressive disorders in Italy. Clin Pract Epidemol Ment Health 2010; 6: 94-100.[http://dx.doi.org/10.2174/1745017901006010094] , 23Carta MG, Angermeyer MC, Sancassiani F, et al. A follow-up on patients with severe mental disorders in Sardinia after two changes in regional policies: Poor resources still correlate with poor outcomes. BMC Psychiatry 2013; 13: 333.[http://dx.doi.org/10.1186/1471-244X-13-333] [PMID: 24313930] ]. In our survey, we separately analyzed the patients with anxiety disorders from those with comorbid anxiety-depression in order to understand if anxiety alone may be a determinant or if comorbidity with mood disorder could be a confounding factor.

Some previous studies used an anxiety disorder diagnosis in accordance with international classification systems [24Salmoirago-Blotcher E, Rosman L, Wittstein IS, et al. Psychiatric history, post-discharge distress, and personality characteristics among incident female cases of takotsubo cardiomyopathy: A case-control study. Heart Lung 2016; 45(6): 503-9.[http://dx.doi.org/10.1016/j.hrtlng.2016.07.008] [PMID: 27553636] ] such as DSM-IV TR [18First M, Spitzer R, Gibbon M, Williams J. Structured clinical interview for DSM-IV axis I disorders, research version, non-patient edition (SCID-I/NP) 1997.]. However, the diagnosis was based on clinical records and therefore, not verified through semi-structured interviews, which is recognized as the method most capable to producing reliable diagnoses in psychiatry. Other surveys adopted screening by brief structured clinical interviews [10Delmas C, Lairez O, Mulin E, et al. Anxiodepressive disorders and chronic psychological stress are associated with Tako-Tsubo cardiomyopathy- New Physiopathological Hypothesis. Circ J 2013; 77(1): 175-80.[http://dx.doi.org/10.1253/circj.CJ-12-0759] [PMID: 22987076] ], questionnaires [11Christensen TE, Bang LE, Holmvang L, et al. Neuroticism, depression and anxiety in takotsubo cardiomyopathy. BMC Cardiovasc Disord 2016; 16: 118.[http://dx.doi.org/10.1186/s12872-016-0277-4] [PMID: 27246461] ], or rating scales [12Goh AC, Wong S, Zaroff JG, Shafaee N, Lundstrom RJ. Comparing anxiety and depression in patients With takotsubo stress cardiomyopathy to those with acute coronary syndrome. J Cardiopulm Rehabil Prev 2016; 36(2): 106-11.[http://dx.doi.org/10.1097/HCR.0000000000000152] [PMID: 26468629] ] but this is the first study to the best of our knowledge that used a more complex methodology.

Anxiety and depression are often associated, especially in cardio-circulatory disorders [25Watkins LL, Koch GG, Sherwood A, et al. Association of anxiety and depression with all-cause mortality in individuals with coronary heart disease. J Am Heart Assoc 2013; 2(2): e000068.[http://dx.doi.org/10.1161/JAHA.112.000068] [PMID: 23537805] -28Carta MG, Sancassiani F, Pippia V, Bhat KM, Sardu C, Meloni L. Alexithymia is associated with delayed treatment seeking in acute myocardial infarction. Psychother Psychosom 2013; 82(3): 190-2.[http://dx.doi.org/10.1159/000341181] [PMID: 23548987] ]. However, in the broad spectrum of mood and anxiety disorders, there are different disorders requiring even different treatments. Although many antidepressants are also indicated in anxiety disorders, they are rarely used in anxiety disorders not associated with depression in Italy [29Carta MG, Tondo L, Balestrieri M, et al. Sub-threshold depression and antidepressants use in a community sample: Searching anxiety and finding bipolar disorder. BMC Psychiatry 2011; 11: 164.[http://dx.doi.org/10.1186/1471-244X-11-164] [PMID: 21985128] ].

If one attempts to gain a better understanding of whether the association of Tako-Tsubo Syndrome with depressive disorders is at least partly due to the use of antidepressants, adequate diagnoses should be used and the anxiety and depression disorders should be clearly distinguished.

