Managing Coronary Heart Disease Patients with Depression

Abstract

Introduction: Coronary heart disease (CHD) is the nature of heart disease that develops within the arteries making it unable to deliver enough oxygen-rich blood to the heart and the presence of depression in the patients with CHD reduces their quality of life.

Aim: The aim of the study is to investigate appropriateness of nursing care for managing coronary heart diseases patients with depression.

Methods: Systematic review of 12 articles that are selected based on inclusion and exclusion criteria are involved in the study.

Results: The Cardiac Depression Scale (CDS) and Hospital Anxiety and Depression Scale (HADS) are the two key tools identified as reliable to be used by nurses in screening depression level in CHD patients so that the patient’s level of distress can be determined and accordingly care can be delivered to them to ensure their enhanced health improvement both mentally and physically. Additionally, the healthcare dissertation help mention the importance of the dual-track intervention nursing model is mentioned to be followed by nurses as it is successful in lowering depression among CHD individuals. Moreover, personalised care delivery by nurses along with supporting leisure-time physical activity leads CHD individuals to overcome depression and show less anxious emotions. The use of multimedia information is to be made by nurses to create awareness regarding depression in CHD patients so that the patients can be made self-efficient to manage their mental health which is important for their physical health improvement.

Conclusion: The review concludes that depression in coronary heart disease (CHD) patients are common and effective nurse-led interventions help manage the condition which eventually helps to improve the quality of life of the patient with CHD.

Introduction

Depression and coronary heart disease (CHD) are seen to have a bi-directional relationship indicating that depression is a major risk factor for CHD and CHD is also responsible for causing depression. Thus, depression is found to be commonly present in CVD patients and vice-versa. Depression, as well as CHD, adversely affects the mental and physical health of the individuals making them develop low-quality life and well-being. In respect to depression and CHD, effective investigation regarding both the health issues and their inter-relationship is to be made to determine the way they affect the patients and care developed to overcome the effects. Depression and CHD in patients are mainly developed due to psychological pressure created through social life and health condition. Therefore, a detailed discussion on patients with coronary heart disease and depression is to be made in the research. This is to understand the efficacy of current nursing care for the coronary heart disease patients with depression in coping their deteriorated health problem to lead a healthy life.

Rationale of the Study

The UK Bank Cohort which includes 401,219 participants reflected that there are 21 cases of heart disease reported each 1000 individuals over 10 years who had high scoring of depression versus 14 cases of heart disease each 1000 individuals among the people who scored less in respect to depression. The risk of stroke caused by coronary heart disease was 15 per 1000 individuals which high depression score versus 10 per 1000 individuals with less depression scores (British Heart Foundation, 2020). This indicates that risk of heart diseases is increased by 7% and the risk of stroke increased by 5% per 1000 individuals who expressed higher symptoms of depression. Similar data is developed from the ERFC cohort of 162,036 individuals taken from 21 countries based on Europe and North America. It was reported from the cohort that 5078 cases of coronary heart disease and 3932 stroke events are seen in the ERFC population on following them for 9.5 years (Harshfield et al., 2020). In both the studies, the researchers informed they determine the score for depression in patients at the beginning of joining the study. It indicates that the patient’s feelings during the study are omitted and not included in the study (Harshfield et al., 2020; British Heart Foundation, 2020).

The presence of depression and coronary heart disease in individuals is considered an issue because they are a risk factor for one another and limits the ability of individuals to have improved health conditions. It is evident from the study of Zhang et al. (2018) which mentioned that depression leads to increase chances of coronary heart disease. This is because the presence of depression leads to increased risk of venous thromboembolism which is considered as life-threatening condition for people. This is because blood clots form within the veins leading to fatal condition. Moreover, the study by Penninx (2017) mentioned that depression accelerates the formation of atherosclerosis within the blood vessels that leads to create increased chances of coronary heart disease. In contrast, the study by Liu et al. (2017) informed that coronary heart disease leads to the development of depression that compromises the mental health and physical efficiency of individuals. This is because coronary heart disease (CHD) is considered a significant health problem due to its high prevalence and mortality rate that causes individuals to develop negative emotions such as depression, anxiety and stress.

Depression and coronary heart disease (CHD) have currently become an issue because both health problems are showing high prevalence among individuals with lack of effective nursing care been provided. It is evident as in the UK, nearly 7.6 million people (3.6 million women and 4 million men) are found to be currently suffering from coronary heart disease (CHD). Nearly, 6300 deaths in the UK occur each year due to CHD and other cardiovascular diseases which is equal to 170 death occurring each day and many of them suffer from depression which is not effectively cared to be resolved by the nurses (British Heart Foundation, 2019). Therefore, the figure indicates that both the health problems are increasing exponentially and effective investigation regarding the health issues is required as appropriate healthcare from nurses are not assured. The mentioned topic is important for me to be investigated because as a nursing professional I intend to develop evidence-based practise knolwdege regarding the way to support patients with cardiac issues who are also facing depression to have stable mental and emotional condition while coping with heart issues. The topic is also essential for me because in my family my father faced cardiac disease and depression which remained undetected for a long time resulting to cause him hindered mental and emotional health and hindered well-being in social and personal life. Thus, the current study is developed to examine the extent of appropriateness of nursing care provided to coronary heart disease patients with depression to cope with the condition to achieve enhanced emotional health and well-being.

Background of the Study

Concept of CHD

Coronary heart disease (CHD) is the nature of heart disease that develops within the arteries making it unable to deliver enough oxygen-rich blood to the heart. CHD is often developed due to atherosclerosis that is plaque deposition which is a waxy layer within the inner lining of the coronary arteries. The build-up of the layer results in partial or total blockage of the large arteries which leads to development of myocardial ischemia which occurs with complete or partial blockage of the coronary arteries. It results in the development of chest pain or discomfort of the chest followed by lightheadedness, pain, shortness of breath and others (Moholdt et al., 2018). This is because blockage of the arteries creates decreased blood flow to the heart resulting in the development of pain or angina in response to the condition (Hagström et al., 2017). The shortness of breath develops due to lack of enough oxygen-rich blood being sent to the heart that elevates pressure around the blood vessels surrounding the lungs (Moholdt et al., 2018).

