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The Clinical Impact of Negative Psychological States: Expanding the Spectrum of Risk for Coronary Artery Disease
Abstract
Research has demonstrated a gradient relationship between depression and the risk of adverse cardiovascular events among both initially healthy individuals and those with known cardiac disease. Moreover, recent investigators have demonstrated that adverse outcomes are even associated with the presence of relatively mild symptoms, as measured by self-report scales like the Beck Depression Inventory. The association between even mild depressive symptoms and sequelae of cardiac disease raises the following question: Is the spectrum of psychological factors associated with cardiac disease greater than previously recognized?
To address this issue, we consider a small but emerging literature that has focused on effects of other negative psychologic states on cardiovascular health.
Five negative states that have been linked in varying degrees to cardiovascular disease or disturbances are identified, including hopelessness, pessimism, rumination, anxiety, and anger. Considering a broader spectrum of risk may help to understand more fully the mechanisms by which depression and other negative affective states influence coronary heart disease risk.
... also been some studies confirming a relationship between anger [10,12,13] and anger rumination [14][15][16] with an increased risk of incident heart disease. It is anticipated that worry and anger rumination have a detrimental effect on the process of adjustment to heart disease. ...
... [36][37][38] Similar relationship between anger rumination and enhanced risk of cardiac diseases have been also confirmed. [14][15][16] According to available evidence, anger rumination is associated with multiple maladaptive consequences such as physiological arousal, [39] increased endothelin-1 in patients with coronary artery disease, [40] and increased risk of myocardial infarction [41] and CHD, [16] as well as the severity of coronary artery stenosis. [14] It is supposed that cognitive representations of stress in the form of anger rumination and worry are the underlying cause of cardiovascular reactions. ...
... [36][37][38] Similar relationship between anger rumination and enhanced risk of cardiac diseases have been also confirmed. [14][15][16] According to available evidence, anger rumination is associated with multiple maladaptive consequences such as physiological arousal, [39] increased endothelin-1 in patients with coronary artery disease, [40] and increased risk of myocardial infarction [41] and CHD, [16] as well as the severity of coronary artery stenosis. [14] It is supposed that cognitive representations of stress in the form of anger rumination and worry are the underlying cause of cardiovascular reactions. ...
Objectives
Heart disease is one of the chronic diseases that require adjustment and extensive changes in the patient's life. The purpose of the present study was to investigate the mediating role of difficulties in emotion regulation on the relationship between anger rumination and worry with adjustment problems to heart disease.
Methods
A total of 327 patients with coronary artery disease (138 women and 189 men) participated in this study. Participants were asked to complete the Penn State Worry Questionnaire, Anger Rumination Scale, Difficulties in Emotion Regulation Scale, and Adjustment to Illness Scale.
Results
Worry, anger rumination, and difficulty in emotion regulation showed a negative correlation with adjustment to heart disease. The results of path analysis indicated that the relationship between worry and anger rumination with adjustment to heart disease was mediated by difficulties in emotion regulation.
Conclusion
Based on the results of the present study, management of worry and anger rumination, as well as emotion regulation strategies, should be implemented in regular medical treatments for patients with heart disease.
... Palavras-chave: ansiedade, depressão, doença cardiovascular, ira, prognóstico con eventos cardiovasculares en los dos años siguientes al evento cardiovascular (Moser et al., 2011), por lo que se recomienda su inclusión en la evaluación primaria en pacientes con enfermedades cardíacas (Celano, Suarez, Mastromauro, Januzzi & Huffman, 2013). Sin embargo, los estudios relacionados con esta emoción son poco concluyentes, quizás porque los resultados varían según el trastorno o si se considera a la ansiedad como crónica o no (Kubzansky, Davidson & Rozanski, 2005). Al respecto, cabe anotar que la relación de la ECV con los niveles de ansiedad subsindrómica no ha sido estudiada sistemáticamente (Kubzansky et al., 2005). ...
... Sin embargo, los estudios relacionados con esta emoción son poco concluyentes, quizás porque los resultados varían según el trastorno o si se considera a la ansiedad como crónica o no (Kubzansky, Davidson & Rozanski, 2005). Al respecto, cabe anotar que la relación de la ECV con los niveles de ansiedad subsindrómica no ha sido estudiada sistemáticamente (Kubzansky et al., 2005). Asimismo, la evidencia acumulada sobre los factores emocionales relacionados con el pronóstico de los pacientes con ECV sugiere una asociación que se da en forma de dosis-respuesta, donde el riesgo está directamente relacionado con el nivel de severidad emocional (Kubzansky et al., 2005;Smith & Blumenthal, 2011). ...
... Al respecto, cabe anotar que la relación de la ECV con los niveles de ansiedad subsindrómica no ha sido estudiada sistemáticamente (Kubzansky et al., 2005). Asimismo, la evidencia acumulada sobre los factores emocionales relacionados con el pronóstico de los pacientes con ECV sugiere una asociación que se da en forma de dosis-respuesta, donde el riesgo está directamente relacionado con el nivel de severidad emocional (Kubzansky et al., 2005;Smith & Blumenthal, 2011). De igual forma, el impacto de la intervención sobre los factores emocionales parece tener relación con la cronicidad de los cuadros y el objeto de estos, ya sea en aspectos estructurales o sintomáticos en los pacientes (Kubzansky & Thurston, 2007). ...
Resumen La depresión, la ansiedad y la ira rasgo han evidenciado ser factores asociados a un peor pronóstico de los pacientes con enfermedad cardiovascular. En el presente estudio se evaluó una muestra de 168 pacientes con cardiopatía isquémica que habían tenido un evento cardíaco en el último mes (edad media = 64 años, DT = 11; 66.7 % hombres) para contrastar la existencia del afecto negativo como factor común entre la depresión, la ansiedad y la ira rasgo. Los instrumentos utilizados fueron las escalas rasgo de los cuestionarios de depresión, ansiedad e ira de Spielberger. Como resultado, los análisis factoriales exploratorios realizados confirmaron la estructura factorial de todas escalas, y el análisis factorial confirmatorio corroboró la existencia del afecto negativo como factor de orden superior (X2 = 3.42, p > .05; CFI > .95, TLI > .95, SRMS < .05). Los resultados de este estudio señalan la importancia de considerar modelos dimensionales para el abordaje de la emoción en esta población.
... However, it is still unclear how specific adverse life-events and Type D personality traits may cluster and how these clusters may be associated with cardiovascular risk markers. Determining profiles and associated cardiovascular markers instead of single factors might be helpful to increase the sensitivity of epidemiologic prediction models and clarify the pathophysiological pathways lining psychological risk markers to cardiovascular conditions [39]. Risk profiles might also be helpful in prevention strategies (e.g., in identifying subgroups associated with modifiable risk markers, such as an unhealthy lifestyle). ...
... distressed personality traits) [53]. Moreover, the current findings may be helpful in the development or improvement of personalized prevention strategies, e.g. in tailoring prevention strategies for specific subgroups [39]. For men with a Type D & Trauma profile, prevention strategies that are focused on the treatment of emotional distress may decrease cardiovascular risk. ...
Background:
Both adverse early life-events and distressed personality are associated with an increased cardiovascular risk. As there is an important link between these psychological factors, we investigated how these might cluster in sex-specific psychological profiles. We further examined the association of these profiles with cardiovascular risk markers.
Method:
446 women (mean age = 49.8 ± 17.9 years) and 431 men (mean age = 49.4 ± 17.5 years) from the Dutch general population completed questionnaires on demographics, adverse early life-events (ETI), Type D personality (DS14), anxiety (GAD-7) and depressive (PHQ-9) symptoms, and traditional cardiovascular risk markers.
Results:
A step-3 latent profile analysis identified three profiles in women (Reference, Type D & trauma, and Type D/no trauma) and four in men (Reference, Type D & trauma, Type D/no trauma, and Physical abuse). In women, the Type D/no trauma was associated with highest levels of emotional symptoms (OR = 2.47; 95% CI: 2.11-2.89), lipid abnormalities (OR = 3.69; 95% CI: 1.47-9.27), and increased levels of alcohol use (OR = 3.63; 95% CI: 1.42-9.30). The Type D & trauma profile was associated with increased levels of emotional symptoms (OR = 2.03; 95% CI: 1.70-2.42), highest levels of smoking (OR = 3.30; 95% CI: 1.21-8.97) and alcohol use (OR = 7.63; 95% CI: 2.86-20.33). Women in both profiles were older as compared to the Reference group (OR = 1.03; 95% CI: 1.01-1.05). In men, the Type D & trauma profile was associated with increased levels of emotional symptoms (OR = 1.11; 95% CI: 1.03-1.20). There were no significant differences between the profiles in lifestyle factors and cardiometabolic factors.
Conclusions:
In women, the Type D/no trauma profile and the Type D & trauma profile were associated with a specific combination of cardiovascular risk markers. In men, the Type D & trauma profile was associated with an increased level of emotional symptoms.
... Stress is a process in which environmental demands tax or exceed one's adaptive capacity, resulting in physiological changes that may place the individual at risk for disease over time (1)(2)(3)(4)(5)(6)(7). Chronic stress may manifest itself in various ways including increased anxiety, depressive symptoms, hostility and poor sleep quality, all which independently predict essential hypertension (EH), cardiovascular disease (CVD), metabolic syndrome and type 2 diabetes (1)(2)(3)(4)(5)(6)8). Stress exposure also increases unhealthy coping behaviors such as comfort eating, smoking, excessive alcohol intake, pharmaceutical abuse and increased sedentary activity. ...
... Stress is a process in which environmental demands tax or exceed one's adaptive capacity, resulting in physiological changes that may place the individual at risk for disease over time (1)(2)(3)(4)(5)(6)(7). Chronic stress may manifest itself in various ways including increased anxiety, depressive symptoms, hostility and poor sleep quality, all which independently predict essential hypertension (EH), cardiovascular disease (CVD), metabolic syndrome and type 2 diabetes (1)(2)(3)(4)(5)(6)8). Stress exposure also increases unhealthy coping behaviors such as comfort eating, smoking, excessive alcohol intake, pharmaceutical abuse and increased sedentary activity. ...
Background:
Chronic stress is an independent risk factor for essential hypertension (EH), cardiovascular disease (CVD), and is sometimes confronted by mal-adaptive coping behaviors (e.g., stress eating, excessive alcohol consumption, etc.). Pre-essential hypertension (preEH) is the leading predictor of future EH status. Breathing awareness meditation (BAM) can result in clinically beneficial blood pressure (BP) reductions, though face-to-face sessions presents barriers to reach those in need. The purpose of this study was to identify if a culturally tailored approach is needed in the design and preferences between groups of preEH African American and White adults toward using a smartphone BAM app, the Tension Tamer (TT) app.