On the other hand, the results may be affected by the fact that a study with a small sample size does not have the power to show differences in the association of Tako-tsubo with anxiety disorders that would have emerged in a larger sample. In any case, it must be emphasized that anxiety disorders have high rates of prevalence in the community: for example, a 12-month prevalence of 1.9-5.1% only for Generalized Anxiety Disorders (GAD) [30Wittchen HU. Generalized anxiety disorder: Prevalence, burden, and cost to society. Depress Anxiety 2002; 16(4): 162-71.[http://dx.doi.org/10.1002/da.10065] [PMID: 12497648] ]. With similar or even lower frequencies in the community, depressive disorders were found to be associated with Tako-Tsubo Syndrome in our sample. It has often been found that Tako-Tsubo Syndrome can be a consequence of stress and that the underlying element of the association may be due to the high stress associated with depressive anxiety disorders [10Delmas C, Lairez O, Mulin E, et al. Anxiodepressive disorders and chronic psychological stress are associated with Tako-Tsubo cardiomyopathy- New Physiopathological Hypothesis. Circ J 2013; 77(1): 175-80.[http://dx.doi.org/10.1253/circj.CJ-12-0759] [PMID: 22987076] ].

The data of our study neither reinforce nor contradict this hypothesis, but are based on theories that depressive lifetime disorders may lower the vulnerability to stress and to the stress linked to life events [31Conway CC, Rutter LA, Brown TA. Chronic environmental stress and the temporal course of depression and panic disorder: A trait-state-occasion modeling approach. J Abnorm Psychol 2016; 125(1): 53-63.[http://dx.doi.org/10.1037/abn0000122] [PMID: 26595465] ]. In our sample, we found high percentages of both depressive disorders and life events in people with Tako-Tsubo Syndrome; these are the elements that may suggest a role of depressive disorders per se, independently of the treatment as a possible causal factor. On the other hand, the cases in our observations showed no impairment of the quality of life of those with Tako-Tsubo Syndrome only or, above all, of those with associated mood disorder, so that one may suspect that the effect on stress of the mood disorders alone may not be sufficient to support that the cause of the association is the depressive disorders alone.

6. LIMITS

A limitation of this survey is the fact that, while the cases received a diagnosis of Tako-Tsubo Syndrome in a clinical setting according to the standard criteria, in the control sample, the diagnoses were based only on medical history and previous investigations. Thus, a number of people who screened negative for Tako-Tsubo Syndrome may be undiagnosed. But this limit does not detract from the relevance of the association with mood disorders, because, in the light of possible false positives in the control group, it will only decrease the measure of association between cases and controls. Also given the low frequency of the Tako-Tsubo Syndrome, the chance of a case between the controls is really low.

CONCLUSION

Our work, first carried out with psychiatric semi-structured interviews administered by clinicians, has confirmed the association of the Tako-Tsubo Syndrome with mood disorders and with depressive disorders in particular.

The results do not appear to confirm the association between Tako-Tsubo Syndrome and anxious syndromes.

Data on the use of antidepressants suggests an effect of these drugs regardless of the effect of depression but the results are not conclusive. The study suggests the need for studies with adeguate sample size and methods to better define if there is an independent role of the two factors (depressive disorders and antidepressants use) and/or a possible interaction.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The study was carried out according to the ethical principles of the Helsinki Declaration. The ethics committee of the Italian National Health Institute (Rome) approved the epidemiological survey from which data bank controls have been drawn, the approved project planned a series of case control studies using the data bank of the study. The ethics committee of the Azienda Mista Ospedaliero Universitaria di Cagliari, Italy approved the study presented in this paper.

HUMAN AND ANIMAL RIGHTS

No animal were used in this study, Reported experiments on humans were in accordance with the ethical standards of the committee responsible for human experimentation (institutional national), and with the Helsinki Declaration of 1975, as revised in 2008 (http://www.wma.net/20activities/10ethics/10helsinki/).