Concept of Depression

Depression is referred to as a mood disorder that makes individuals feel sadness, increased anger, loss and others that interferes with the ability of a person to execute everyday activities (Azim and Baig, 2019). According to DSM-V, the key symptoms of major depressive disorder (MDD) or clinical depression are irritable mood, lack of interest in executing activities, unexplained weight change, psychomotor retardation or agitation, sleep disturbance, worthlessness feeling, reduced concentration and recurrent suicidal or harmful thoughts. The DSM-V mentions that at least five of the symptoms are required to be presented to indicate the patient is suffering from MDD or clinical depression (psychiatry.org, 2021). The presence of depression is a risky condition as it leads to create additional health problems such as thyroid, vitamin deficiency, coronary heart disease and others (Azim and Baig, 2019).

Factors influencing the development of Coronary Heart Disease (CHD)

Air pollution is one of the key factors responsible for causing coronary heart disease. This is because the particulate matter present in the polluted air accelerates the development of atherosclerosis in the arteries leading to development and worsening of CHD (Mossavar-Rahmani et al., 2019). The presence of high blood is another factor for development of CHD because the added pressure on the arterial walls leading to erosion of the inner lining of the cells that support the formation of plague associated with atherosclerosis (Zhao et al., 2017). The family history of heart disease acts as another risk factor for coronary heart disease. This is because genetic factors surpassed from one generation to another may lead the individual vulnerable to develop CHD (Mossavar-Rahmani et al., 2019). The lifestyle of individuals acts as major factor for development of CHD. This is evident as physical inactivity leads to development of cholesterol in the body and raises the risk of diabetes, obesity and others that are responsible for causing CHD. The lack of sleep leads to development of CHD because it leads the blood pressure to be elevated which gradually leads to development of CHD (Zhao et al., 2017). The increased rate of smoking along with depression leads to CHD because they cause tightening of the arteries leading to hindered blood flow to the heart (Zhao et al., 2017).

Factors influencing the development of Depression

The risk factors for depression include a family history of the condition as it is considered to be an inherited factor that leads an individual in the family to be prone to the disorder. However, the exact genes responsible for the development of depression are not yet known but multiple genes are found to be responsible for causing depression (Azim and Baig, 2019). The early childhood trauma of abuse in the family may leads individuals to develop depression. This is because of the fear and uncertain thoughts developed in the mind of the individual during stressful situations (Klein et al., 2017). The use of certain drugs may lead to development of depression as a result of side effects as they lower the production of serotonin in the brain (Azim and Baig, 2019). The presence of work pressure and long-term health condition leads individuals to be prone to develop depression as such conditions create emotional and psychological pressure on the person to effectively think and manage cognitive ability to overcome negative emotions (Klein et al., 2017).

Current guidance regarding the management of CHD

The NICE guidance for coronary heart disease (CHD) indicates that lifestyle changes are the key to prevent and manage the condition among individuals. This is because change lifestyle activities such as enhanced physical activity would help to avoid the deposition of fat and cholesterol in the body which accelerate the formation of plaque, in turn, helping individuals to avoid the development of CHD (NICE, 2019). Moreover, involving in a healthy diet and avoiding fatty food as a change in lifestyle habits leads individuals to prevent the risk of CHD because a healthy diet helps in lowering LDL Cholesterol level which assists in avoiding acceleration of atherosclerosis which is the main cause of worsening of CHD (Nettleton et al., 2017). The other guidance for the management of CHD is that different medications are to be used based on the health diagnosis of the patients to helps them manage the condition. Blood-thinning medication such a low-dose aspirin, prasugrel, ticagrelor and others are to be used for reducing the risk of heart attack as a result of CHD. This is because the medication helps in lowering thickness of the blood which avoid the formation of blood clots leading to smooth flow of blood to the heart (Mukherjee et al., 2018).

According to NHS, the management of CHD is to be made by administering statins to the individuals. This is because statin helps in blocking the formation of lower density lipoprotein receptors in the liver and cholesterol. It contributes towards less to no deposition of plaque in the arteries making individuals manage development of CHD (NHS, 2019). Beta-blockers are to be used in managing CHD because they help in blocking the release of epinephrine that assist in lowering the heart rate and improving blood flow to different parts of the body (Warburton et al., 2019). The nitrates are used as pharmacotherapy in managing CHD development because they assist in widening the blood vessels resulting in enhanced blood flow to the heart and avoiding development of pressure on the arteries that helps in reducing pain in the chest (Al‐Mohammad, 2019). The angiotensin-converting enzyme (ACE) inhibitors are used for managing and treating CHD. This is because they help in blocking the expression of angiotensin-2 hormone responsible for narrowing the blood vessels, which in turn, helps enhanced blood flow to be maintained towards the heart for its effective performance in supporting the well-being of the individuals (Knopf et al., 2019). In the study by Raygan et al. (2019), calcium blockers are mentioned to be used for managing CHD as it acts to lower high blood pressure which is one of the key reasons for worsening of the disease. This is because calcium-channel blockers help in decreasing blood pressure in the arteries by allowing relaxation of muscles surrounding the arteries which in turn assist in managing CHD.

Current guidance regarding the management of Depression

The NICE guidance for management of depression mentions that people with impaired social and personal functioning as a result of the condition are to be involved in cognitive behavioural therapy (CBT) and required to be administered anti-depressant medication. This is because CBT helps in guiding individuals to understand the patterns of their behaviour and way to modify them to develop enhanced mood as well as behaviours to manage well-being and enhanced mental health (NICE, 2019). The use of medication such as selective serotonin reuptake inhibitors (SSRIs) is made in the management of depression as they help in the increasing rate of serotonin in the synapses. It assists in improving the mood of the individual to show enhanced mood and behaviour (Park and Jang, 2021). The involvement of peer support is required in managing depression among individuals. This is because the peer helps individuals to feel cared for and valued along with assist in enhancing their personal experience through active personal and social support which leads the individuals to gradually overcome their depressed state (McConnell and Erath, 2018).

Aim

The aim of the study is to investigate appropriateness of nursing care for managing coronary heart diseases patients with depression.