Methods:
TT includes audio delivered BAM instructions, real-time heart rate, feedback graphs and motivational reinforcement text messaging. Questionnaires and two focus groups each of African American and White adults, [n=34, mean age =43.1 years, (SD 13.8 years), 44.1% African American] were conducted to understand stress, EH knowledge, app usage along with feedback from a hands-on demonstration of TT. Grounded theory using NVivo 10 was used to develop themes and combined with the questionnaires in the analysis.
Results:
No racial differences were found in the analysis including app use scenarios, preferences, knowledge, technology use or the attitudes and acceptance toward mobile health (mHealth) programs. Reported stress was high for African Americans [PSS-4: mean 6.87 (SD 3.3) versus mean 4.56 (SD 2.6); P=0.03]. Four main themes were found: (I) stress was pervasive; (II) coping strategies were both positive and negative; (III) BAM training was easy to incorporated; and (IV) tracking stress responses was useful. Responses suggest that additional personalization of app interfaces may drive ownership and adherence to protocols. Measures and reports of heart rate monitoring while in session were favorably viewed with low issues with confidentiality or trust issues on collected session data.
Conclusions:
Results suggest that a culturally tailored approach may be unnecessary in the design of BAM apps. Further investigation is warranted for other racial groups, age ranges, and disease conditions.
... Contextual variables such as demographics (sex, age) and culture (ethnicity) are also important to consider, as they may influence the patients' perception of illness, coping styles, and psychological response to a cardiovascular event [24]. Determining multidimensional psychosocial profiles and associated characteristics instead of single factors might increase the sensitivity of epidemiologic prediction models and clarify the pathophysiological pathways lining negative psychosocial states to cardiovascular conditions [25]. ...
... The current findings indicate the importance of assessing both psychological and social factors in patients with coronary artery disease. Previous studies have focused on clustering of mood constructs mostly [1,17,25,47,48]. Only recently, a study was published in which a broader range of constructs were introduced in a cluster analysis, resulting in a social cluster and a distress cluster [49]. ...
Background
While single psychosocial factors have been associated with cardiovascular outcomes, it is still unclear how they cluster. Therefore, we examined whether latent multidimensional psychosocial risk profiles could be identified in the European Society of Cardiology (ESC) psychosocial screening interview. Additionally we examined whether these profiles were associated with specific characteristics.
Method
681 cardiac patients (age = 64.9 ± 10.6; 80% men) completed the ESC interview, comprising 15 items on 7 predefined components. Multiple self-report questionnaires focusing on demographics, mood symptoms, personality, coping, and life events. Clinical information was extracted from patients' medical records.
Results
Latent class analysis identified four psychological classes: 1. Low psychological distress (62%), 2. High hostility (19%) 3. High tension (11%), 4. High psychological distress (8%), and two social classes: Low chronic stress (81%), and High work stress (%19). Characteristics increasing the odds to belong to the “High hostility” class were male sex, negative affectivity, and psychiatric history. “High tension” membership was associated with female sex, being single, a sedentary lifestyle, seeking social support, NA, early adverse life-events, depression, anxiety, and psychiatric history. “High psychological stress” characteristics were younger age, smoking, a sedentary lifestyle, NA, depression, anxiety, early adverse life-events, psychiatric history. Being younger, alcohol use and avoidance-oriented coping increased the odds to be in the “High work stress” class.
Conclusions
This study characterized four psychological and two social latent risk profiles. Results indicate the importance of a multidimensional psychosocial screening, potentially uncovering differential mechanistic pathways, which also may proof beneficial in clinical practice and in risk prevention strategies.
... Indeed, anxiety may be more strongly associated with the onset of cardiac disease than depression (Kubzansky and Kawachi, 2000). In particular, worry is a component of anxiety that appears to be especially associated with cardiac disease (Kubzansky et al., 2005). In patients with acute cardiovascular disease, the population most vulnerable to catastrophic cardiac events and complications, several studies have found that elevated anxiety after MI has been independently associated with in-hospital cardiac complications (Huffman et al., 2008). ...
... Their descriptions frequently included stories of loss, relationship ruptures, low social support, and chronic health problems, including experiencing chronic pain. HOP is a known risk factor for depression (36) and health problems (40,41). Additionally, depression and depression-like traits (i.e., hopelessness) and chronic pain have bi-directional associations (42,43). ...
Background
The Four Factor Personality Vulnerability model identifies four specific personality traits (e.g., sensation seeking [SS], impulsivity [IMP], anxiety sensitivity [AS], and hopelessness [HOP]) as implicated in substance use behaviors, motives for substance use, and co-occurring psychiatric conditions. Although the relationship between these traits and polysubstance use in opioid agonist therapy (OAT) clients has been investigated quantitatively, no study has examined the qualitative expression of each trait using clients’ voice.
Method
Nineteen Methadone Maintenance Therapy (MMT) clients (68.4% male, 84.2% white, mean age[SD] = 42.71 [10.18]) scoring high on one of the four personality traits measured by the Substance Use Risk Profile Scale [SURPS] completed a semi-structured qualitative interview designed to explore their lived experience of their respective trait. Thematic analysis was used to derive themes, which were further quantified using content analysis.
Results
Themes emerging from interviews reflected (1) internalizing and externalizing symptoms, (2) adversity experiences, and (3) polysubstance use. Internalizing symptoms subthemes included symptoms of anxiety, fear, stress, depression, and avoidance coping. Externalizing subthemes included anger, disinhibited cognitions, and anti-social and risk-taking behaviors. Adverse experiences subthemes included poor health, poverty, homelessness, unemployment, trauma, and conflict. Finally, polysubstance use subthemes include substance types, methods of use, and motives. Differences emerged between personality profiles in the relative endorsement of various subthemes, including those pertaining to polysubstance use, that were largely as theoretically expected.
Conclusion
Personality is associated with unique cognitive, affective, and behavioral lived experiences, suggesting that personality may be a novel intervention target in adjunctive psychosocial treatment for those undergoing OAT.
... Igualmente, en una evaluación de 46 pacientes comenzando un programa de rehabilitación cardíaca el optimismo no se asoció con medidas de resultado de un programa de rehabilitación cardíaca 12 semanas después (Glazer, Emery, Frid y Banyasz, 2002). Otro rasgo de personalidad que ha mostrado evidencia empírica suficiente en su relación con la salud cardiovascular es la hostilidad, la cual se define como una actitud cognitiva relativamente estable en el tiempo desarrollada por la exposición repetida a situaciones de ira y caracterizada por cinismo, suspicacia y resentimiento hacia los otros, llevando a intercambios negativos y mayores oportunidades de experimentar ira (Kubzansky, Davidson y Rozanski, 2005;Oblitas, 2007;Smith y Ruiz, 2002). Este rasgo se basa en un estilo atribucional explicado por la cognición de amenaza y la presunción de malevolencia por parte de los demás. ...
La psicología de la salud es un campo de aplicación de la psicología en el que el estudio de los factores de riesgo y protección de enfermedades crónicas tiene una alta importancia. En este campo los estudios señalan la importancia de la personalidad como un factor de vulnerabilidad para el desarrollo y el mal pronóstico de diferentes enfermedades crónicas. Esta revisión de la literatura presenta algunos de los modelos dimensionales de la personalidad y su relación con la salud/enfermedad, haciendo hincapié en el efecto de ciertos rasgos de personalidad en la enfermedad cardiovascular. Se discute la validez de conceptos como el de personalidad tipo d, la relación de los modelos dimensionales con los temperamentales y se enfatiza en la importancia del modelo de cinco factores, específicamente del neuroticismo y de la extraversión, como factores de alta relevancia para la psicología de la salud.
... Hopelessness has been defined as having negative expectations about the future and life as well as a sense of futility (Do et al., 2010). Hopeless people, when in new situations, have negative thoughts about themselves and these thoughts are obstacles to their success (Kubzansky et al., 2005). Beck (1967) noted that hopelessness is one component of depression. ...
... A prior study involving a cohort of community-dwelling older people from Australia demonstrated increased risk of death, specifically death due to cardiovascular disease, in participants with SI but did not analyse those reporting WTD. 25 WTD has been shown to increase the risk of 5-year mortality in a cohort of older people attending primary care, however, analysis was adjusted for baseline disability, smoking status and Hamilton Depression Score only and did not examine cases by cause of death. 26 WTD in later life is more prevalent in those with heart disease, 27 and older adults with a history of myocardial infarction are three times more likely to endorse WTD. 28 Death by suicide also correlates strongly with ischaemic heart disease 29 and incident cardiovascular disease modifies the risk of all-cause mortality in older people with depressive symptoms. ...
Background
There is an established bidirectional relationship between mental and heart health in later life but the link between wish to die (WTD) and cardiovascular mortality is less well defined.
Methods
This is a longitudinal study examining the association between WTD and mortality over 9‐year follow‐up in a large population‐representative sample of older adults.
Individual‐level survey data was linked to official death registration data, divided into cardiovascular and non‐cardiovascular causes.
WTD was defined as answering affirmatively when asked ‘In the last month, have you felt that you would rather be dead?’.
Regression models were used to obtain hazard ratios for the association between WTD at Wave 1 and mortality. Kaplan‐Meier plots were used to compare survival across groups.
Results
Just over 3% (275/8,124) of participants reported WTD. Mortality data was available for 9% of participants (755/8,124).
WTD was significantly associated with all‐cause mortality, with a hazard ratio of 1.41(95% CI 1.00 – 1.99). Findings were attenuated and no longer significant after excluding participants with heart disease or depression/anxiety/other psychiatric illness.
WTD was significantly associated with cardiovascular mortality (HR 2.14 (95% CI 1.21 – 3.78)), even after excluding participants with depression/anxiety/other illnesses but not heart disease.
WTD was not associated with an increased risk of death due to non‐cardiovascular causes.
Conclusions
Older people who report WTD have over double the likelihood of death from cardiovascular disease during the next 9 years, even when we exclude those with depression/anxiety and other psychiatric illnesses. Further work examining biological mechanisms underpinning this association would be welcome.
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... Eine Typ D-Persönlichkeit kann von einer depressiven Störung begleitet werden, allerdings scheint es sich um separate Entitäten mit jeweils individuellem Einfluss auf das kardiovaskuläre Risiko zu handeln (Denollet et al., 2009). Typisch depressive Denkmuster und Persönlichkeitsmerkmale wie Hoffnungslosigkeit, Pessimismus und Ängstlichkeit sind dabei mit dem kardiovaskulären Risiko assoziiert, selbst wenn noch keine psychiatrischen Diagnosekriterien erfüllt sind (Kubzansky, Davidson, & Rozanski, 2005). Für eine depressive Störung gilt dieser Zusammenhang in noch wesentlich erheblicherem Maß, so rechnen Metaanalysen ihr ein relatives Risiko von zumindest 1,43 bis 1,63 bzgl. ...
