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Annals of Psychophysiology                                                                                                              Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                   www.aeirc-edu.com 

ISSN 2412 - 3188 
 

Original Article 

Depressive Symptoms among Patients of  

Myocardial Infarction 

Aatir H. Rajput1, Hina Naz2 & Anser Iqbal3 
Virtual University of Pakistan1 

Liaquat University Hospital, Hyderabad2 and 3 

Liaquat University of Medical & Health Sciences, Jamshoro1, 2 and 3 

Corresponding Author: aatirh.rajput@gmail.com 

 

Abstract 
Objective To investigate the prevalence of depressive symptoms among pre-diagnosed patients of 

myocardial infarction at a tertiary care hospital in Hyderabad. Methodology This observational, 

cross-sectional communal survey comprised of a sample of 100 patients chosen via simple random 

sampling from 1st December 2015 to 28th February 2016. Written informed consent was obtained 

before collecting data using interview based structured questionnaires. The data obtained was 

analyzed using SPSS v. 19.0 and Microsoft Excel 2013. Results All the patients in the study 

belonged to an age group between 40 to 90 years. 69% of them being males and 31% females. 

48% were uneducated while 52% were educated. 54% belonged to lower economic class, 43 were 

middle class and just 3% belonged to higher economic class. Mean depression score remained 

16.12 for the patients with single heart attack whereas for the patients with repeated heart attacks 

the score was 19.62. 83% of the patients showed symptoms of anxiety. 51% were retarded in their 

speech and thought process, while 90% complained of difficulty in work. 62% complained of 

general aches, 54% had loss of appetite 38% had somatic complaints. 63% of the patients has 

health worries, 59% lost weight while 52% felt depressed. Conclusion Study suggests that patients 

belonged to an age group of mostly 40 and onwards. Major number of patients belonged to male 

gender. A significant number of patients were un-educated. Patients with repeated attacks showed 

higher levels of depression. Majority of the patients showed symptoms of depression and 

complaints due to it. 

 

Keywords 

Ischemia, Myocardial Infarction, Depression, Anxiety, Heart Attack and Depressive Symptoms. 

 

Introduction 

Although abundant scientific literature 

regarding mood disorders following 

myocardial infarction (MI) exists, the 

severity, prevalence, and persistence of 

depression have been uncertain, and standard 

rating scales and criteria for depressive 

disorders have infrequently been utilized. In 

1912, Herrick reported an absence of 

significant psychopathology in patients 

recovering from acute myocardial infarction 

(Herrick, 1912), but subsequent investigators 

observed a high prevalence of depression 

(Weiss, 1957; Verwoerdt, 1964 & Rosen, 

1964) with adverse effects on rehabilitation 

(Wynn, 1967). Hackett and colleagues found 

that 80 percent of admissions for acute MI 

were anxious, 58 percent depressed, and that 

these symptoms were the most common 

cause for consultation referrals (Hackett, 

1968 & Cassem, 1971). 

 

Lloyd and Cawley examined 100 consecutive 

males admitted for first acute MI using the 

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Aatir H. Rajput 51 

  

Annals of Psychophysiology                                                                                                              Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                   www.aeirc-edu.com 

ISSN 2412 - 3188 
 

Standardized Psychiatric Interview (SPI) and 

ICD-8 psychiatric diagnoses (Lloyd, 1978; 

Lollyd & Cawley, 1982, 1983). “Psychiatric 

morbidity” was found among 35 percent of 

the sample at one week post-MI: sixteen 

patients were judged to have been 

psychiatrically ill at the time of MI, whereas 

nineteen developed their psychiatric disorder 

after the cardiac event. In the latter group, 

twelve patients had “depressive neurosis” 

and six had “anxiety neurosis,” but only 25 

percent maintained a psychiatric diagnosis at 

four and twelve months follow-up. There was 

a much wider range of psychiatric diagnoses 

in the sixteen patients whose psychiatric 

disorder preceded myocardial infarction, and 

75 percent were still psychiatrically ill at 

follow-up. 

 

More recently, Schleifer et al. interviewed 

283 acute MI patients using the Schedule for 

Affective Disorders and Schizophrenia 

(Schleifer, et al., 1989). They found that 18 

percent had “probable or definite” major 

depression (the proportion of “definite” cases 

was not specified) and 27 percent had minor 

depression by Research Diagnostic Criteria. 

Seventy-seven percent of the patients with 

major depression in hospital had major or 

minor depression at three months follow-up. 

Failure to return to work was most frequent 

among patients with persisting cardiac 

symptoms who also had major depression. 

We report the initial evaluation of a 

longitudinal investigation of patients 

hospitalized for acute MI.  

 

Methodology 
This observational, cross-sectional 

communal survey comprised of a sample of 

100 patients chosen via simple random 

sampling from 1st December 2015 to 28th 

February 2016. Written informed consent 

was obtained before collecting data using 

interview based structured questionnaires. 