CONSENT FOR PUBLICATION

The participants gave their written informed consent forparticipation and for the subsequent publication of the results. Data were anonymously collected with a code number identifying each subject.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Sato HT, Uchida T, Dote K, Ishihara M. Tako-tsubo-like left ventricular dysfunc- tion due to multivessel coronary spasm.Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure 1990; 56-64.
[2] Dote K, Sato H, Tateishi H, Uchida T, Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: A review of 5 cases. J Cardiol 1991; 21(2): 203-14. [abstract].[PMID: 1841907]
[3] Templin C, Ghadri JR, Diekmann J, et al. Clinical features and outcomes of takotsubo (stress) cardiomyopathy. N Engl J Med 2015; 373(10): 929-38.[http://dx.doi.org/10.1056/NEJMoa1406761] [PMID: 26332547]
[4] Williams R, Arri S, Prasad A. Current concepts in the pathogenesis of takotsubo syndrome. Heart Fail Clin 2016; 12(4): 473-84.[http://dx.doi.org/10.1016/j.hfc.2016.06.002] [PMID: 27638018]
[5] Madias JE. Is the association of history of psychiatric disorders with takotsubo syndrome partially mediated by the underlying psychotropic drug therapy? Int J Cardiol 2016; 220: 307-9.[http://dx.doi.org/10.1016/j.ijcard.2016.06.307] [PMID: 27390946]
[6] O’Reardon JP, Lott JP, Akhtar UW, Cristancho P, Weiss D, Jones N. Acute coronary syndrome (Takotsubo cardiomyopathy) following electroconvulsive therapy in the absence of significant coronary artery disease: case report and review of the literature. J ECT 2008; 24(4): 277-80.[http://dx.doi.org/10.1097/YCT.0b013e31815fa4ab] [PMID: 18955900]
[7] Serby MJ, Lantz M, Chabus BI, Bernay LJ. Takotsubo cardiomyopathy and electroconvulsive treatments: A case study and review 2010.[http://dx.doi.org/10.2190/PM.40.1.g]
[8] Celano CM, Torri A, Seiner S. Takotsubo cardiomyopathy after electroconvulsive therapy: A case report and review. J ECT 2011; 27(3): 221-3.[http://dx.doi.org/10.1097/YCT.0b013e31821537c0] [PMID: 21673587]
[9] Narayanan A, Russell MD, Sundararaman S, Shankar KK, Artman B. Takotsubo cardiomyopathy following electroconvulsive therapy: An increasingly recognised phenomenon 2014.[http://dx.doi.org/10.1136/bcr-2014-206816]
[10] Delmas C, Lairez O, Mulin E, et al. Anxiodepressive disorders and chronic psychological stress are associated with Tako-Tsubo cardiomyopathy- New Physiopathological Hypothesis. Circ J 2013; 77(1): 175-80.[http://dx.doi.org/10.1253/circj.CJ-12-0759] [PMID: 22987076]
[11] Christensen TE, Bang LE, Holmvang L, et al. Neuroticism, depression and anxiety in takotsubo cardiomyopathy. BMC Cardiovasc Disord 2016; 16: 118.[http://dx.doi.org/10.1186/s12872-016-0277-4] [PMID: 27246461]
[12] Goh AC, Wong S, Zaroff JG, Shafaee N, Lundstrom RJ. Comparing anxiety and depression in patients With takotsubo stress cardiomyopathy to those with acute coronary syndrome. J Cardiopulm Rehabil Prev 2016; 36(2): 106-11.[http://dx.doi.org/10.1097/HCR.0000000000000152] [PMID: 26468629]
[13] WHO International Classification of Diseases: eighth revision 1992.
[14] Carta MG, Moro MF, Pinna I, et al. The impact of Fibromyalgia Syndrome and the role of co-morbidity with Mood an Post-Traumatic Stress Disorder in worsening the Quality of Life. Int J Soc Psychiatry 2018.
[15] Carta MG, Conti A, Lecca F, et al. The burden of depressive and bipolar disorders in celiac disease. Clin Pract Epidemiol Ment Health 2015.
[16] Carta MG, Moro MF, Lorefice L, et al. The risk of bipolar disorders in multiple sclerosis. J Affect Disord 2014; 155: 255-60.[http://dx.doi.org/10.1016/j.jad.2013.11.008] [PMID: 24295600]