Die hier vorliegende Arbeit beschäftigt sich mit dem Zusammenhang zwischen affektiven Störungen und dem kardiovaskulären Risiko. Besonderer Fokus lag dabei auf der Evaluation des Hypothalamus-Hypophysen-Nebennierenrinden-Systems bei depressiven Patienten. Kardiovaskuläre Erkrankungen stellen weltweit die führende Todesursache dar, während unipolare depressive Störungen insbesondere innerhalb der Industrieländer einen beträchtlichen Anteil der gesundheitsökonomischen Last bilden. Gemeinsam ist den Erkrankungen eine hohe und auf absehbare Zeit ansteigende Prävalenz, hinzukommt ein nicht unerheblicher Anteil an internistisch-psychiatrischer Komorbidität. So entwickeln kardiologische Patienten nach einem Myokardinfarkt bspw. häufig eine depressive Störung. Während dieser Einfluss somatischer Erkrankungen auf die psychische Gesundheit ausführlich untersucht ist, gilt dies für den umgekehrten nosologischen Zusammenhang nur eingeschränkt. Fest steht, dass depressive Patienten eine gegenüber Gesunden erhöhte Sterblichkeit aufweisen, die sich nicht allein auf Suizide, sondern allen voran auf ein schlechteres kardiovaskuläres Risikoprofil zurückführen lässt. So begünstigt das Vorliegen einer depressiven Störung die Entwicklung somatischer Pathologien wie z. B. des metabolischen Syndroms, was wiederum zu einer Erhöhung der Inzidenz artherosklerotischer Erkrankungen beiträgt. Neben behavioralen und inflammatorischen Prozessen scheint dabei v. a. dem Hypothalamus-Hypophysen-Nebennierenrinden-System eine entscheidende Mediator-Rolle zuzukommen. Bei diesem handelt es sich um ein komplexes endokrines System, das hauptsächlich im Rahmen des Stresserlebens zahlreiche Auswirkungen auf den Metabolismus besitzt und darüber hinaus enge Verknüpfungen zum autonomen Nervensystem sowie dem Immunsystem aufweist. Die Evaluation der Funktion des Hypothalamus-Hypophysen-Nebennierenrinden-Systems erfolgt anhand verschiedener Methoden, die jeweils spezifische Vor- und Nachteile besitzen und in ihrer Aussagekraft nicht als äquivalent anzusehen sind. Ein Konsens bzgl. des zur Untersuchung somatischer Folgeschäden bei depressiven Patienten vorrangig einzusetzenden Verfahrens besteht bislang nicht. Dies ist insofern von wissenschaftlicher Relevanz, als dass bei Patienten mit affektiven Störungen regelmäßig und in unterschiedlichem Ausmaß eine Überaktivierung des Stress-Systems z. B. in Form eines erhöhten Sympathikotonus oder einer Hypercortisolämie vorliegt, was mit diversen somatischen Folgeschäden in Verbindung gebracht wird/werden kann. So ließen sich einige Pathologien, die bei Patienten mit Cushing-Syndrom vorliegen, auch bei depressiven Patienten finden, z. B. eine viszerale Adipositas, ein reduziertes Volumen des Hippocampus sowie eine verringerte Knochendichte. In einer Pilotstudie konnte bei depressiven Patienten, die eine Dysfunktion des Hypothalamus-Hypophysen-Nebennierenrinden-Systems in Form einer Non-Suppressionsreaktion auf den Dexamethason-Hemmtest oder eine Hypercortisolämie aufwiesen, außerdem eine im Vergleich zu gesunden Kontrollen signifikante linksventrikuläre Hypertrophie festgestellt werden, die als eigenständiger Risikofaktor hinsichtlich der kardiovaskulären Mortalität gilt. Im Rahmen der dieser Arbeit zugrundeliegenden STRESSD HEART-Studie wurde daher an 57 Patienten, die sich aufgrund einer depressiven Episode im Zentralinstitut für Seelische Gesundheit Mannheim in Behandlung befanden, die Aktivität des Hypothalamus-Hypophysen-Nebennierenrinden-Systems evaluiert und die Auswirkung einer Funktionsstörung auf die linksventrikuläre Masse untersucht. Letztere wurde dabei echokardiographisch ermittelt. Im Hinblick auf die Funktion des Stresssystems erfolgte ein Methodenvergleich zwischen Dexamethason-Hemmtest, Messung der Cortisol-Ausscheidung über den Nachturin sowie einer abendlichen Cortisol-Bestimmung im Speichel. Die Prävalenz einer linksventrikulären Hypertrophie lag bei den untersuchten Probanden mit je nach verwendetem echokardiographischen Index 12 – 37 % deutlich höher als es bei einer vergleichbaren gesunden Population zu erwarten gewesen wäre. Die Werte für die linksventrikuläre Masse bei Non-Suppressoren betrugen dabei im Mittel 207 ± 73 g gegenüber 343 ± 97 g in der Pilotstudie. Das Vorliegen einer Hypertrophie korrelierte jedoch nur eingeschränkt mit den Parametern zur Evaluation des Hypothalamus-Hypophysen-Nebennierenrinden-Systems, sodass sich ein signifikanter Unterschied nur zwischen den Gruppen der Non-Suppressoren und Suppressoren fand, jedoch nicht in Bezug auf die nächtliche Cortisol-Ausscheidung über den Urin oder die Konzentration im Speichel. Auch der Zusammenhang zwischen gestörter Reaktion auf den Dexamethason-Hemmtest und linksventrikulärer Masse erreichte nach statistischer Kontrolle für das Alter und das Geschlecht nicht mehr das Signifikanzniveau. Mit Hilfe der multiplen linearen Regressionsanalyse konnte ein eigenständiger Einfluss der Reaktion auf den Dexamethason-Suppressionstest auf die linksventrikuläre Masse dementsprechend nicht festgestellt werden. Für den Blutdruck ließ sich jedoch ein solcher Einfluss nachweisen, was auch nach Kontrolle für die Variablen Alter, Geschlecht sowie BMI Bestand hatte. Der Methodenvergleich der verschiedenen Parameter zur Evaluation des Hypothalamus-Hypophysen-Nebennierenrinden-Systems ergab insgesamt unterschiedlich starke Korrelationen. So wiesen insbesondere die Cortisol-Bestimmungen im Speichel nur eine schwache Assoziation zu den übrigen Methoden und keine Assoziation zu somatischen Parametern auf. Die nächtliche Cortisol-Ausscheidung über den Urin korrelierte hingegen stark und positiv mit dem Cortisol-Serumspiegel nach Dexamethason-Gabe und identifizierte bei einzelnen Probanden Dysfunktionen des Hypothalamus-Hypophysen-Nebennierenrinden-Systems, die im Dexamethason-Hemmtest eine unauffällige Reaktion gezeigt hatten. Zusammenfassend legen die Ergebnisse der Arbeit nahe, dass zum Zwecke einer Untersuchung des Zusammenhangs zwischen der Aktivität des Hypothalamus-Hypophysen-Nebennierenrinden-Systems und somatischen Folgeschäden eine Kombination aus DST mit anschließender Serum-Cortisol-Bestimmung und eine Messung des freien Cortisols im Nachturin erfolgen sollte, da letztere dazu geeignet zu sein scheint, einzelne Probanden mit gestörter Funktion des Hypothalamus-Hypophysen-Nebennierenrinden-Systems zu identifizieren, die im DST unerkannt bleiben. Mit Hinblick auf die Anwendung im klinischen Setting gehen diese Methoden mit spezifischen Vorteilen einher, so zeigen sich die nächtliche Urinsammlung sowie die Durchführung eines DST als Kurztest mit einmaliger Blutentnahme als günstige, gegenüber Störungen robuste und von Patienten gut akzeptierte Verfahren. Hinsichtlich des Vorliegens einer linksventrikulären Hypertrophie widersprechen die in der Arbeit vorgestellten Daten der Annahme der Pilotstudie. Zwar lag bei depressiven Patienten eine erhöhte Prävalenz für eine linksventrikuläre Hypertrophie vor, diese schien sich jedoch nur unter bestimmten Voraussetzungen zu entwickeln, sodass von einer klinisch relevanten Hypertrophie mit signifikanten Auswirkungen auf das kardiovaskuläre Risiko bei depressiven Patienten nur im Falle einer starken Dysfunktion des Hypothalamus-Hypophysen-Nebennierenrinden-Systems bei gleichzeitig vorliegender arterieller Hypertonie auszugehen sein dürfte. Diese Ergebnisse sind jedoch in Anbetracht der geringen Fallzahl der untersuchten Probanden mit Vorsicht zu betrachten.
... Akut koroner sendrom sonrasında depresyon ve anksiyete görülme sıklığı yüksektir (5)(6). Akut koroner sendrom tanısı ile koroner bakım ünitesinde yatan hastalarda, depresyon ve anksiyetenin varlığı, yaşam kalitesinde azalma; tekrarlayan akut koroner olay sıklığı ve mortalitede artışa neden olmaktadır (8)(9)(10). ...
Purpose: Anxiety and depression are common health problems affecting course of the cardiac rehabilitation in patients with acute coronary syndrome. The purpose of this study was to investigate the determinants of anxiety and depression in patients with acute coronary syndrome. Methods: Fifty patients (42 males, 8 females) hospitalized in coronary care unit with a diagnosis of acute coronary syndrome participated in the study. Physical, physiological and demographic characteristics of the patients were recorded. The Global Registry of Acute Coronary Events (GRACE) risk score was calculated. Functional level was determined using the New York Heart Association Classification (NYHA). Anxiety was evaluated using the State-Trait Anxiety Inventory (STAI). Depression was determined using the Beck Depression Inventory (BDI). Cognitive function evaluated using the Mini Mental State Examination (MMSE). Results: According to multiple linear regression analysis, the BDI score and NYHA class explained 45% of the variance in the STAI-Trait Anxiety score (p=0.016). Duration of education, previous percutaneous intervention, and coronary care unit admission respiratory rate explained 39% of STAI-State Anxiety score (p<0.0001). The STAI-Trait Anxiety score and MMSE score explained 37% of the variance in the BDI score (p<0.0001). Conclusion: Functional level, duration of education, cognitive function, previous percutaneous applications, and admission respiratory rate determine depression and anxiety level in acute coronary syndrome. Psychosocial status as well as physical function should be taken into consideration to plan in to the cardiac rehabilitation programs.
... In addition, trait worry has been conceptualized as a personality characteristic of permanent vigilance to negative information and low tolerance of uncertainty. Trait worry is associated with aversive states and has been considered a risk factor for physical and mental problems, especially cardiovascular disease (Brosschot et al., 2006;Kubzansky et al., 2005). ...