Objectives

To identify concept among the nurses regarding presence of depression in coronary heart disease adults

To assess the efficacy of the nurses in mannaging depression among adults with coronary heart disease

To determine the validity and reliability of the tools for measuring depression in adults with coronary heart disease

To analyse the nursing care required in overcoming depression among patients with coronary heart disease

Methodology

Research Design

The research design to be used in the study is a systematic review that is the review process of primary information in articles to be identified, critically apprised and examined to present enhanced evidence in resolving the raised question and problem in the study (Han et al., 2019). The systematic review is important because it assists in presenting guidance through evidence about the potential treatment to be followed by healthcare professionals in managing any health condition (Deckers et al., 2017). The systematic review is to be used because it helps in providing reliable information as the data are collected and presented from logically and scientifically approve studies with less bias. It also assists the study to be easily reproducible and reach an accurate conclusion regarding study results for the topic (Han et al., 2019). The systematic review is also to be used because it helps in widening knowledge regarding the study topic and resolves gaps identified in single studies through the collection of wider data from multiple researchers regarding a similar topic (Han et al., 2019).

The narrative literature review is not to be used in framing the study. This is because the narrative review process is increasingly subjective which is evident as the process tries to access information from studies to conclude and not analysing them critically for presenting them (Raeissadat et al., 2018). It is also not to be used because narrative review causes biased interpretation of findings in the study which leads to raise an error in the presentation of results in the research. the biases may be raised from the selection process of information to be presented as findings in the study (Lomivorotov et al., 2020).

Research Question

The development of an enhanced research question is important because it helps to provide direction to the researchers regarding the required information to be gathered in the study for its successful fulfilment (Stack et al., 2020). The PEO framework is to be used in the study because it mentions about the key participants to be focussed and the exposure to be considered in regard to the topic to gather valuable results in the end which meets the outcomes of the study (Stack et al., 2020). The PEO represents the population, exposure and outcome in the study. The population to be targeted in the study are adults or elderly who are above the age of 18 years and suffering from coronary heart disease and depression. The exposure would identify the nursing care available in managing coronary heart disease and depression in adults. The outcome to be focussed on is improved health in adults with coronary heart disease and depression. Thus, the research question is: Is the current nursing care for managing coronary heart disease and depression in adults is appropriate?

Electronic database

The electronic databases are to be used in gathering information for the study. This is because they are cost-effective and less time-consuming in gathering valuable data needed to frame the study. The electronic databases are also to be used because they involve a simple process of supporting identifying wider amount of relatable data regarding the study within minimum time and energy (Faggion et al., 2018). The platforms to be used for electronic search are CINHAL, PubMed, Medline and EMBASE. The CINHAL is to be used because it contains indexing of various key nursing and allied healthcare literature along with nursing journals from different countries which would help in presenting wider scenarios regarding any study topic to be evaluated and presented in an enriched manner (Cumulative Index to Nursing and Allied Health Literature, 2021). The Medline is to be used because it contains wide number of articles and medical journals from trusted places which are useful in formulating meaningful research (Ayiku et al., 2017). The PubMed database is to be used in formulating the study because it contains many advanced medical articles and journals regarding wider topics and involves detailed descriptive information regarding the topic within the selected journals (PubMed, 2021).

Search Terms

The electronic search is to be developed by using effective key terms as they lead the search to be narrowed in determining and identifying related articles for fulfilling the study needs. The keywords are identified in the study mainly by exploring the research question and aim of the study. The key terms in the study are “coronary heart disease”, “depression”. “nursing care”, “nursing views”, “nursing opinions”, “adults”, “cardiac disease”, “CHD”, nursing care”, “nurses”, and “healthcare”. The relevant search terms in the study are truncated by asterisk to ensure the search is able to capture the words with different spelling and endings. The combination of the search terms is also made by use of Booleans operators like AND and OR. The operators are needed to be used as they help in forming meaningful search results.

Inclusion and exclusion criteria

The inclusion criteria in the study are key features of target population which the researchers consider to be used in formulating meaningful and potential search of valued articles. The exclusion criteria for the study are features that are not considered to be included in the study as it would lead to raise error. The inclusion criteria for the study are articles that are published on and not later than 2012, fully accessible, contain primary data (qualitative or quantitative), involves information for nursing care regarding coronary heart disease and depression in adults. academic and written in English language. The exclusion criteria for the study are articles that are articles published before 2012, involves information regarding depression and coronary heart disease about children and adolescent, contains secondary data, systematic review and metanalysis, non-academic and written in language other than English.

The articles published on and not later than 2012 to be used as they have presence of vital updated scientific information regarding the study topic which would help in the enriched analysis of determining results to present enhanced findings that meet the criteria for the study. The articles written in English are to be used because the researchers belong to the UK where the key language spoken and understood is English. Thus, the inclusion of articles written in English would help the researchers to derive effective findings from them to develop an enriched study.

The articles that contain data regarding coronary heart disease and depression among adults are included as they are the specific population of interest in the study and thus inclusion of such articles would result in gathered valued information to present enriched finding and results. The primary studies (qualitative and quantitative studies) are to be included in the research because they contain first-hand information from the population which are not manipulated by the person beliefs and analysis of the researchers. Moreover, such articles contain more updated data and avoid inclusion of backdated information. The systematic review and meta-analysis studies are excluded because they contain presentation of data that may be biased by the thinking and belief of the researcher during presentation in the study.

Critical Evaluation

In research, critical evaluation is important because it helps in identifying the strength and weakness of the study by evaluating their usefulness along with reliability and validity. It is important as helps in reducing the information overload in research by assisting in eliminating the irrelevant studies. Moreover, critical analysis helps in inclusion of relevant papers that supports in developing enhanced research findings to be presented. It also helps in effectively distinguishing assumptions, opinion, beliefs and others along with helps in including studies which has high validity and reliability. It also assists in recognition potentially biased studies and ensure improved clinical applicability of the study (Shea et al., 2017). The critical analysis of the selected papers is to be made in the study by using Caldwell quantitative appraisal tool. This is because the tool includes set of questionnaires which helps the novice researchers to easily develop critical analysis of articles. The researchers do not require any require additional experiences and skills in using the tool which makes them less complex to be used (Higgins et al., 2019).

