y 2020, depression will move into second place on the list of top-ranked illnesses, just behind cardiovascular disease, according to the Global Burden of Disease Study conducted by the World Health Organization (WHO), the World Bank, and Harvard University (Murray & Lopez, 1996). There is also a link between coronary heart disease and depression. Data from the National Health and Nutrition Examination Survey (NHANES 1) identified that men and women with depression are more at risk for coronary artery disease (Ferketich, Schwartzbaum, Frid, & Moeschberger, 2000).

Depression in the first 18 months after a myocardial infarction is a significant predictor of mortality in both men and women (Frasure-Smith, Lesperance, & Talajic, 1995). The experience of depression also increases the risk of cardiac arrest due to the physiologic edge produced by imbalanced catecholamine circulation (Empana et al., 2006). Ziegelstein et al. (2000) suggest that patients with depression after a myocardial infarction are less likely to choose healthier lifestyle habits (e.g., diet, exercise, social support) or take their medications as instructed. In order to help patients maintain the highest possible level of health, it is imperative that APRNs screen patients carefully for physiologic symptoms attributable to coronary heart disease events and those diagnostic for major depression (Valentine, Byers, & Peterson, 2001).

Early in my practice, I became involved with Bristol Hospital’s Phase II Cardiopulmonary Rehabilitation program called Heart Works. The mental health segment consisted of a 12-week, psychoeducational class format that included information on stress management and cognitive behavioral techniques. Attendance was typically small, and patients complained they did not like being “in school.” After discussion with the program director we eliminated the classroom model, and we established interviews during the orientation to the program with both the Psychiatric Consultation Liaison Nurse (PCLN) and the dietician. The PCLN interview format offers both the patient and family an opportunity to share their perception of their illness/recovery experience, to identify current health promotion behaviors, and to participate in a traditional mental status exam; it also offers an opportunity to screen for depression. We encourage patients to invite any family members they wish to accompany them. Naturally, patients always have the option to refuse the interview.

Content of the Interview

No single assessment tool met my need for a holistic focus; therefore, I created a format that is systemically based, assessing multiple levels of a system and using theory to guide the questions I ask. Included are family nursing theory (Wright & Leahey, 1989), behavioral domains from the Health Promotion Lifestyle Profile (HPLP II) (Walker, Sechrist, & Pender, 1987), and stages of change theory/motivational interviewing (Miller & Rollnick, 1991). The purpose of the interview and depression screening is explained to each patient/ family member. The beginning of the discussion focuses on the beliefs that the patient/family have regarding etiology, diagnosis/prognosis, role of patient/family/providers in recovery, and the impact of the event on the family’s routines. One strategy to elicit the patient’s experience involves the use of interventive interviewing, meaning that you create a conversation inviting change.

Karl Tomm (1988) defined four categories of questions: lineal, circular, strategic, and reflexive. Lineal questions are simple and factual (”Do you have heart disease in your family?”). Circular questions help the patient think about the feedback in relationships (”Who worries the most about your recovery?”). Strategic questions help expand the options to change (”What kinds of help would you need to stay smoke free?”). Reflexive questions help the patient think differently about an issue (”If you succeeded in making your house smoke free, what other concerns might come up?”). Finally, inclusion of a genogram provides a window into the patient’s living room and explores multiple perspectives.

My assessment of current health promotion behaviors covers independent activities of daily living, including the perception of the role of spirituality in recovery. The topics were adapted from the original HPLP II tool, which addressed self-actualization, health responsibility, exercise, nutrition, interpersonal support, and stress management. I created a question about the patient’s perceptions of coping, the perception of family coping, and the expected utility of Heart Works. This is a self-report score from 1 to 10 with 10 being highest. This was added so that staff might compare results at their 6-month follow-up phone call.

The mental status exam is straightforward and includes a brief assessment of present/prior medical illness and how those experiences impact the patient’s perception of the here and now process of recovery. Substance use is also discussed during the evaluation. I have found the brief intervention strategy model, developed by Miller and Rollnick (1991), very helpful. Finally, the patient is given a self-report depression screening questionnaire to complete at home and is requested to return it to staff. There are many tools available, and we currently use the Zung Depression Scale (Zung, 1965). The Zung is a self-administered, 20-item scale that is short, simple, and quantitative. It is sensitive to severity of depression across many patient subgroups with unipolar depression. It is less specific to symptoms common to atypical depression.