Trait worry refers to a tendency toward increased vigilance to threat and reduced tolerance of uncertainty. While it has been established as a risk factor of general morbidity, knowledge about autonomic regulation in trait worry remains scarce. This study investigated parasympathetic cardiac control in trait worry, in the context of attentional focus. Healthy groups with high and low worry were selected using the Penn State Worry Questionnaire (n = 40 per group). Heart rate variability (HRV) was recorded in the high frequency (HF) and low frequency (LF) bands while participants performed a breathing focus task. The task included a phase of instructed worry and two phases during which participants´ ability to concentrate on their breathing was assessed. As compared to the low worry group, the high worry group exhibited lower HRV in the LF band during both breathing focus phases and smaller reduction of LF HRV during instructed worry. HF HRV did not differ between groups. High worry was associated with impaired ability to concentrate on breathing and more intrusive thoughts. In the total sample, negative intrusions correlated negatively with LF HRV during the first breathing focus phase and LF HRV reactivity. Instructed worry led to greater perceived stress and deterioration of mood in high worry participants. Reduced LF HRV reflects blunted parasympathetic cardiac control in trait worry, associated with elevated risk of poor health outcomes. In addition, it might represent a psychophysiological correlate of reduced cognitive inhibition, which interferes with attentional focus and impedes control of threat processing and perseverative thinking.
... Data from the more recent cross-sectional and longitudinal studies provide relatively strong support for a relationship between obesity and depression among older adults. Because subclinical levels of both BMI (e.g., overweight but not obese) and depression (e.g., depressive symptoms that do not meet a clinical threshold) have been linked to negative health outcomes (Field et al., 2001;Kubzansky, Davidson, & Rozanski, 2005), it is important to evaluate the degree to which they are related, and the extent to which one variable may contribute to change in the other. BMI is particularly relevant among older adults because higher BMI is a risk for morbidity and mortality during the earlier years of older adulthood (Peeters et al., 2003), but over age 80 there is evidence that BMI may become less closely associated with mortality (Dahl et al., 2013) and that higher BMI, paradoxically, is associated with survival, especially among individuals with chronic illness (Curtis et al., 2005;Weiss et al., 2008). ...
Objectives:
Body fat, measured with body mass index (BMI), and obesity are associated with depressive symptoms. Among younger adults there is stronger evidence of obesity leading to depressive symptoms than of depressive symptoms leading to obesity, but the temporal relationship is unknown among older adults. This study utilized dual-change-score models (DCSMs) to determine the directional relationship between body mass and depressive symptoms among older adults.
Method:
Participants (n=1743) from the Swedish Twin Registry (baseline age range 50-96 years) completed at least one assessment of BMI (nurse measurement of height and weight) and the Center for Epidemiologic Studies-Depression scale (CESD). More than half the sample completed three or more assessments, scheduled at intervals of 2-4 years. DCSMs modeled the relationship of BMI and CESD across age, both independently and as part of bivariate relationships.
Results:
Depressive symptoms contributed to subsequent changes in BMI after age 70, while BMI contributed to subsequent changes in depressive symptoms after age 82. Thus, there is a reciprocal relationship that may change with age. The effect was more pronounced for women.
Discussion:
The association of BMI and depressive symptoms is bi-directional among older adults, and it appears to be affected by both age and sex.
... Another possible explanation of such differences might be attributed to the way socioeconomic status was taken into account. It is important for the health care providers when discussing traditional risk factors, to incorporate discussion of different aspect of socioeconomic factor management as part of the overall cardiovascular health [11,30]. ...
Introduction
Coronary artery disease (CAD) is a leading cause of death worldwide. The association of socioeconomic status with CAD is supported by numerous epidemiological studies. Whether such factors also impact the number of diseased coronary vessels and its severity is not well established.
Materials and Methods
We conducted a prospective multicentre, multi-ethnic, cross sectional observational study of consecutive patients undergoing coronary angiography (CAG) at 5 hospitals in the Kingdom of Saudi Arabia and the United Arab Emirates. Baseline demographics, socioeconomic, and clinical variables were collected for all patients. Significant CAD was defined as ≥70% luminal stenosis in a major epicardial vessel. Left main disease (LMD) was defined as ≥50% stenosis in the left main coronary artery. Multi-vessel disease (MVD) was defined as having >1 significant CAD.
Results
Of 1,068 patients (age 59 ± 13, female 28%, diabetes 56%, hypertension 60%, history of CAD 43%), 792 (74%) were from urban and remainder (26%) from rural communities. Patients from rural centres were older (61 ± 12 vs 58 ± 13), and more likely to have a history of diabetes (63 vs 54%), hypertension (74 vs 55%), dyslipidaemia (78 vs 59%), CAD (50 vs 41%) and percutaneous coronary intervention (PCI) (27 vs 21%). The two groups differed significantly in terms of income level, employment status and indication for angiography. After adjusting for baseline differences, patients living in a rural area were more likely to have significant CAD (adjusted OR 2.40 [1.47, 3.97]), MVD (adjusted OR 1.76 [1.18, 2.63]) and LMD (adjusted OR 1.71 [1.04, 2.82]). Higher income was also associated with a higher risk for significant CAD (adjusted OR 6.97 [2.30, 21.09]) and MVD (adjusted OR 2.49 [1.11, 5.56]), while unemployment was associated with a higher risk of significant CAD (adjusted OR 2.21, [1.27, 3.85]).
Conclusion
Communal and socioeconomic factors are associated with higher odds of significant CAD and MVD in the group of patients referred for CAG. The underpinnings of these associations (e.g. pathophysiologic factors, access to care, and system-wide determinants of quality) require further study.
... Traditional risk factors comprise the majority of the increase for cardiovascular events [4] . Additional factors such as physiological, psychological, emotional, social, and stress, both acute and chronic, have been studied [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] . The interactions between risk factors also have great consequences [24] . ...
AIM
To assess the association of inter-ethnic vs intra-ethnic marriage with severity of coronary artery disease (CAD) in men undergoing angiography.
METHODS
We conducted a prospective multicenter, multi-ethnic, cross sectional observational study at five hospitals in Saudi Arabia and the United Arab Emirates, in which we used logistic regression analysis with and without adjustment for baseline differences.
RESULTS
Data were collected for 1068 enrolled patients undergoing coronary angiography for clinical indications during the period of April 1st, 2013 to March 30th, 2014. Ethnicities of spouses were available only for male patients. Of those enrolled, 687 were married men and constituted the cohort for the present analysis. Intra-ethnic marriages were reported in 70% and inter-ethnic marriages in 30%. After adjusting for baseline differences, inter-ethnic marriage was associated with lower odds of having significant CAD [adjusted odds ratio 0.52 (95%CI: 0.33, 0.81)] or multi-vessel disease (MVD) [adjusted odds ratio 0.57 (95%CI: 0.37, 0.86)]. The adjusted association with left main disease showed a similar trend, but was not statistically significant [adjusted odds ratio 0.74 (95%CI: 0.41, 1.32)]. The association between inter-ethnic marriage and the presence of significant CAD and MVD was not modified by number of concurrent wives (P interaction > 0.05 for both).
CONCLUSION
Among married men undergoing coronary angiography, inter-ethnic, as compared to intra-ethnic, marriage is associated with lower odds of significant CAD and MVD.
... Le pessimisme est parfois précurseur de dépression. Les deux aspects psychiques du pessimisme (vision négatived um onde et croyance que l'avenir est nécessairement sombre) sont corrélésa ur isque de survenue d'événements coronariens [20,21]. Il est très important de mentionner qu'ac ontrario l'optimisme est un important facteur protecteur [22]. ...
... In our study, the mechanism of excess self-perceived poor health among pessimists may be related to poor adaptation to critical circumstances associated with the particularly rapid transition in Kosovo, as suggested by previous research on this field (3), where obvious differences in coping strategies between optimists and pessimists have been convincingly demonstrated (3,15,16). Conversely, negative reaction towards political and socioeconomic aspects of transition may also serve as a marker of depression (17,18), which may lead to poor health status in general. This study may suffer from several limitations including its design, representativeness of the study population and the possibility of information bias. ...
Aim: The objective of our study was to assess the association of reaction to political and socioeconomic transition with self-perceived general health status in adult men and women in a region of Kosovo, a post-war country in the Western Balkans which has proclaimed independence in 2008.
Methods: This was a cross-sectional study carried out in Gjilan region of Kosovo in 2014, including a representative sample of 867 primary health care users aged ≥35 years (419 men aged 54.3±10.9 years and 448 women aged 54.0±10.1 years; overall response rate: 87%). Reaction to political and socioeconomic aspects of transition was assessed by a three-item scale (trichotomized in the analysis into positive attitude, intermediate attitude, and negative attitude towards transition), which was previously used in the neighbouring Albania. Self-reported health status was measured on a 5-point scale which was dichotomized in the analysis into “good” vs. “poor” health. Demographic and socioeconomic data were also collected. Binary logistic regression was used to assess the association of reaction to transition with self-rated health status.
Results: In crude/unadjusted models, negative attitude to transition was a “strong” predictor of poor self-perceived health (OR=2.5, 95%CI=1.7-3.8). Upon multivariable adjustment for all the demographic factors and socioeconomic characteristics, the association was attenuated and was only borderline statistically significant (OR=1.6, 95%CI=1.0-2.6, P=0.07).
Conclusion: Our findings indicate an important association between reaction to transition and self-perceived health status in the adult population of the newly independent Kosovo. Policymakers and decision-makers in post-war countries such as Kosovo should be aware of the health effects of attitudes towards political and socioeconomic aspects of transition, which is seemingly an important psychosocial factor.
... Indeed, anxiety may be more strongly associated with the onset of cardiac disease than depression (Kubzansky and Kawachi, 2000). In particular, worry is a component of anxiety that appears to be especially associated with cardiac disease (Kubzansky et al., 2005). In patients with acute cardiovascular disease, the population most vulnerable to catastrophic cardiac events and complications, several studies have found that elevated anxiety after MI has been independently associated with in-hospital cardiac complications (Huffman et al., 2008). ...
... For individuals with an early onset, these disorders lead to increased risk of comorbid mental and substance use disorders (Kessler, Ruscio, Shear, & Wittchen, 2010 ). Anxiety disorders are also independently linked to increased mortality due to heightened risk for coronary heart disease (Kubzansky, Davidson, & Rozanski, 2005 ) and suicide (Bolton et al., 2008 ). ...
Anxiety disorders are highly prevalent and costly both to the individual and society. Established treatments are effective, but a number of patients fail to respond optimally. Mindfulness- and acceptance-based interventions (MABIs) constitute a family of treatments emphasising present-centred awareness, a stance of non-judgment, and value-oriented action. Anxiety disorders are instigated and maintained by a set of transdiagnostic processes within the domains of cognition, emotion, behaviour, and self-experience. A conceptual and empirical overview suggests that MABI may impact beneficially on these processes. Clinical trials and meta-analyses provide support for their effectiveness in anxiety disorders, although a pattern of divergent findings emerges. Clinical trials show strongest support for MABIs in the treatment of heterogeneous anxiety disorders and generalised anxiety disorder. Evidence for social anxiety disorder is mixed, and there is at present insufficient evidence to assess the impact of MABIs on panic disorder, PTSD, and OCD. Despite equivalent outcomes to cognitive behavioural therapy (CBT) in most head-to-head comparisons, MABIs have yet to perform as well as CBT at its best. While CBT is still the treatment of choice for most anxiety disorders, MABIs constitute a viable treatment option for CBT nonresponders and may also be preferred by some patients. Further tailoring of MABIs to discrete anxiety disorders may be needed. Clinical implementation is discussed, and recommendations for further research are presented.