The data obtained was analyzed using SPSS 

v. 19.0 and Microsoft Excel 2013.Our study 

utilized a structured psychiatric interview, 

standardized rating scales (for depression, 

social function, and intellectual or physical 

impairment), and DSM-III diagnostic 

criteria. 

 

Results 

All the patients in the study belonged to an 

age group between 40 to 90 years. 69% of 

them being males and 31% females. 48% 

were uneducated while 52% were educated. 

54% belonged to lower economic class, 43 

were middle class and just 3% belonged to 

higher economic class. The Figure 1 below, 

graphically illustrates the demographic 

spectrum of the sample clearly. 

 

 

 

 

 

 

 

 

 

 

 

 

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Aatir H. Rajput 52 

  

Annals of Psychophysiology                                                                                                              Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                   www.aeirc-edu.com 

ISSN 2412 - 3188 
 

Figure 1 Uneducated males belonging to the lower socioeconomic class dominated the 

sample in terms of quantity. While uneducated females belonging to higher socioeconomic 

class were present in the least quantity in the sample. 

 

 
 

Figure 2 Mean depression score remained 16.12 for the patients with single heart attack 

whereas for the patients with repeated heart attacks the score was 19.62. 83% of the 

patients showed symptoms of anxiety. 51% were retarded in their speech and thought 

process, while 90% complained of difficulty in work. 

 
 

 

 

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Aatir H. Rajput 53 

  

Annals of Psychophysiology                                                                                                              Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                   www.aeirc-edu.com 

ISSN 2412 - 3188 
 

Figure 3 Difficulty in work was the most common complaint, immediately followed by the 

complaint of anxiety. However, less than half of the sample complained of retardation in 

thinking and speech. 62% of the sample complained of general aches, 54% had loss of 

appetite 38% had somatic complaints. Figure 4 shows the problems in 

relation to each other graphically. 

 
Figure 4 shows the greatest proportion of patients reported to suffer from general aches, 

followed by the complaint of loss of appetite and then somatic complaints. All of these 

complaints can lead to serious discomfort if experienced chronically. 63% of the patients 

has health worries, 59% lost their weight while 52% felt depressed. Figure 5 below 

illustrates the intensity of the said problems. 

 
 

 

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Aatir H. Rajput 54 

  

Annals of Psychophysiology                                                                                                              Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                   www.aeirc-edu.com 

ISSN 2412 - 3188 
 

Figure 5 shows worries were high frequent among the patients and complaints of weight 

loss too were common. A little more than half of the sample self-professedly suffered from 

depression as well. 

 

 
 

 

Discussion 

The present study has demonstrated that 19 

percent of a series of acute MI patients had 

the DSM-III symptom cluster of major 

depression: Less severe forms of depression 

were far less prevalent: only 2 percent of the 

population had dysthymic disorder, and just 

5 percent had depressed mood in the absence 

of a DSM-III affective or anxiety disorder. 

Eight percent of the patients had generalized 

anxiety disorder. Several factors were 

associated with the diagnosis of mood 

disorder and its severity: gender, past history 

of mood disorder, large myocardial infarction 

(as indicated by peak CK > l500), severity of 

functional physical impairment (JHFI), and 

quality of social relationships (SFE).  

 

Our study population was predominantly 

male, and from lower socioeconomic classes. 

Thus, our results may not be fully applicable 

to patients with different demographic 

characteristics. Moreover, we could not 

reliably examine the most critically ill 

patients, and chose not to examine those 

scheduled for emergency bypass surgery or 

angioplasty (whose mental state would have 

been affected by intraoperative and 

postoperative variables in addition to MI). 

However, we did sample patients from three 

different hospital settings, and this should 

enhance the generalizability of our findings 

to other groups of patients of similar medical 

acuity. Finally, we failed to enlist a 

substantial number of patients secondary to 

refusal or early discharge. Whether 

assessments of such patients would have 

substantially affected the prevalence of 

depression is uncertain. Future studies with 

other patient groups are needed to 

corroborate the generalizability of our 

findings. 

 

Early studies of acute MI inpatients reported 

prevalence rates for depression ranging from 

22 percent to 64 percent, although none of 

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Aatir H. Rajput 55 

  

Annals of Psychophysiology                                                                                                              Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                   www.aeirc-edu.com 

ISSN 2412 - 3188 
 

these studies utilized strict diagnostic criteria 

and structured psychiatric interviews for the 

assessment of depression (Weiss, 1957; 

Verwoerdt, 1964; Rosen, 1964; Hackett, 

1968 & Cawley, 1971). The largest 

outpatient study of depression in patients 

with ischemic heart disease found that 

depression contributed to disability in 40 

percent of cases (Wynn, 1967). This 

important study, however, investigated only 

patients “whom standard medical measures 

had failed to rehabilitate,” and therefore 

probably exaggerated the prevalence of 

psychiatric cases. The comparatively lower 

prevalence of depression found in our study 

is in accord with more recent investigations: 