Data analysis method

The data analysis is to be made by following the thematic analysis method. This is because thematic analysis helps to create higher flexibility among the researchers to present findings in the study. Moreover, it is suitable to be used in analysing wide amount of data to be complied together for enriched presentation in the study. It also permits developing wider data to be interpreted under themes in a concerned manner (Stockmann et al., 2019). In this study, based on the selected articles and study aim, a key theme is to be developed within which gathered data are to be presented categorically in a critical manner under various sub-themes.

Ethical Consideration

The ethical consideration in the study is to ensure for moral execution of the research without violation of any legal or ethical obligation in research (Varkey, 2021). Thus, the information from the studies are to be presented through paraphrasing with the authors who have mentioned them to avoid plagiarism. Moreover, no articles that are not developed by following ethical principles are to be included in framing the study. The manipulation of the gathered data is to be avoided by ensuring no personal beliefs and thinking of the researchers are influenced in presenting information in the study. The data is to be presented in such a way so that non-maleficence, beneficence, justice and autonomy are followed.

Thematic Analysis

Theme 1: Nurses view in managing depression in patients with coronary heart disease (CHD)

The study by Maxwell et al. (2013) and Barley et al. (2012) are the two studies out of 9 selected studies that explain the view of nurses and primary care professionals regarding the initial link and steps to manage depression in coronary heart disease (CHD). According to Barley et al. (2012), nurses and general practitioners view that distress following the diagnosis of the cardiac event if endured leads the individuals with coronary heart disease to develop severe depression. This leads the researchers to indicate that the psychological problem created by cardiac events leads individuals with heart disease to develop depression. The fact is supported by the study of Maxwell et al. (2013) who mentioned that depression from a chronic condition such as coronary heart disease is very severe and usually develop in patients. However, the lack of training among the nurses and primary carers regarding the management of mental health problems in patients leads them to face barriers in routine review and effective care consultation for the patients to ensure their enhanced health. The mentioned barrier is also highlighted in the study by Barley et al. (2012) which is evident as it mentioned that nurses reported depression in CHD patients and mentally ill patients are similar and they are no provided with any coherent training or education regarding the way to identify it in CHD patients. It leads them to face hindrances in making personalised approaches to helps CHD individuals in overcoming depression.

The study by Barley et al. (2012) also highlighted that patient’s choice and preferences are important for their increased adherence to the intervention made by nurses. In this regard variety of management, options are made, but the nurses often fail to identify the differences in using them for depression in CHD and depression in general that create hindrance in developing enhanced well-being in CHD patients. There are no supporting facts mentioned in the other study by Maxwell et al. (2013) in this regard due to which validity of the statement could not be ensured. Both the studies by Barley et al. (2012) and Maxwell et al. (2013) are similar prices of work regarding nursing intervention views for patients with CHD having depression. Both the studies in explaining the facts used qualitative data analysis process. This is advantageous because it helped in accessing detailed and direct overview of the nurses view regarding intervention for patients with CHD and depression. Both the studies in gathering information used similar nature of participants. This is evident as the study by Barley et al. (2012) recruited 10 general practitioners and 12 primary nurses and Maxwell et al. (2013) recruited 5 primary care practitioners and 5 community healthcare partners. This helped in contrasting the facts as views from similar nature of participants are portrayed in the researches. The study by Barley et al. (2012) concluded that clinicians and nurses are to be encouraged in using existing resources strategically. In similar, the study by Maxwell et al. (2013) also concluded that effective training to the nurses is to be provided to improve their confidence in dealing with mental problem in patients with CHD and others. Thus, one study mentioned the way effective nursing intervention for depression and CHD patients is to be made while the other informs the way to achieve it.

Theme 2: Tools used by nurses in measuring depression in coronary heart disease (CHD) patients

The use of specific tools in screening and detection for depression among coronary heart disease (CHD) patients is needed to ensure early detection of mental problems and their management. In this context, the studies by Kiropoulos et al. (2012) and Christensen et al. (2018) mentioned two tools that are used in nursing settings for determining the depression scale and properties in patients with CHD. The study by Kiropoulos et al. (2012) mentioned that Cardiac Depression Scale (CDS) is developed as a specific depression scale for measuring the depression level in cardiac patients. It is a 26-item questionnaire developed as an alternative to detection of specific depression in CHD patients from general depression. The study used Beck Depression Inventory- 2 (BDI-2) and the State-Trait Anxiety Inventory (STAI) scale to support the reliability of CDS. The results mentioned that the factorial composition of CDS regarding depression was similar to the original observation of depression in patients with CHD. Moreover, the CDS expressed high concurrent validity with BDS-II that are significantly correlated with STAI ensuring their effective use in accurate detection of depression levels in CHD patients.

In contrast, the study by Christensen et al. (2018) reported the use of the Hospital Anxiety and Depression Scale (HADS) to measure the level of depression and anxiety in CHD patients. One criticism of HADS highlighted by the study of Kiropoulos et al. (2012) is that the tool considers signs like fatigue for cardiac-related symptoms instead of considering it as somatic symptoms of depression in people with cardiac issues. However, in the study of Christensen et al. (2018), it is mentioned that the use of the HADS tool for the detection of depression has consistency in reporting the condition in CHD patients. This is evident as the Cronbach’s alpha score of HAD is found to 0.82 for depression and 0.87 for anxiety detection in CHD patients. Thus, both the studies of Christensen et al. (2018) and Kiropoulos et al. (2012) is found to has a similar aim of examining the efficient tool to be used by nurses in the detection depression scale in CHD patients. The study by Kiropoulos et al. (2012) highlighted that factors like mood, cognition, anhedonia, fear, sleep and suicide are influenced by depression in CHD individuals. However, the study by Christensen et al. (2018) did not highlight which social and mental factors are influenced due to depression in CHD patients.