Vital Exhaustion (VE) refers to a physical and mental state of excessive fatigue, feelings of demoralization, hopelessness, and increased irritability. The short form of the Maastricht Vital Exhaustion Questionnaire (MVEQ) is a widely used measure to assess VE. Despite its utility is broadly recognized, the validity and reliability of the scale have yet to be examined in the Italian context. The present study aimed to evaluate the psychometric properties of the shortened MVEQ in a community sample of Italian older adults. A total of 722 older adults (Mage = 72.97, SD = 7.71; 60.4% females) completed the MVEQ, as well as other self-report questionnaires assessing anxiety, depression and stress in order to evaluate the criterion-related validity of the scale. A confirmatory factor analysis (CFA) was conducted to examine the original MVEQ latent structure. Internal consistency was assessed through model-based omega coefficient. Test-retest reliability was examined by re-administering the MVEQ after three months to a subsample of 568 participants. Factorial invariance tests across gender were conducted by means of multi-group CFAs. The one-factor model showed an acceptable fit to the data. The MVEQ yielded a reliable total score (ω = 0.822) and showed moderate-to-large correlations with measures of anxiety, depression, and stress (r range 0.30 to 0.75, ps < 0.001). Test-retest reliability was supported by an Intraclass Correlation Coefficient (ICC) of 0.661. Lastly, the scale was factorially invariant across gender. Overall, the MVEQ provided evidence of reliability and criterion-related validity in a sample of Italian older adults and may be useful for both clinical and research practices.
Das Thema der affektiven Komorbidität wird für folgende kardiovaskuläre Krankheiten skizziert: Koronare Herzkrankheit, Herzinsuffizienz, akute Stress-Kardiomyopathie (Takotsubo-Syndrom), arterielle Hypertonie, kardiale Arrhythmien, kardiologische und herzchirurgische Interventionen. Epidemiologische Studien belegen, dass vorbestehende affektive und Stress-bezogene Störungen das Inzidenzrisiko einer kardiovaskulären Krankheit erhöhen. Umgekehrt ist eine kardiovaskuläre Krankheit mit einem erhöhten Inzidenzrisiko von affektiven und Stress-bezogenen Störungen im Krankheitsverlauf assoziiert. Hiermit gehen eine erhöhte Morbidität und Mortalität sowie eine ungünstigere Lebensqualität einher. Vorbestehende affektive und Stress-bezogene Störungen vermitteln spezielle kardiometabolische Krankheitsrisiken sowohl auf einer systemisch-biologischen Ebene als auch auf einer Verhaltensebene. Langzeiteffekte in der Entwicklung zur klinischen Manifestation und im Verlauf sind von Akuteffekten zu unterscheiden, die zu kritischen kardialen Ereignissen führen. Psychotherapeutische und psychopharmakologische Ansätze weisen auf differentielle, häufig aber auch auf inkonsistente Effekte in der Behandlung koexistenter depressiver, Angst- und posttraumatischer Störungen hin. Trotz ermutigender Hinweise bestehen noch keine klaren empirischen Belege dafür, dass eine wirksame psychotherapeutische oder psychopharmakologische Behandlung dieser koexistenten psychischen Störungen auch schon den Verlauf des biologischen kardiovaskulären Krankheitsgeschehens entscheidend beeinflusst.
Cognitive reappraisal is an emotion regulation strategy that is postulated to reduce risk for atherosclerotic cardiovascular disease (CVD), particularly the risk due to negative affect. At present, however, the brain systems and vascular pathways that may link reappraisal to CVD risk remain unclear. This study thus tested whether brain activity evoked by using reappraisal to reduce negative affect would predict the multiyear progression of a vascular marker of preclinical atherosclerosis and CVD risk: carotid artery intima-media thickness (CA-IMT). Participants were 176 otherwise healthy adults (50.6% women; aged 30-51 years) who completed a functional magnetic resonance imaging task involving the reappraisal of unpleasant scenes from the International Affective Picture System. Ultrasonography was used to compute CA-IMT at baseline and a median of 2.78 (interquartile range, 2.67 to 2.98) years later among 146 participants. As expected, reappraisal engaged brain systems implicated in emotion regulation. Reappraisal also reduced self-reported negative affect. On average, CA-IMT progressed over the follow-up period. However, multivariate and cross-validated machine-learning models demonstrated that brain activity during reappraisal failed to predict CA-IMT progression. Contrary to hypotheses, brain activity during cognitive reappraisal to reduce negative affect does not appear to forecast the progression of a vascular marker of CVD risk.
Supplementary information:
The online version contains supplementary material available at 10.1007/s42761-021-00098-y.
Le corps et l’esprit sont intimement liés. Les relations entre cœur et cerveau sont très fortes. La naissance de la psychocardiologie apparaît comme une évidence. Le stress psychosocial est à la fois un facteur de risque indépendant et un facteur pronostic d’événements cardiovasculaires. Il comprend des aspects psychologiques, des composantes sociologiques et socio-économiques. Il apparaît aussi que la maladie cardiaque est elle-même un événement déclenchant de stress psychosocial. Les recommandations européennes sont de grade 1A pour l’évaluation du risque psychosocial et de grade 1B pour la prise en charge. Les connaissances actuelles sur le développement cérébral permettent de mieux comprendre la relation qui existe entre le stress psychosocial et le risque cardiovasculaire. Le risque psychosocial augmente les facteurs de risque classiques et entraîne par ailleurs une dysfonction endothéliale, une réponse inflammatoire et une activation de la coagulation. Les anxiolytiques et les antidépresseurs ne sont pas très efficaces dans la prise en charge du stress psychosocial, en revanche l’activité physique et les psychothérapies sont plus indiquées en particulier les thérapies cognitivo-comportementales, les thérapies de la pleine conscience et la thérapie EMDR. Depuis qu’il a été proposé à la fin des années 70, le modèle biopsychosocial ne cesse d’accumuler des preuves de sa pertinence. Les recherches en médecine psychosomatique , en cardiologie et en psychologie de la santé ont permis de faire en sorte que la psychocardiologie devienne une nouvelle spécialité fondée sur l’evidence based medicine. Il reste maintenant à faire en sorte que ces connaissances puissent être transmises aux praticiens et qu’ils puissent inclure cet aspect dans leur pratique quotidienne.
Comprendere i fattori che influenzano la riabilitazione dei pazienti dopo un evento coronarico acuto è importante per ridurre il rischio di complicanze o il verificarsi di nuovi episodi. Il percorso riabilitativo successivo all'evento acuto è influenzato da fattori fisiologici e psicologici; tra questi, l'ansia è implicata sianell'esordio della malattia che nel percorso di guarigione. La letteratura fornisce risultati contrastanti rispetto al ruolo giocato dall'ansia nelle malattie cardiache. Sono necessarie quindi ulteriori indagini per comprendere se sia un fattore di rischio o un fattore protettivo. L'obiettivo di questo studio è quello di determinare come cambiano i livelli di ansia in pazienti che hanno aderito a un programma di Riabilitazione Cardiologica in relazione alla consapevolezza sulla propria condizione di salute. La ricerca si propone in particolare di studiare il cambiamento dei due fattori dall'inizio del programma riabilitativo (pre-test) e alla sua conclusione (post-test). I risultati delle analisi statistiche mostrano che i pazienti al post-test risultano più ansiosi e stressati rispetto al pre-test ma anche più consapevoli rispetto alla durata della malattia. Questi risultati suggeriscono che il fattore ansia dopo il percorso riabilitativo può essere considerato generativo alla luce di un effettivo aumento della consapevolezza della malattia.
Burgeoning evidence supports psychological conditions as potential risk factors for ischemic heart disease, though traditional behavioral risk factors are often cited as confounders. In this chapter, this concept is illustrated through a review of the literature evaluating associations between depression, tobacco smoking, and ischemic heart disease. First, the evidence supporting an association between depression and ischemic heart disease is outlined. To provide a disease prevention and health promotion perspective, research evaluating the association between depression and subclinical ischemic heart disease, as measured by coronary artery calcification, is presented. Finally, the role of tobacco smoking in these associations is addressed. The chapter concludes with a discussion of the implications of this research for health psychologists.
Background:
Diabetes distress is an important factor in treatment outcomes and results in poor behavioral and biological consequences. Technology has been used in management programs of diabetes to improve communication between patients and health care providers and to promote education about the disease and its psychological aspects, which can impact the self-efficacy of the programs. However, the true impact of technological approaches on the management of type 2 diabetes distress remains controversial.
Aim:
To investigate the effectiveness of technology interventions on the management of type 2 diabetes distress.
Methods:
Studies published from 2014 to 2019 were searched in five databases: MEDLINE, PubMed, Library and Information Science Source, Academic Search Ultimate and PsycINFO. The Boolean logic search terms were: (1) T2Diabetes; (2) diabetes distress; and (3) technology OR mobile OR phone OR application OR web. We also systematically searched the reference lists of the included studies and relevant reviews. Randomized controlled trials with technology interventions, type 2 diabetes patients and diabetes distress as the outcome were selected. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed.
Results:
Of the 88 studies selected, nine full articles met the inclusion criteria and were subjected to final careful review. On the JADAD scale, one article was classified as having poor quality and eight as having good quality. Six out of nine articles showed that technology interventions had a positive impact on diabetes distress scale scores when compared with the initial data. Among the six articles, five showed a greater reduction in the diabetes distress scores from control interventions. Web-based interventions had good results when users received personalized feedback and routine caregiver support and attention.
Conclusion:
Technology interventions can contribute positively to the management of type 2 diabetes distress, especially with a tailored approach in conjunction with caregiver interaction with patients.
Dissertation from University of North Carolina at Charlotte
Recent decades have seen increased interest in the integration of mental and physical healthcare. Healthcare reform in the US has provided an opportunity for integration of evidence-based mental health programmes. Three quarters of patients with behavioural health disorders are seen in medical settings, where behavioural problems are largely unaddressed. The human and economic toll of unaddressed mental and behavioural health needs is enormous and often hidden from view, since the behavioural or mental health implications of medical conditions like heart disease and diabetes have only recently begun to be appreciated. This paper has three goals: (1) to review models of integrated services delivery, providing a framework for making sense of strategies for integration; (2) to consider some evidence for clinical outcomes when care is integrated; and (3) to highlight some factors that enhance or impede integration in practice. The review concludes with comments on where the field is going.