Cay et al. found that 26 percent of 131 acute 

MI patients were depressed and 32 percent 

were anxious, using “maximal clinical 

estimates” without specific diagnostic 

criteria (Cay, et al.,1972). Stem and 

colleagues found depression in 25 percent of 

acute MI cases, using clinical impressions in 

their initial study and Zung Self-Rating 

Depression Scales > 40 as the criterion in 

their second investigation (Stem et al; 1972, 

1973). Lloyd and Cawley’s work, detailed 

above, found ICD-8 “depressive neurosis” in 

18 percent of patients (Lloyd, 1978; 1982 & 

1983). Schleifer, et al., did observe 

depressive syndromes in 45 percent of their 

sample, but the majority of these were minor 

depressions (Schleifer, et al., 1978). Stem et 

al. found that six weeks after MI, 25 percent 

to 50 percent of depressed patients admitted 

to anxiety or depression in the preceding 

year. (Stern M. J. et al., 1976 & 1977).   (Cay, 

et al., 1972) reported that two thirds of the 

patients they rated as emotionally disturbed 

post-MI reported mounting psychological 

distress pre-MI. Lloyd and Cawley found that 

one third of their patients with depressive 

neurosis were psychiatrically ill prior to their 

MI (Lloyd, 1978; 1982 & 1983). Schleifer, et 

al., found no such correlation with prior 

mood disorder, but speculated that their 

patients may have underreported their past 

histories (Schleifer, et al., 1978).  

 

We suspect that the greater frequency of 

major depression versus dysthymic disorder 

in our study is partly the reflection of pre-

existing genetic vulnerability to severe forms 

of mood disorder being precipitated by the 

physiological and emotional distress of MI. 

Perhaps those without such a constitutional 

vulnerability develop only mild depressions, 

if they become depressed at all. Such a 

conclusion, of course, remains speculative 

because most of our patients with major 

depression had no known prior history of 

mood disorder, and family histories of mood 

disorder did not distinguish our diagnostic 

groups. Yet, we had only one informant for 

past personal and family psychiatric 

histories, and this probably underestimated 

such risk factors for affective disorder. Our 

observation of a greater vulnerability to 

depression among females post-MI has been 

suggested by Stem et al., and confirmed by 

(Schleifer, et al., 1978). This Observation, 

which appears to be independent of prior 

history of mood disorder, warrants further 

inquiry.  

 

Despite Cassem and Hackett’s comment that 

severity of depression positively correlated 

with severity of myocardial infarction 

(Cassem, 1971), subsequent quantitative 

assessments have generally failed to support 

this observation. Severity of infarction as 

measured by Peel and Norris indices have not 

positively correlated with psychiatric 

morbidity (Lloyd; 1978, 1982 & 1983) and 

Stem found no difference between depressed 

and non-depressed patients for peak CK 

values (Stern, M. J., et al., 1977). Our study, 

one of the few to quantitate peak CK as an 

independent variable, found no significant 

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Aatir H. Rajput 56 

  

Annals of Psychophysiology                                                                                                              Volume 4, July 2017 
©Advance Educational Institute & Research Centre                                                                   www.aeirc-edu.com 

ISSN 2412 - 3188 
 

evidence that large MIS contribute to 

depression severity.  

 

Many investigators have described post-MI 

depressions as “seldom pathological” 

(Hackett, T. P., et al., 1968; Cassem, N. H., 

et al., 1971) or “neurotic rather than 

psychotic” (Stern, 1976 & 1977). Others 

have noted more severe depressive problems 

requiring specific antidepressant treatment 

(Wynn, 1967; Schleifer, 1978 & Wishnie, 

1971). It is difficult to reconcile these 

divergent views simply because uniform 

diagnostic measures have not been used. 

Although certain aspects of our findings have 

been reported by other investigators, our 

study is one of the few to utilize a structured 

psychiatric interview with well-defined 

diagnostic criteria.  

 

Since our patients were examined in hospital 

within two weeks of MI, a strict DSM-III 

duration criterion for major depression 

obviously could not be utilized. It can 

however be argued that the DSM-III duration 

criterion for major depression is, at best, 

arbitrary, but it is a matter for inquiry whether 

the major depressive syndromes seen acutely 

in our patients will persist on longer term 

follow-up. If symptoms of major depression 

persist as reported by (Schleifer, et al., 1978) 

we believe that these are the patients most 

likely to benefit from specific antidepressant 

treatment, treatments which are safe if used 

carefully in this population (Goldman, 1986).  

 

Conclusion 
Study suggests that patients belonged to an 

age group of mostly 40 and onwards. Major 

number of patients were male. A significant 

number of patients were un-educated. 

Patients with repeated attacks showed higher 

levels of depression. Majority of the patients 

showed symptoms of depression and 

complaints due to it. 

 

Acknowledgements 

We would like to acknowledge the 

intellectual assistance and technical support 

provided by Dr. Muhammad Muneeb and 

LUMHS Research Forum.  

 

Conflict of Interest 
All the authors disclosed that there is no 

competing interest associated with the 

preparation of this article.  

 

Funding 
We declare that we did not acquire funding 

from any source. 

 

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