Theme 3: Impact of depression on the quality of life of coronary heart disease (CHD) patients

The analysis of existing studies has highlighted there are fewer reports of detailed impact of depression on CHD patients. In this context, the studies by Shen et al. (2019), Shen and Gau (2017) and Palacios et al. (2016) are explored to inform the way depression affects the physical life of CHD patients. The study by Shen et al. (2019) mentioned that psychological distress in CHD patients leads them to how worst decline in physical functioning as predicted from baseline data while controlling the covariates related to it. Both anxiety (β = − 0.24, p < 0.001) and its increased over 6 months (β = − 0.29, p < 0.001) mentioned high reduction in the physical functioning of the patients at the end of 6 months. Moreover, the study informed that baseline increase of depression with time led to higher decline in the physical efficiency of each follow-up individual while adjusting covariates. The fact is also supported by the study of Shen et al. (2019) where it is mentioned that hostility demonstration towards reduction of depression symptoms in CHD patients leads them to show lower baseline exercise tolerance and reduced physical improvement (B = −.10, p < .01) over 6 weeks. The study also mentioned that improvement in exercise tolerance was mostly linear for 3-4 weeks but the decline in the last 2 weeks among CHD patients with depression indicating loss of physical efficiency in CHD patients with time who have depression and anxiety as psychological issues. In both the studies, one of the common limitations is that they are longitudinal studies due to which the majority of the information regarding psychological distress in patients is gathered at initial examination without considering the way they may change with time and influence the change in results.

Theme 4: Nursing intervention for managing depression in patients suffering from coronary heart disease (CHD)

All the existing six studies from 9 selected pieces of research informed that elderly patients with coronary heart disease (CHD) suffering from psychological reactions like depression and anxiety that compromise their health and well-being (Yang et al., 2020; Barley et al., 2014; Li et al., 2020). Yang et al. (2020) informed that dual-track intervention nursing model is effective intervention in aiming to create specific and community nursing that helps patients with CHD to overcome depression and associated psychological problems. According to the model, the patient-patient interaction and double-tracking interaction are included as the content to be used by nurses in managing depression among CHD patients. The model mentions that longitudinal-dual track intervention is to be taken by nursing staffs jointly to identify the health intervention target of each patient that are based specific health situation. Thereafter, the nurses are to develop corresponding prescriptions of health education to patients, encourage family members of patients and patients themselves to share experiences, allow patients to learn scientific lifestyle of overcoming depression and assist patient to develop self-esteem and confidence to cooperate effectively with the provided treatment. The dual-track interaction also involves communicating experiences of controlling disease and information for healthcare with patients by nurses. The result of the study informed that dual-track intervention nursing led to show lower score of obsessive-compulsive disorder, interpersonal sensitivity, anxiety, depression, paranoia and hostility among intervention group compared to the control group (p < 0.05). The intervention group also expressed high coping ability of negative emotions compared to the control group after the intervention. Thus, it proved dual-track intervention nursing is effective in managing depression in CHD patients and improve their mental health.

In contrast, the study by Barley et al. (2014) informed that implementation of nurse-led personalised care is effective in tackling and managing depression in patients with CHD. According to the intervention, the nursing manager is required to execute standardised face-to-face biopsychological examination of patients. This means problems with physical and mental health, treatment regimes, social actions and daily activities are to be examined directly regarding the patients. Thereafter, the patients are to be assisted in identifying three problem which they consider are contributing to the rise of their depression and which they need to be managed. On the basis of the information, the nurse case managers are to circulate information and sign-post patients to required resources such as social clubs, leisure centres, IAPT therapy and others along with other behaviour change techniques. The key aim of the intervention is to enhance the self-efficacy of the patient for achieving the desired emotional health goals. The assessment details are to be recorded in the personalised health plan of the patients and progressive interview with the patients are to be developed to determine the new care goals to be ensured with time for the patients. The intervention led to create 9% less attrition in care and increased quality care management with minimal use of nursing time for the patients. The intervention group mentioned having less chest pain, lower depression, higher emotional activity and others after the intervention in comparison with the control group.

The study by Li et al. (2020) mentioned depression to be major risk in CHD patients and informed use of transtheoretical-based intervention along with motivational interviewing to be effective in managing depressive symptoms among CHD patients with depression. The transtheoretical-based intervention includes three session to be followed in delivering care. The first session in making CHD patients get educated regarding depression to make them realise the need for its management to have improved mental and physical health. In the second stage, the patients who understood the condition are to be provided support and education about the strategies and actions to be followed in coping with depression. In this stage, the action plan is to be developed by the nurses in consultation with the CHD patients in coping depression. In the third stage, the patient with CHD is to be provided evidence regarding the experiences of the impact of following successful intervention of tackling depression and stress. The motivational interviewing process involves nurses who are to make face-to-face interactions with the CHD patients to make them motivated in adopting positive lifestyle activities to overcome depression. The results informed that after the intervention increased emotional and behaviour efficiency in CHD patients were seen who were previously reported to show hindered behaviour and emotion due to depression. Moreover, the CHD patient after the intervention expired higher self-efficacy and lower depression score indicating the intervention was successful in tackling depressive symptoms in CHD patients.

The study of Yang et al. (2020) included 136 elderly patients with CHD in executing the study with mean age of 63 years and total of 53 and 50 patients are randomly selected in intervention group and control group. The control group were provided routine longitudinal nursing intervention whereas the intervention group were provided dual-track intervention nursing. The small number of participants acted as limitation for the study as it led to neglect the generalisation of the results. However, the randomised control trial design acted as strength for the study as it helped in explaining the difference to be expected with intervention and lack of mentioned intervention in CHD patients in regard to the management of their depression. In contrast, Barley et al. (2014) was a multi-centre randomised control study which included 1001 individuals from 17 general practise clinics with registered CHD patients and among them 126 individuals were found to be potentially eligible for the study. The limitation of the study is that it is a trial method and not yet been effectively implemented in any primary care centre to ensure its authentic outcome.