Health is often recognized as a medical and or psychological notion belonging to an individual and its larger social, political and global context is missed out. However, being a part of a social reality, health operates under the influence of several interactive determinants. This chapter focuses on key contextual and personal factors including education, literacy, optimism, future orientation, perceived control and coping strategies, and examines their role in shaping health and well-being in diverse groups of people (e.g., patients, healthcare professionals, homemakers, rural women, elderly people and young students). Studies suggested links between health/illness beliefs, psychological resources and coping strategies.
BACKGROUND: Subliminal oxidative stress and systemic inflammation, putatively mediated/modulated by long-term nutrimetabolic imbalance, are known pathophysiologic mechanisms in chronic disease development. Their early detection may enable timely intervention to prevent onset, favorably alter course or mitigate outcome of chronic disorders. Contemporary healthcare framed in a biomedical reductionist health-disease dualism so far has largely disregarded predisease and malnutrition phenotypes, perhaps by reason of paradigmatic reluctance and technological limitations. Primarily focused on clinical disease, conventional circulating biomarkers unable to capture the complexity of multiple actors, targets and levels of biological organization, thus, may fail to yield actionable results.
OBJECTIVE: This work aims to evaluate the strengths and weaknesses of the nutritional phenotype‟s post-genomic subset (nutritional transcriptome, proteome, and metabolome) in illuminating molecular signatures indicating early homeostatic perturbations of chronic disease. The term “nutritional phenotype” denotes “a defined and integrated set of genetic, proteomic, metabolomic, functional, and behavioral factors that, when measured, form the basis for assessment of human nutritional status. [It] integrates the effects of diet on disease/wellness and is the quantitative indication of the paths by which genes and environment exert their effects on health (Zeisel et al, J Nutr 2005 Jul, 135(7):1613-6).”
METHODOLOGY: A PUBMED literature survey has been carried out to retrieve published material (reviews and original research) between 1999 and 2010 linking post-genomic technologies to the early detection of molecular redox and inflammation states.
FINDINGS: In general, post-genomics provides insight into biopathologic mechanisms and regulatory networks; challenges may largely arise from experiments (eg, study design, (pre-)analytics, tissue availability, protocols), biology (eg, intersubject variability, marginal dietary ad-hoc effects) and technology (eg, innate limitations, low dietary signal-to-noise ratio, inter-assay/platform/laboratory variability, standards, systems, infrastructure, laboratory equipment). Beyond this, each technology naturally features specific pros and cons (transcriptomics: eg, illuminating functional relationships vs. limited capacity to reliably predict the ultimate phenotype; proteomics: eg, identifying/quantifying protein abundance, function, activity, interactions etc. vs. complexity due to protein diversity, dynamics, localization etc.; metabolomics: eg, assessing net metabolic effects vs. comprehending genome-microbiome crosstalk). In a nutshell, although nutrigenomic profiling studies targeting aberrant redox/inflammation states are scarce, preliminary evidence based on various biofluids, cell types, model systems and disorders furnish proof of its capacity and enormous potential in deciphering unique molecular signatures.
CONCLUSION: Well-designed (integrative) nutrigenomic profiling studies plus challenge tests may enable assessment of homeostatic robustness as well as detection of early onset and magnitude of physiologic derangements in redox and inflammation related networks. Further studies employing nutritional phenotype (subsets) are warranted to early assess nutritional, metabolic and health status of yet asymptomatic individuals as part of a comprehensive prevention, risk assessment and health promotion program.
Emotional regulation has been related to HRV patterns (Thayer 2005; Appelhans and Luecken 2008). Emotion regulation ability has been operationalized and associated with lower or higher HRV (Appelhans and Luecken 2008; Thayer and Fischer 2009; Thayer et al. 2009). Thus, a meta-analysis proposed that “HRV is important not so much for what it tells us about the state of the heart as much as it is important for what it tells us about the state of the brain” (Thayer et al. 2012).
Background:
Depression, hostility, and hopelessness are risk factors for adult cardiovascular disease (CVD). People living in inner-city environments are particularly vulnerable. These associations may begin in adolescence, but research in this area is hampered by inadequate knowledge about how these negative psychological factors are related in teens and how they are affected by demographic characteristics. We hypothesized that depression, hostility, and hopelessness are one construct, and that this construct would be associated with race and gender in attendees at an inner-city adolescent health clinic.
Methods:
Two hundred and forty-six 15-18-year-old patients filled out instruments measuring depressive symptoms, hostility, and hopelessness. Confirmatory factor analysis was used to determine whether the negative psychological factors comprised a single construct or three separate ones. General linear modeling (GLM) was used to test the associations between demographic characteristics and the results of the factor analysis.
Results:
Depressive symptoms, hostility, and hopelessness were best characterized as three separate constructs, not one (root mean square error of approximation (RMSEA)=0.041, 90% confidence interval (CI)=(0.035, 0.047), comparative fit index (CFI)=0.98). There were no significant relationships between demographic variables and depressive symptoms or hostility. Six percent of the variance in hopelessness scores was accounted for by gender, race, and the interaction between the two (F=3.76; p=0.006), with White males, reporting the highest levels of hopelessness.
Conclusion:
In an urban adolescent health clinic population, depressive symptoms, hostility, and hopelessness were best understood as three separate constructs. Hopelessness was significantly higher in White males. Implications for future clinical research on negative psychological factors in teens are discussed.
Objective
The study aimed to assess the subjectively perceived need for additional general disease-oriented and psychotherapeutic care in patients with suspected cardiac disease and to investigate if the request for additional care is consistent with impairment of generic quality of life and the presence of psychosomatic risk factors.
Material and methods
Patients referred for cardiac stress testing because of suspected cardiac disease completed the assessment of the demand for additional psychological treatment (ADAPT) questionnaire, an assessment tool for counselling demand in patients with chronic illness, the SF-36 quality of life and the hospital anxiety and depression scale (HADS) questionnaires.
Results
The questionnaires were administered to 233 patients (age: 54.5 ± 13.4, 57.5 % male). Exclusive demand for disease-oriented counselling was indicated by 45.1 %, demand for psychotherapeutic counselling (exclusive or combined with disease-oriented demand) by 33.9 %. Almost all patients with psychotherapeutic demand (96.3 %) expressed also request for disease-oriented counselling. Patients with exclusive demand for disease-oriented counselling showed significantly lower scores in the emotional and physical functioning and role domains of the SF-36 than the norm population. Patients demanding psychotherapeutic counselling reported significantly lower scores in all SF-36 domains than the norm population. Psychotherapeutic demand was strongly associated with positive indicators for mental distress: SF-36 MH (OR: 4.1), SF-36 MCS (OR: 5.9), HADS anxiety (OR: 3.9), and HADS depression (OR: 3.0).
Conclusions
Our study shows that the patients’ request for additional care reflects impairment of generic health status and psychological risk load. This indicates that the assessment of subjectively perceived demand allows to screen for patients who are in need of psychosomatic care and motivated to participate in additional counselling and therapy.
PURPOSE: Although cardiac rehabilitation programs have been shown to decrease cardiovascular risk, morbidity, and mortality, few programs have integrated a balanced mind/body approach in which patients are taught the relaxation response and utilize cognitive behavior skills for stress management, along with diet and exercise. We examined the medical and psychological outcomes of patients treated in such a cardiac rehabilitation program in a general hospital setting. METHODS: From 1997 to 2005, outcomes were measured in 637 patients with coronary artery disease at baseline and after a 3-month program. Components of the intervention included smoking cessation, moderate aerobic exercise, nutrition counseling, relaxation response training, and cognitive/behavioral skills. RESULTS: Men and women improved significantly with respect to medical outcomes (blood pressure, lipids, weight, exercise conditioning, frequency of symptoms of chest pain and shortness of breath) and psychological outcomes (general severity index, depression, anxiety, and hostility) (P<.0001). Patients considered "at higher risk" for cardiac events due to high baseline measures improved their measures to a less than "at higher risk" level. Data indicate that specific components of the intervention, that is, increased relaxation response practice and exercise, significantly contributed to these improvements (P<.05). Furthermore, age and gender differences, particularly for psychological measures, were found; younger patients and female patients had greater improvements than older patients and male patients. CONCLUSIONS: This study provides preliminary data for a subsequent randomized control trial to test mind/body-based interventions to determine the most effective outcomes at an affordable cost.
Numerous studies have documented an inverse relationship between blood pressure and sensitivity to experimental nociceptive stimulation. The present study aimed to investigate possible associations between blood pressure and the occurrence and intensity of paradoxical pain induced by the thermal grill paradigm. Thirty-one healthy subjects were stimulated three times for 1 min with the nonnoxious temperatures of 15°C and 41°C set at the interlaced cold and warm bars of a water bath-driven thermal grill. Blood pressure and heart rate were recorded concomitantly. On account of previous observations of an association between the sensitivity of the cardiac baroreflex and pain perception, this parameter was additionally obtained. Numerical rating scales were used to quantify subjective pain intensity and pain unpleasantness; subjects were classified as responders and nonresponders to thermal grill stimulation based on pain intensity ratings. Responders exhibited lower systolic and diastolic blood pressure than nonresponders, and inverse linear associations arose between blood pressure and pain intensity and unpleasantness. Baroreflex sensitivity was unrelated to pain ratings. The findings confirmed the hypothesis of a blood pressure dependence of paradoxical pain and support the notion that the cardiovascular and pain regulatory systems interact not only in the processing of pain elicited by noxious input, but also in nonnoxiously generated illusive pain. While this finding is not consistent with the assumption of an involvement of the baroreflex system in mediating the observed interaction, psychological traits and neurochemical factors are alternatively considered.
Researchers currently focus on a wide range of aspects associated with coincidence of cardiovascular diseases and depression. These include a search for a possible causal link between depression and coexisting cardiovascular disorder as well as the association between depression and poorer recovery after myocardial infarction or higher complication rate. Major depression is connected with comorbidities such as the metabolic syndrome and diabetes mellitus. Impaired autonomous nerve system function and unhealthy lifestyle can also play their role. Depression is more frequent in patients with a history of myocardial infarction and is considered a major risk factor of poorer prognosis. It is undoubtedly important to screen this patient group for both depression and anxiety so that appropriate treatment can be initiated if needed.
In this chapter, we provide an overview of the relationship between physical health and depression, including excess disability and mortality associated with depression, and discuss what we know about prevention of depression in the context of medical conditions such as diabetes and cardiovascular disease. We describe a conceptual framework linking depression and medical illness, with a literature review of randomized controlled trials of prevention that recruited nondepressed persons with at least one physical disorder. Most of the reported studies, though not all, showed that pharmacologic or non-pharmacologic strategies can reduce rates of depression. Methodologic considerations and future directions are described. Prevention of depression in the context of medical conditions is a new field with implications for research, policy, and practice.