[17] Carta MG, Aguglia E, Bocchetta A, Balestrieri M, Caraci F, Casacchia M. Dell 'Osso L, Di Sciascio G, Drago F, Faravelli C, Lecca ME, Moro MF, Morosini PL, Nardini M, Palumbo G, Hardoy MC. The use of antidepressant drugs and the lifetime prevalence of major depressive disorders in Italy. Clin Pract Epidemol Ment Health 2010; 6: 94-100.[http://dx.doi.org/10.2174/1745017901006010094]
[18] First M, Spitzer R, Gibbon M, Williams J. Structured clinical interview for DSM-IV axis I disorders, research version, non-patient edition (SCID-I/NP) 1997.
[19] Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996; 34(3): 220-33.[http://dx.doi.org/10.1097/00005650-199603000-00003] [PMID: 8628042]
[20] Apolone G, Mosconi P, Quattrociocchi L, Gianicolo EA, Groth N, Ware JE. Questionario sullo stato di salute SF-12 versione italiana 2001.
[21] Bybee KA, Kara T, Prasad A, et al. Systematic review: Transient left ventricular apical ballooning: A syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 2004; 141(11): 858-65.[http://dx.doi.org/10.7326/0003-4819-141-11-200412070-00010] [PMID: 15583228]
[22] Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction. Am Heart J 2008; 155(3): 408-17.[http://dx.doi.org/10.1016/j.ahj.2007.11.008] [PMID: 18294473]
[23] Carta MG, Angermeyer MC, Sancassiani F, et al. A follow-up on patients with severe mental disorders in Sardinia after two changes in regional policies: Poor resources still correlate with poor outcomes. BMC Psychiatry 2013; 13: 333.[http://dx.doi.org/10.1186/1471-244X-13-333] [PMID: 24313930]
[24] Salmoirago-Blotcher E, Rosman L, Wittstein IS, et al. Psychiatric history, post-discharge distress, and personality characteristics among incident female cases of takotsubo cardiomyopathy: A case-control study. Heart Lung 2016; 45(6): 503-9.[http://dx.doi.org/10.1016/j.hrtlng.2016.07.008] [PMID: 27553636]
[25] Watkins LL, Koch GG, Sherwood A, et al. Association of anxiety and depression with all-cause mortality in individuals with coronary heart disease. J Am Heart Assoc 2013; 2(2): e000068.[http://dx.doi.org/10.1161/JAHA.112.000068] [PMID: 23537805]
[26] Machado S, Sancassiani F, Paes F, Rocha N, Murillo-Rodriguez E, Nardi AE. Panic disorder and cardiovascular diseases: An overview. Int Rev Psychiatry 2017; 29(5): 436-44.[http://dx.doi.org/10.1080/09540261.2017.1357540] [PMID: 28893114]
[27] Meloni L, Montisci R, Pippia V, Sancassiani F, Carta MG. Alexithymia affects the time from symptom onset to calling the emergency system in STEMI patients referred for primary PCI. Int J Cardiol 2016; 219: 428-32.[http://dx.doi.org/10.1016/j.ijcard.2016.06.038] [PMID: 27372605]
[28] Carta MG, Sancassiani F, Pippia V, Bhat KM, Sardu C, Meloni L. Alexithymia is associated with delayed treatment seeking in acute myocardial infarction. Psychother Psychosom 2013; 82(3): 190-2.[http://dx.doi.org/10.1159/000341181] [PMID: 23548987]
[29] Carta MG, Tondo L, Balestrieri M, et al. Sub-threshold depression and antidepressants use in a community sample: Searching anxiety and finding bipolar disorder. BMC Psychiatry 2011; 11: 164.[http://dx.doi.org/10.1186/1471-244X-11-164] [PMID: 21985128]
[30] Wittchen HU. Generalized anxiety disorder: Prevalence, burden, and cost to society. Depress Anxiety 2002; 16(4): 162-71.[http://dx.doi.org/10.1002/da.10065] [PMID: 12497648]
[31] Conway CC, Rutter LA, Brown TA. Chronic environmental stress and the temporal course of depression and panic disorder: A trait-state-occasion modeling approach. J Abnorm Psychol 2016; 125(1): 53-63.[http://dx.doi.org/10.1037/abn0000122] [PMID: 26595465]

Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


Browse Contents



Advertisements


Webmaster Contact: info@benthamopen.com
Copyright © 2018 Bentham Open