Critical Review of Articles:

According to Caldwell critiquing framework, the presence of well-defined title is important and the authors in the study are to be credible to ensure the study is executed by qualified professionals and has less changes of presence of inappropriate error in them (Caldwell et al., 2011). In all the 12 studies, it is seen that well-defined tiles are present, and the authors involved in the executing the studies were credible. This is because most of the authors are found to be highly qualified professors in Department of Cardiology or Internal Medicine or School of Nursing and others who has wide knolwdege regarding presence of depression in patients with cardiovascular (Yang et al., (2020), Barley et al., (2014), Li et al., (2020), Barley et al., (2012), Maxwell et al., (2013), Kiropoulos et al., (2012), Christensen et al., (2020) Shen and Gau (2017) and Shen et al., (2019)). The Caldwell critiquing framework informs that well-descriptive abstract and effective explanation of the cause of executing the mentioned studies are strength of well-presented studies (Caldwell et al., 2011). In all the 12 studies, well-described abstract with aim along with rationale are present. For example, Yang et al., (2020) mentioned to execute the study to develop wider clarification of the dual-track nursing intervention in coping anxiety and depression in patients. This is because the presence of anxiety and depression in heart disease patients makes them show hindered emotional stability in complying with the care which adversely affect their health. The presence of well-descriptive abstract in all the studies assured the reader would be able to summarise the content to be expected from the chosen study to effectively refer them to understand the extent of usability of the findings from the study in developing the current research.

The Caldwell framework mentions to critique an article, the population in the study and adequate explanation of the choice of the sample and sampling process are to be identified (Caldwell et al., 2011). In all the studies, exact population used are informed along with the way they are gathered is effectively explained. This is evident as in the studies by Yang et al., (2020) 136 elderly people, Barley et al., (2014) 1001 people, Li et al., (2020) 110 people, Barley et al., (2012) 12 physicians and 12 nurses, Maxwell et al., (2013) 2 focus groups including 5 care professionals and nurses, Kiropoulos et al., (2012) 152 patients with CHD, Christensen et al., (2020) 12806 patients, Shen and Gau (2017) 142 patients and Shen et al., (2019) 255 CHD patients were recruited as population. In all the studies, purposive sampling method is used in recruiting the participants. This is evident as in each study the researchers effectively choose the participants either from national records or directly from hospitals based on their own judgement. The strength faced with the use of the method is that niche criteria for maintaining the focus of the study was able to be ensured which limited error in recruit of participants who are irrelevant to the study (Ames et al., 2019). However, the limitation may have been faced due to use of purposive sampling in the studies is lower reliability of results and inability of generalisation of findings (Sharma, 2017). This to some extent evident as in Yang et al., (2020) and Li et al., (2020) generalisation of results could not be achieved that hindered evidence-based practise.

The study by Kiropoulos et al. (2012) used comparatively lower number of participants in detecting the reliability of the depression scaling tool compared to Christensen et al. (2018) in CHD patients. This is evident as Kiropoulos et al. (2012) used 152 patients with CHD after 3.5 months of hospitalisation in executing the study whereas Christensen et al. (2018) used 12.806 patients in executing the study for detection of implementation efficiency of the tool. The use of large sample in the study acts as its advantage because it helped in explaining more accurate mean values of the use of the tool and ensured lesser margin of error in the study helping to create increased transferability of the data (Mishra et al., 2019). This compared to Kiropoulos et al. (2012) research is found to have sample size due to which transferability of its results could not be achieved as a minimum of 200 people is mentioned to be used as sample for factor analysis.

The Caldwell framework mentions that the research methods and data collection methods are required to be reliable and validated (Caldwell et al., 2011). In all the studies, expect Chair et al., (2020), Barley et al., (2012) and Maxwell et al., (2013), the quantitative data collection process is used whether in the mentioned studies qualitative data collection process were used. The use of the data collection process was appropriate for the studies because the articles which used quantitative data collection process intended to gather statistical data regarding the topic. However, the studies such as Barley et al., (2012) and Maxwell et al., (2013) which used qualitative data collection process that is mainly interview and focus group discussion intended to gather descriptive explanation in regard to resolve the raised problem in the study.

The Caldwell framework mentions to evaluate if the results in the study are effectively mentioned and the transferability of the results (Caldwell et al., 2011). In all the studies, the results are well-explained. However, the results from studies by Barley et al., 2012, Barley et al., 2014 and Maxwell et al., 2013 are effectively transferable in framing evidence-based practise in relation to depression management in cardiovascular patients in the UK as they set in the UK. The studies by Yang et al., 2020, Li et al., 2020 and Chair et al., 2020 is set in China which has similar health care facility and environment for depression management in coronary heart disease patients like the UK due to which the results can be transferable to be used for implication in develop strategies of care.

In the study by Palacios et al. (2016), the researchers used longitudinal cohort study design which is different method used in the other two studies by Shen and Gau (2017) and Shen et al. (2019). This is advantageous for the current study to provide more accurate values of the data with smaller margin of error compared to the other two studies as the tracking of the attitude of the population regarding depression in CHD condition could be accomplished that was not able to be identified in two other studies. The studies by Yang et al., (2020), Barley et al., (2014) and Li et al., (2020) use randomised control trail method in executing the research. this was advantageous for the studies as it helped them understand the effect relationship of discussed intervention for experimental and control population. The study by Chair et al. (2020) used cross-sectional research design to execute the research. This acted as limitation because the design does not lead the researcher to determine the cause and effect relationship in the study.

In the studies by Yang et al., (2020) and Li et al., (2020), 136 and 110 patients with CHD are included. The participants are randomly recruited into intervention and control group. The small sample size acted as limitation for the study as it limited the generalisation of the resulted developed. The short-term follow up of patients for detecting their level of depression was another limitation faced in the study because patients may develop depression in the long term which led to be neglected due to the nature of choice of selection of study participants. The other limitation faced in the study by Li et al., (2020) was that patients were blinded due to which it may have influenced in partial reporting of management of depression among CHD individuals.

Discussion

The chapter is going to discuss the gathered data in relation to the main theme and subthemes from current articles and journals. The current view of the nurses regarding depression among patients with coronary heart disease (CHD) is that depression is developed in the patients out of psychological trauma faced during any cardiac event by them (Barley et al., 2012; Maxwell et al., 2013). This is because the cardiac event makes the person develop fear and anxiety regarding their health condition and ability to manage well-being along with chances of mortality (Hernández-Palazón et al., 2018). The fact is supported by He et al. (2020) which mentions that after cardiac event the patients feel fear of life and tis it leads them to be in depression and distress. The nurses further view that persistent presence of depressed condition for longer time among CHD patients worsen their mental well-being and makes increased progression of the disease (Barley et al., 2012; Maxwell et al., 2013). This is because the presence of depression leads to cause hindered efficiency of the neuronal synapses in the brain to work effectively in transmitted signals from brain to the body. This causes individuals with CHD to face worsened health conditions regarding mental health as well as physical efficiency to led life (Khandaker et al., 2020).