Flooding and heavy rainfall are the most frequent climatic hazards and have been associated with substantial risks to human health. To better understand the health burden, this chapter reviews the health effects, risks, and impacts of flooding and rainfall extremes under the following categories: diarrhea, acute respiratory infections, malaria, dengue fever, other infectious diseases, long-term effects of flooding on mortality and morbidity, chemicals, mold, and nutrition. Finally, the chapter provides a review of the health effects of low rainfall.
This book not only discusses clinical applications, but also links HRV to systems biology and theories of complexity. This publication should be interesting for several groups of clinicians and scientists, including cardiologists, anesthesiologists, intensivists and physiologists. Heart Rate Variability is in principle easy and cheap, making it interesting for all kind of hospitals and private practice. The book will be an example of using translational medicine (bench to bedside) where newest theoretical results are linked to newest clinical research.
Many studies have provided clear and convincing evidence that psychosocial factors contribute to the causation of coronary heart disease (CHD). Coronary heart disease is associated with a large number of psychosocial factors. The present study was conducted to investigate the role of coronary - prone behaviour pattern, presumptive stressful life events, optimism, and subjective well-being in pathogenesis of coronary heart disease. Coronary Scale (CS), Ercta-A, Presumptive Stressful Life Events Scale, Subjective Well-Being Inventory (SUBI), and Optimism Scale were administered on 118 participants (56 CHD Patients and 62 Healthy Controls). The age ranged between 40 and 80 years. Data were processed for Discriminant Function Analysis and One way Analysis of Variance (ANOVA). Analysis of variance showed that patients with Coronary Heart Disease and the normal group were significantly different in personality type along with perceived ill health. Discriminant Analysis clearly revealed a linear combination of coronary scale and two subpart of subjective well-being i.e. transcendence and social support which account for considerable degree of variation between coronary heart disease and normal controls.
The Italian Task Force for the Psychological Guidelines in Cardiac Rehabilitation (2003) recommended screening coronary patients for anxiety and depression and to treat adequately those emerging with these emotional disturbances. Our retrospective study had the aim to evaluate the short term efficacy of a cognitive-behavioral brief intervention on cardiac patients in a rehabilitation setting. One hundred and fifty-two in-patients were interviewed by the psychologist the day of admission and assessed for state anxiety and depression symptoms using STAI-X1 and QD questionnaires the day after. On the basis of the psychologist's judgement and the questionnaires' scores, patients were divided in two groups: one receiving an health educational programme (HEP) and one other receiving the same educational programme plus some sessions of cognitive-behavioral counselling (CBT). Before being discharged from the hospital (about 12-15 days after the admission), all of the patients filled in the same questionnaires again. Results showed that patients with critical scores in anxiety, in the CBT group were correctly inserted patients with critical scores in anxiety, depression or both, were correctly placed in the CBT group. These patients were younger than those of HEP group and all of them still working. They reported a significant decrease in emotional disturbances when compared to that of the HEP group. The most important result, however, was the evidence that 44% of CBT patients were not identified by the questionnaires' scores but by the psychologist's interview. This suggests caution in using the questionnaires' scores as discriminative of the patients' needs, and underlines the importance of involving the psychologist to realize a good clinical practice.
There is considerable evidence for a relationship between psychologic distress and coronary artery disease and coronary events. While a causal relationship between depression and coronary disease is not established, any interaction that contributes to the outcome of both needs to be understood and evaluated. Depression is associated with poor diet, less physical activity, smoking, and decreased adherence with medical treatments. Available evidence supports regular screening for depressive symptoms by primary care physicians, cardiologists, and others caring for patients with cardiovascular disease. Treatment of depression and depressive symptoms, whether pharmacologic or counseling, may improve health related quality of life and compliance with evidence based treatments, as well as possibly directly reduce morbidity and mortality in cardiovascular disease.
Administered the Beck Hopelessness Scale (HS) to 400 randomly selected adults to derive norms for the general population. The mean score was 4.45 with a standard deviation of 3.09, approximately 1 standard deviation lower than the reported means for clinical groups. The relationship between HS scores and sex, age, socioeconomic status, and marital status was also examined. (9 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Presents an overview of research on the effects of an optimistic orientation to life on psychological well-being. The chapter begins by commenting on a distinction between two ways of assessing optimism and pessimism. Then the authors review some of the empirical evidence linking positive thinking to well-being, focusing on prospective studies in both health- and nonhealth-related contexts. They then consider why optimism might confer benefits, arguing that the benefits are due, in part, to the way in which optimists and pessimists cope with problems. The conclusion addresses whether or not the effects of optimism are always good and the effects of pessimism are always bad. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We describe the relationship of depression and depressive symptoms to disability days and days lost from work in 2980 participants in the Epidemiologic Catchment Area Study in North Carolina after 1 year of follow-up. Compared with asymptomatic individuals, persons with major depression had a 4.78 times greater risk of disability (95% confidence interval, 1.64 to 13.88), and persons with minor depression with mood disturbance, but not major depression, had a 1.55 times greater risk (95% confidence interval, 1.00 to 2.40). Because of its prevalence, individuals with minor depression were associated with 51% more disability days in the community than persons with major depression. This group was also at increased risk of having a concomitant anxiety disorder or developing major depression within 1 year. We conclude that the threshold for identifying clinically significant depression may need to be reevaluated to include persons with fewer symptoms but measurable morbidity. Only by changing our nosology can the societal impact of depression be adequately addressed.
To determine whether optimism predicts lower rates of rehospitalization after coronary artery bypass graft surgery for the 6 months after surgery.
A prospective, inception cohort design was used. The sample consisted of all consenting patients (N=309) from a consecutive series of patients scheduled for elective coronary artery bypass graft surgery at a large, metropolitan hospital in Pittsburgh, Pa. To be eligible, patients could not be scheduled for any other coincidental surgery (eg, valve replacement) and could not be in the cardiac intensive care unit or experiencing angina at the time of the referral. Participants were predominantly men (69.9%) and married (80.3%), and averaged 62.8 years of age. Recruitment occurred between January 1992 and January 1994.
Compared with pessimistic persons, optimistic persons were significantly less likely to be rehospitalized for a broad range of aggregated problems (including postsurgical sternal wound infection, angina, myocardial infarction, and the need for another bypass surgery or percutaneous transluminal coronary angioplasty) generally indicative of a poor response to the initial surgery (odds ratio=0.50, 95% confidence interval=0.33- 0.76; P=.001). The effect of optimism was independent of traditional sociodemographic and medical control variables, as well as independent of the effects of self-esteem, depression, and neuroticism. All-cause rehospitalization also tended to be less frequent for optimistic than for pessimistic persons (odds ratio=0.77, 95% confidence interval=0.57-1.05; P=.07).
Optimism predicts a lower rate of rehospitalization after coronary artery bypass graft surgery. Fostering positive expectations may promote better recovery.
Psychosocial characteristics may be associated with an increased risk of coronary heart disease (CHD). Whether hostility predicts recurrent coronary events is unknown. A total of 792 women in the Heart and Estrogen/progestin Replacement Study (HERS) were evaluated prospectively to determine the role of hostility as a risk factor for secondary CHD events (nonfatal myocardial infarction and CHD death). The mean age of study participants was 67 years, and the average length of follow-up was 4.1 years. The study was conducted between 1993 and 1998, and all study sites were in the United States. High Cook-Medley hostility scores were associated with greater body mass index (p = 0.01) and higher levels of serum triglycerides (p = 0.05), and they were inversely associated with high density lipoprotein cholesterol (p = 0.04), self-rated general health (p < 0.001), age (p = 0.05), and education (p = 0.001). Compared with women in the lowest hostility score quartile, women in the highest quartile were twice as likely to have had a myocardial infarction (relative hazard = 2.03, 95% confidence interval: 1.02, 4.01). The relation between hostility and CHD events was not mediated or confounded by the biologic, behavioral, and social risk factors studied. In this study, hostility was found to be an independent risk factor for recurrent CHD events in postmenopausal women.
Prospective studies on physically healthy subjects have shown an association between depression and the subsequent development of coronary heart disease (CHD). The relative risk in meta-analytic aggregation is 1.64 (confidence interval [CI], 1.29-2.08) for any CHD event. However, the adverse impact of depression on CHD patients has not yet been the subject of a meta-analysis.
To quantify the impact of depressive symptoms (eg, BDI, HADS) or depressive disorders (major depression) on cardiac or all-cause mortality. We analyzed the strength of the relationship, the time dependency, and the differences in studies using depressive symptoms or a clinical diagnosis as predictors of mortality.
English and German language databases (Medline, PsycInfo, PSYNDEX) from 1980 to 2003 were searched for prospective cohort studies. Sixty-two publications were identified. The inclusion criteria were met by 29 publications reporting on 20 studies. A random model was used to estimate the combined overall effect as crude odds ratios (OR) or adjusted hazard ratios (HR [adj]).
Depressive symptoms increase the risk of mortality in CHD patients. The risk of depressed patients dying in the 2 years after the initial assessment is two times higher than that of nondepressed patients (OR, 2.24; 1.37-3.60). This negative prognostic effect also remains in the long-term (OR, 1.78; 1.12-2.83) and after adjustment for other risk factors (HR [adj], 1.76; 1.27-2.43). The unfavorable impact of depressive disorders was reported for the most part in the form of crude odds ratios. Within the first 6 months, depressive disorders were found to have no significant effect on mortality (OR, 2.07; CI, 0.82-5.26). However, after 2 years, the risk is more than two times higher for CHD patients with clinical depression (OR, 2.61; 1.53-4.47). Only three studies reported adjusted hazard ratios for clinical depression and supported the results of the bivariate models.
Depressive symptoms and clinical depression have an unfavorable impact on mortality in CHD patients. The results are limited by heterogeneity of the results in the primary studies. There is no clear evidence whether self-report or clinical interview is the more precise predictor. Nevertheless, depression has to be considered a relevant risk factor in patients with CHD.
Background— Although previous research demonstrated an independent link between depression symptoms and cardiac mortality after myocardial infarction (MI), depression was assessed only once, and a dose-response relationship was not evaluated.
Methods and Results— We administered the Beck Depression Inventory to 896 post-MI patients during admission and at 1 year. Five-year survival was ascertained using Medicare data. We observed a significant long-term dose-response relationship between depression symptoms during hospitalization and cardiac mortality. Results remained significant after control for multiple measures of cardiac disease severity. Although 1-year scores were also linked to cardiac mortality, most of that impact was explained by baseline scores. Improvement in depression symptoms was associated with less cardiac mortality only for patients with mild depression. Patients with higher initial scores had worse long-term prognosis regardless of symptom changes.
Conclusions— The level of depression symptoms during admission for MI is more closely linked to long-term survival than the level at 1 year, particularly in patients with moderate to severe levels of depression, suggesting that the presumed cardiovascular mechanisms linking depression to cardiac mortality may be more or less permanent for them.
