Journal Article Annotations
2018, 3rd Quarter

Infectious Diseases

Annotations by Aum Pathare, MD
October 2018

Anxiety and depression symptoms in a general population and future risk of bloodstream infection: The HUNT Study

PUBLICATION #1 — Infectious Diseases

Anxiety and depression symptoms in a general population and future risk of bloodstream infection: The HUNT Study

Askim Å, Gustad LT, Paulsen J, et al

Abstract: Psychosom Med 2018; 80(7):673-679

OBJECTIVE: We examined whether anxiety and depression symptoms constitute increased risk of bloodstream infection (BSI), as a proxy for sepsis.

METHODS: A general population with self-reported anxiety and depression symptoms was followed prospectively for hospital-verified BSI. Using multivariable Cox regression analysis, we estimated hazard ratios (HR) with 95% confidence intervals (CI) of BSI and BSI mortality, with and without statistical adjustment for comorbidities, BMI, and life-style factors that may confound or mediate the associations.

RESULTS: During 14.8 years, median follow-up of 59,301 individuals, 1578 (2.7%) experienced BSI and 328 (0.55%) participants died within 30 days after a BSI. Severe depression symptoms were associated with a 38% increased risk of BSI, adjusted for age, sex, and education (HR = 1.38, 95% CI = 1.10-1.73). The HR was attenuated to 1.23 (0.96-1.59) after adjustment for comorbidities and to 1.15 (0.86-1.53) after additional adjustment for BMI and life-style factors. For severe anxiety symptoms, the corresponding HRs were 1.48 (1.20-1.83), 1.35 (1.07-1.70), and 1.28 (0.99-1.64). Moderate symptoms of depression and anxiety were not associated with increased BSI risk. The analysis of BSI mortality yielded imprecise results but suggested an increased risk of BSI mortality in participants with moderate depression symptoms.

CONCLUSIONS: Severe depression and anxiety symptoms were associated with a moderately increased risk of BSI. The association may, at least in part, be confounded or mediated by comorbidities, BMI, and life-style. Future research should investigate whether interventions targeting improved BMI and life-style may reduce the risk of BSI and sepsis in people with depression and anxiety symptoms.

On PubMed: Psychosom Med 2018; 80(7):673-679

Annotation

Type of study: Population-based cohort study

The finding: Severe symptoms of anxiety and depression were associated with an elevated risk of bloodstream infection, with adjustment for comorbidities, BMI and lifestyle partly attenuating the risk. A similar trend was noted with moderate depressive symptoms and BSI-linked mortality, although the relatively low total number of events limit the utility of this finding. Two measurements of elevated mixed symptom scores of anxiety and depression, in the first and second study (ten years apart), did not constitute any higher risk than one measurement alone at baseline.

Strength and weaknesses: The population-based nature of the study, large sample, and a well-linked health care system are the strengths for this study. The Hospital Anxiety and Depression Scale (HADS), and Anxiety and Depression Index (ADI-4), preclude the inclusion of somatic symptoms overlapping with anxiety and depression, but are less specific, report smaller effects than clinical interviews, and are not considered diagnostic. The chronological sequence of events is unclear, especially as the symptom scales offer only a cross-sectional view of the patient’s state.

Relevance: BSI is a significant cause of mortality and morbidity, meeting clinical sepsis criteria in ~98% of the patients. Other studies have shown increased HADS (A & D) scores to be associated with worse physical health, along with nonadherence towards interventions for changing the lifestyle, such as healthy eating, physical activity, and smoking cessation, which are in turn found to increase the risk of sepsis. In this study, severe anxiety and depression symptoms were associated with an increased risk of BSI, again modulated by BMI, lifestyle and comorbid conditions. Early focus on detection and treatment of these psychiatric symptoms may lower catastrophic complications associated with BSI, and positively influence other risks associated with sepsis, which appear have a bidirectional relationship with them. This is especially relevant as integrated care expands, specifically in initiatives for infection prevention, in order to utilize appropriate behavioral health screening/treatment with C-L psychiatrist participation.