Identifying the Internalizing Disorder Clusters Among Recently Hospitalized Cardiovascular Disease Patients: A Receiver Operating Characteristics Study

Abstract

Depression and anxiety disorders are common among cardiovascular disease (CVD) populations, leading several cardiology societies to recommend routine screening to streamline psychological interventions. However, it remains poorly understood whether routine screening in CVD populations identifies the broader groups of disorders that cluster together within individuals, known as anxious-misery and fear. This study examines the screening utility of four anxiety and depression questionnaires to identify the two internalizing disorder clusters; anxious-misery and fear. Patients with a recent hospital admission for CVD (n = 85, 69.4% males) underwent a structured clinical interview with the MINI International Neuropsychiatric Interview. The participants also completed the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7) scale, Overall Anxiety Severity Impairment Scale (OASIS), and the stress subscale of the Depression Anxiety Stress Scale (DASS). The PHQ-9 and the GAD-7 yielded appropriate screening properties to detect three different iterations of the anxious-misery cluster (sensitivity >80.95% and specificity >82.81%). The GAD-7 was the only instrument to display favorable screening properties to detect a fear cluster omitting post-traumatic stress disorder (PTSD) but including obsessive-compulsive disorder (OCD; sensitivity 81.25%, specificity 76.81%). These findings indicate that the PHQ-9 and GAD-7 could be implemented to reliably screen for anxious-misery disorders among CVD in-patients, however, the receiver operating characteristics (ROC) to detect fear disorders were contingent on the placement of PTSD and OCD within clusters. The findings are discussed in relation to routine screening guidelines in CVD populations and contemporary understandings of the internalizing disorders.

Keywords: anxiety; cardiovascular disease; depression; internalizing disorders; post-traumatic stress disorder; receiver operating characteristics.

FIGURE 1

A flow chart of participant eligibility through the study. Step 1 screening was performed in hospital. Step 2 screening was performed 2 weeks after the index CVD admission. CVD, cardiovascular disease; GAD-7, Generalized Anxiety Disorder scaIe-7; PHQ-9, Patient Health Questionnaire scale-9.

FIGURE 2

Screening measure AUC to detect anxious-misery disorders. Graph showing the AUC (sensitivity and 1- specificity) for the GAD-7, PHQ-9, OASIS, and DASS-stress scales to detect the anxious-misery^a cluster (major depressive disorder, dysthymia, generalized anxiety disorder, post-traumatic stress disorder, bipolar disorder). AUC, area under the curve; DASS-stress, Depression, Anxiety and Stress Scales-stress subscale; GAD-7, Generalized Anxiety Disorder 7 item scale; OASIS, Overall Anxiety Severity and Impairment Scale; PHQ-9, Patient Health Questionnaire scale 9 item scale.

FIGURE 3

Screening measure AUC to detect fear disorders. Graph showing the AUC (sensitivity and 1- specificity) for the GAD-7, PHO-9, OASIS, and DASS-stress scales to detect the fear^a cluster (panic disorder, agoraphobia, social anxiety disorder, obsessive-compulsive disorder). AUC, area under the curve; DASS-stress, Depression, Anxiety and Stress Scales-stress subscale; GAD-7, Generalized Anxiety Disorder 7 item scale; OASIS, Overall Anxiety Severity and Impairment Scale.