The nurses view that the depression in CHD patients worsen and remains not properly cared because they are not effectively trained regarding the way to identify the differences in general depression and depression caused in CHD individuals and failure of early detection of the disease (Barley et al., 2012; Maxwell et al., 2013). In this condition, the current view is nurses are to be trained and educated regarding the way to timely and appropriately detect depression in CHD patients and way to manage it (Barley et al., 2012; Maxwell et al., 2013). In order to accomplish effective training of nurses regarding depression management for CHD patients, experienced psychologist is to be involved. This is because the psychologist are experts in delivering psychological support by analysing the psychological condition of the patients as per their health (Richards et al., 2017). Thus, involving them to train the nurses helps them share knolwdege from the psychologists regarding the way to detect depression due to CHD in patients apart from general depression and the psychological support to be initially provided by the nurses and so that depression in CHD patients remain under control. According to NICE guidelines, depression and other mood disorder are to be treated by involving psychiatrist and psychologists as they are experienced individual in detecting the extent of mood disorder in patients measures to be taken along with treatment to be implemented for the patient’s enhanced mental condition (NICE, 2019). Thus, not only the psychologist but also the psychiatrist is to be involved in develop care plan and delivering treatment for supporting management of depression in CHD patients. However, the availability of psychologist and psychiatrist for cardiac inpatients and outpatients in the UK are found not to be specified in detail and they are mostly mentioned to be involved in caring for patient diagnosed with MDD as psychological disorder (Oxford Psychological Medicine Centre, 2018). This indicates that there is lack of the key psychologist and psychiatrist for cardiac patients to be delivered support for their well-being as most of them are involved in caring for mentally ill patients.

The screening tools in monitoring and detection of depression in CHD patients is important. This is because effective screening tools assist in the early detection of any disease which results in supporting better management and treatment of the disease in the patients. Moreover, it assists in reducing risks of health complications regarding the disease in the patient along with enhances the chances of better outcomes of health (Pogosova et al., 2017). The two effective screening tools identified for the detection of depression in CHD patients are the Cardiac Depression Scale (CDS) and Hospital Anxiety and Depression Scale (HADS) (Kiropoulos et al., 2012; Christensen et al., 2018). The tools are important to be included by nurses in caring for depression in CHD patients because it helps in better monitoring of the progression of depressed health of the CHD patients and take timely action to treat the condition (Pogosova et al., 2017). In the studies, the criticism highlighted in the case of using HADS is that it fails to differentiate certain common symptoms of depression in CHD and mention if the symptom appeared in CHD patients is due to the cardiac event or mental trauma following the cardiac event (Kiropoulos et al., 2012; Christensen et al., 2018). Thus, the CDS is to be chosen over HADS by nurses for accurate detection of depression in CHD patient as it helps in providing better diagnosis of he conditions compared to the other tool.

The studies highlighted that depression in CHD patients leads them to face worsened physical functioning along with develop hostility in executing exercise (Shen et al., 2019; Shen and Gau, 2017). This is evident as depression makes the individual have fluctuating moods with lower cognition that lower their intention to execute effective physical actions and exercise to be improve their health (Siow et al., 2018). The inclusion of physical activity and exercise performance in CHD patient is vital because enhanced physical functioning and exercise helps the CHD patients to effectively regulate heart muscles to reduce risk of heart attack and ensure stronger pumping of blood around the body with reduced effort to support the enhanced functioning of different parts of the body (Beram et al., 2021). Therefore, reduced physical action created out of depression in CHD patients is major concern as it is compromises efficiency of them to reach enhanced health and well-being.

The motivation to execute physical activity in the CHD patient to overcome depression may be hindered by the presence of mood disorder (Chair et al., 2020). In this condition, psychological therapy and emotional support is to be initially provided to the CHD patient to overcome depression as they help in overcoming the negative thoughts which hindered motivation required to adapt to new healthy lifestyle for managing mood in CHD patients (Song et al., 2019). Thus, the psychologist is to be involved in caring for the CGD patients with depression initially to make them overcome negative emotions and motivate them to involve in physical activity by informing the way it would help in maintain their stable emotional health. The NICE guidelines mention use of anti-depressants as pharmacological intervention and psychological counselling as non-pharmacological intervention to be effective in managing depression and mood disorder (NICE, 2019). The guidance is to be followed through assistance from psychologist by nurses caring for CHD patients to ensure them better mood and overcome depression with ease.

One of the nursing interventions identified to be effective in managing depression among CHD patients is use of dual-track intervention nursing model in delivering care to the patients. This is because the model helps to enhance self-management and rehabilitation in CHD patients to have enhanced health. It is found to be more effective in managing health conditions of CHD patients compared to longitudinal transfer intervention and single physical exercise (Yang et al., 2020). The dual track nursing intervention model means that patient-patient interaction is to be allowed and interaction with physicians and nurses is to be allowed for the patients. According to the model, CHD patients with depression are to be allowed to share their experience regarding care and health information with other patients to discuss ideas regarding the way they can have improved health condition. Moreover, interaction with both nurses and physicians are to be allowed for the depressed CHD patients so that they can understand the cause of the condition from physicians and able to mention personal needs regarding the condition to the nurses to provide them idea regarding needs of the patients to be fulfilled to promote their enhanced mood and resolve depression (Yang et al., 2020).

The study by Barley et al. (2014) mentioned personalised care delivery to CHD patients by nurses helps in managing their depression and improving their health regarding the cardiac disease. This is evident as the study by Fors et al. (2015) also mentions that person-centred care helps in identifying the distinguished need and demands of the patients suffering from any health issues in comparison to similar patients. It helps the nurses to accordingly arrange separate care plan that is specific to the need of the patients in resolving their raised needs to support their enhanced well-being. It is evident as Barley et al. (2014) reported that nurse-led personalised care helps in sign posting the needs of the patient and accordingly arrange resources for their care.

Li et al. (2020) reported the use of motivational interviewing and transtheoretical-based intervention to be effective nursing intervention in overcoming depression in CHD patients. The nurses caring for CHD patients are to be equipped with using transtheoretical-based intervention for managing depression in the patients by accessing training regarding the way to gradually implement the intervention in step-by-step process. Moreover, experienced older nurses are to be involved in supporting the nurses to learn regarding the tricks to effectively and successfully implement such intervention (Pols et al., 2018). The use of motivational interviewing is better than transtheoretical-based intervention to manage depression in CHD patients. This is because motivational interviewing considers the social as well as mental context which influences depression in CHD patients whereas in transtheoretical-based intervention, the social context influencing mental health of the patients is ignored (Li et al. 2020). In CHD patients, the presence of lack of carer in the society, inability to maintain effective social connection due to hardship related with CHD and others acts as social condition their influence depression in CHD patients (Shen et al., 2019). Therefore, considering the social context is important in delivering holistic care support to improve management of depression in CHD patients.

Recommendations

The results from the review and critical analysis of the current information provide ideas regarding the following improvement to be made for creating good health opportunity of CHD patients.

Research

The recommendation developed from the study is that further researches are to be executed with larger sample so that greater generalisation of the results can be achieved. Further qualitative researches are to be arranged that would explain the way mentioned nursing strategies to cope with depression in CHD patients manages the risk created by each factor influencing depression in CHD patients. More studies are to be framed where instruction regarding the way multi-professional intervention would be effective in controlling in controlling depression in CHD patients are to be explained. It is also recommended that future studies are required to focus on the specified psychological therapies in managing depression among CHD patients.

Training and Education

The nurses caring for CHD patients are to be involved in advanced medical training for improving their skills and knowledge to differentiate between general depression and depression in CHD patients. Moreover, the training is reduced to make the nurses caring for CHD patient develop enhanced skills along with self-confidence and self-reliance to make effective care initiatives required by CHD patients to resolve their depressed state and improve their quality of life. Moreover, education regarding early detection of depression in CHD patients is to be provided to the nurses so that they can minimise the risk of the condition in the patient that has detrimental impact on their physical and mental condition. Further, it is recommended that nurses are to be educated regarding the way they can use multimedia applications to reach wider number of CHD patients within minimum time and effort in education them regarding the way to be self-efficiency in detecting depression and overcoming the issue at the initial stage. The nurses are to ensure multi-media resources to be accessed by indicating the manager regarding the resources they need and ensuring their manager acts to arrange the resources. The nurses would get multi-media resources at the workplace to share with the service users to initially educate them regarding the way to use to connect with the nurses. Moreover, internet education to the nurses and patients are required to be provided by experts to made them skilled in using multi-media services to enjoy enhanced health and allow nurses to delivery timely support.

Practise

The local policies are to be framed by considering the facts identified in the study to mention the nursing role to be played by nurses along with skills and knowledge to be present in the nurses who are caring for patients with CHD also having depression. The nurses are to be made aware of the medical jargon and tools to be used in analysing mental health condition of patients with CHD and ensure it is a must process to be followed for all CHD individuals. The managers controlling the activities of the nurses to support delivery of quality care are to develop actions for resolving unprofessional behaviour of the nurses towrads CHD patients with depression. They are to ensure transparency in care is maintained by following evidence-based action mentioned in the current study.

Limitations of the review

The limitation of the review is that it used minimum number of articles relevant to the study. In total 12 studies are included in the research with many potential studies been rejected for inclusion due the age considered for the research. In most of the included studies, transferability and generalisation of the results was mentioned to be key difficulty due to which the data accessed from them presented in the study may not be used for effective evidence-based practice in any situation. It also compromised the reliability and validity of the current research. The lack of time and money was another limitation faced in the study due to which few potential studies could not be accessed as they were not freely accessible and compromised the critical representation of results. The other limitation is that only the views of the nurses regarding the impact of strategies in managing depression in CHD patients are present while the views regarding satisfaction and health effect from the patients are entirely ignored.

Conclusion

The review concludes that depression in coronary heart disease (CHD) patients is common and, in the UK, as well as globally many individuals are suffering from the condition. Nearly 5078 cases of coronary heart disease and 3932 stroke events are reported in the European continent only. In the current condition, depression among CHD individuals have become an issue because more people are found to be affected by CHD but there is lack of effective intervention in controlling their mental health which is leading create hindered health effect on their well-being. The nursing intervention for managing depression in CHD individuals is identified in the study through the use of systematic review. This is because systematic review helps in better critical analysis of facts and ensure a comprehensive overview of the topic which could not be accomplished by using narrative review. The thematic analysis process is been developed to explain the gathered results in a categoric manner.

The initial objective of the study was to determine the way nurses view the condition of depression among CHD patients. It was found that they consider depression in CHD patients are often undetected by them due to lack of training and education about mental health management Moreover, they view depression in CHD patients to worsen with long term lack of care and support for its management and compromises their well-being and response towards care. The impact of depression in CHD patients was found by nurses to cause lower physical efficiency, increase hostility and lower exercise functioning among the patient. This is because distress made the CHD patients avoid concentrating on their self-efficacy to manage their own health.

The Cardiac Depression Scale (CDS) and Hospital Anxiety and Depression Scale (HADS) are the two key tools identified as reliable to be used by nurses in screening depressing condition in CHD patients so that the patient’s level of distress can be determined and accordingly care can be delivered to them to ensure their enhanced health improvement both mentally and physically. The dual-track intervention nursing model is mentioned to be followed by nurses as it is successful in lowering depression among CHD individuals. Moreover, personalised care delivery by nurses along with supporting leisure-time physical activity leads CHD individuals to overcome depression and show less anxious emotions. The use of multimedia information is to be made by nurses to create awareness regarding depression in CHD patients so that the patients can be made self-efficient to manage their own mental health which is important for their physical health improvement. Thus, most of the nursing intervention for managing depression in CHD patients is found to be effective to in controlling the condition. The recommendations developed from the study is that greater training and education to the nurses are to be offered in supporting them to be capable of effectively delivering mental health support at the earliest to the CHD patients in overcoming depression.

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