Psychosocial characteristics may be associated with an increased risk of coronary heart disease (CHD). Whether hostility predicts recurrent coronary events is unknown. A total of 792 women in the Heart and Estrogen/ progestin Replacement Study (HERS) were evaluated prospectively to determine the role of hostility as a risk factor for secondary CHD events (nonfatal myocardial infarction and CHD death). The mean age of study participants was 67 years, and the average length of follow-up was 4.1 years. The study was conducted between 1993 and 1998, and all study sites were in the United States. High Cook-Medley hostility scores were associated with greater body mass index (p = 0.01) and higher levels of serum triglycerides (p = 0.05), and they were inversely associated with high density lipoprotein cholesterol (p = 0.04), self-rated general health (p < 0.001), age (p = 0.05), and education (p = 0.001). Compared with women in the lowest hostility score quartile, women in the highest quartile were twice as likely to have had a myocardial infarction (relative hazard = 2.03, 95% confidence interval: 1.02, 4.01). The relation between hostility and CHD events was not mediated or confounded by the biologic, behavioral, and social risk factors studied. In this study, hostility was found to be an independent risk factor for recurrent CHD events in postmenopausal women. coronary disease; hostility; postmenopause; risk factors; women Abbreviations: CHD, coronary heart disease; CI, confidence interval; HERS, Heart and Estrogen/progestin Replacement Study; HMG-CoA, 3-hydroxy-3-methylglutaryl coenzyme A; RH, relative hazard. Epidemiologic evidence suggests that psychological behaviors may be associated with coronary heart disease (CHD) risk. Hostility, a construct that includes cynicism, anger, mistrust, and aggression (1), has been correlated with carotid atherosclerosis (2, 3), angiographic coronary artery disease (4, 5), exercise-induced ischemia (6), and restenosis after mechanical revascularization in women (7). High hostility scores have also been associated with an increased risk of nonfatal myocardial infarction among older women (8, 9) but not with fatal events in patients with documented
Background:
Untreated anxiety may be particularly difficult for primary care physicians to recognize and diagnose because there are no reliable demographic or medical profiles for patients with this condition and because these patients present with a high rate of comorbid psychological conditions that complicate selection of treatment.Method:
A prospective assessment of untreated anxiety symptoms and disorders among primary care patients.Results:
Approximately 10% of eligible patients screened in clinic waiting rooms of a mixed-model health maintenance organization reported elevated symptoms and/or disorders of anxiety that were unrecognized and untreated. These patients with untreated anxiety reported significantly worse functioning on both physical and emotional measures than "not anxious" comparison patients; in fact these patients reported reduced functioning levels within ranges that would be expected for patients with chronic physical diseases, such as diabetes and congestive heart failure. The most severe reductions in functioning were reported by untreated patients whose anxiety was mixed with depression symptoms or disorders.Conclusion:
Primary care physicians may benefit from screening tools and consultations by mental health specialists to assist in recognition and diagnosis of anxiety symptoms and disorders alone and mixed with depression.
Major depression has been associated with mortality from ischemic heart disease (IHD). In addition, a symptom of depression-hopelessness-has been suggested as a determinant of health status. We studied the relation of both depressed affect and hopelessness to IHD incidence using data from a cohort of 2,832 U.S. adults age 45-77 years who participated in the National Health Examination Follow-up Study (mean follow-up = 12.4 years) and had no history of IHD or serious illness at baseline. We used the depression subscale of the General Well-Being Schedule to define depressed affect and a single item from the scale to define hopelessness. At baseline, 11.1% of the cohort had depressed affect; 10.8% reported moderate hopelessness, and 2.9% reported severe hopelessness. Depressed affect and hopelessness were more common among women, blacks, and persons who were less educated, unmarried, smokers, or physically inactive. There were 189 cases of fatal IHD during the follow-up period. After we adjusted for demographic and risk factors, depressed affect was related to fatal IHD [relative risk = 1.5; 95% confidence interval (CI) = 1.0-2.3]; the relative risks of fatal IHD for moderate and severe levels of hopelessness were 1.6 (95% CI = 1.0-2.5) and 2.1 (95% CI = 1.1-3.9), respectively. Depressed affect and hopelessness were also associated with an increased risk of nonfatal IHD. These data indicate that depressed affect and hopelessness may play a causal role in the occurrence of both fatal and nonfatal IHD. (Epidemiology 1993;4:285-294)
(C) Lippincott-Raven Publishers.
This study investigates the relation of psychosocial variables to the 20-year incidence of myocardial infarction or coronary death among women in the Framingham Study. In 1965-1967, a psychosocial interview was given along with the collection of other coronary risk factor data. This study includes 749 women aged 45-64 years who were free of coronary disease at this baseline examination. Demographic variables, psychosocial scales (such as tension and reactions of anger), and individual interview items (such as attitudes toward children, money, and religion) were measured. When age, systolic blood pressure, the ratio of serum total cholesterol to high-density lipoprotein cholesterol, diabetes, cigarette smoking, and body mass index were controlled for in multivariate proportional hazards models, the predictors of the 20-year incidence of myocardial infarction or coronary death were as follows: among employed women, perceived financial status only; among homemakers, symptoms of tension and anxiety, being lonely during the day, difficulty falling asleep, infrequent vacations, housework affecting health, and believing one is prone to heart disease (p less than 0.05 for all variables); and among both groups of women combined, low educational level, tension, and lack of vacations. These results are discussed in relation to previous findings from the Framingham Study.
Untreated anxiety may be particularly difficult for primary care physicians to recognize and diagnose because there are no reliable demographic or medical profiles for patients with this condition and because these patients present with a high rate of comorbid psychological conditions that complicate selection of treatment.
A prospective assessment of untreated anxiety symptoms and disorders among primary care patients.
Approximately 10% of eligible patients screened in clinic waiting rooms of a mixed-model health maintenance organization reported elevated symptoms and/or disorders of anxiety that were unrecognized and untreated. These patients with untreated anxiety reported significantly worse functioning on both physical and emotional measures than "not anxious" comparison patients; in fact these patients reported reduced functioning levels within ranges that would be expected for patients with chronic physical diseases, such as diabetes and congestive heart failure. The most severe reductions in functioning were reported by untreated patients whose anxiety was mixed with depression symptoms or disorders.
Primary care physicians may benefit from screening tools and consultations by mental health specialists to assist in recognition and diagnosis of anxiety symptoms and disorders alone and mixed with depression.
We examined the relationship among low, moderate, and high levels of hopelessness, all-cause and cause-specific mortality, and incidence of myocardial infarction (MI) and cancer in a population-based sample of middle-aged men. Participants were 2428 men, ages 42 to 60, from the Kuopio Ischemic Heart Disease study, an ongoing longitudinal study of unestablished psychosocial risk factors for ischemic heart disease and other outcomes. In 6 years of follow-up, 174 deaths (87 cardiovascular and 87 noncardiovascular, including 40 cancer deaths and 29 deaths due to violence or injury), 73 incident cancer cases, and 95 incident MI had occurred. Men were rated low, moderate, or high in hopelessness if they scored in the lower, middle, or upper one-third of scores on a 2-item hopelessness scale. Age-adjusted Cox proportional hazards models identified a dose-response relationship such that moderately and highly hopeless men were at significantly increased risk of all-cause and cause-specific mortality relative to men with low hopelessness scores. Indeed, highly hopeless men were at more than three-fold increased risk of death from violence or injury compared with the reference group. These relationships were maintained after adjusting for biological, socioeconomic, or behavioral risk factors, perceived health, depression, prevalent disease, or social support. High hopelessness also predicted incident MI, and moderate hopelessness was associated with incident cancer. Our findings indicate that hopelessness is a strong predictor of adverse health outcomes, independent of depression and traditional risk factors. Additional research is needed to examine phenomena that lead to hopelessness.
Recent laboratory and epidemiological studies have suggested that high levels of anger may increase the risk of coronary heart disease (CHD).
We examined prospectively the relationship of anger to CHD incidence in the Veterans Administration Normative Aging Study, an ongoing cohort of older (mean age, 61 years) community-dwelling men. A total of 1305 men who were free of diagnosed CHD completed the revised Minnesota Multiphasic Personality Inventory (MMPI-2) in 1986. Subjects were categorized according to their responses to the MMPI-2 Anger Content Scale, which measures the degree to which individuals have problems controlling their anger. During an average of 7 years of follow-up, 110 cases of incident CHD occurred, including 30 cases of nonfatal myocardial infarction hostility. (MI), 20 cases of fatal CHD, and 60 cases of angina pectoris. Compared with men reporting the lowest levels of anger, the multivariate-adjusted relative risks among men reporting the highest levels of anger were 3.15 (95% confidence interval) [CI]: 0.94 to 10.5) for total CHD (nonfatal MI plus fatal CHD) and 2.66 (95% CI: 1.26 to 5.61) for combined incident coronary events including angina pectoris. A dose-response relation was found between level of anger and overall CHD risk (P for trend, .008).
These data suggest that high levels of expressed anger may be a risk factor for CHD among older men.
Worry is an important component of anxiety, which recent work suggests is related to increased incidence of coronary heart disease (CHD). Chronic worry has also been associated with decreased heart rate variability. We hypothesized that high levels of worry may increase CHD risk.
We examined prospectively the relationship of worry with CHD incidence in the Normative Aging Study, an ongoing cohort of older men. In 1975, 1759 men free of diagnosed CHD completed a Worries Scale, indicating the extent to which they worried about each of five worry domains: social conditions, health, financial, self-definition, and aging. During 20 years of follow-up, 323 cases of incident CHD occurred: 113 cases of nonfatal myocardial infarction (MI); 86 cases of fatal CHD; and 124 cases of angina pectoris. Worry about social conditions was the domain most strongly associated with incident CHD. Compared with men reporting the lowest levels of social conditions worry, men reporting the highest levels had multivariate adjusted relative risks of 2.41 (95% CI, 1.40 to 4.13) for nonfatal MI and 1.48 (95% CI, 0.99 to 2.20) for total CHD (nonfatal MI and fatal CHD). A dose-response relation was found between level of worry and both nonfatal MI (P for trend, .002) and total CHD (P for trend, .04).
These results suggest that high levels of worry in specific domains may increase the risk of CHD in older men.
The importance of hope has long been recognized, whereas a lack of hope, or "giving up," is generally believed to have a negative impact on psychological well-being and physical health. Recently, hopelessness has been identified as a strong, independent predictor of cardiovascular disease morbidity and mortality in both American and Finnish populations. In this study we examined the association between high levels of hopelessness and progression of carotid atherosclerosis in participants (n = 942) in the Kuopio Ischemic Heart Disease Study, a population-based study of middle-aged men from eastern Finland who underwent carotid ultrasonography at baseline and 4 years later. Men reporting high levels of hopelessness at baseline had faster progression of carotid atherosclerosis, assessed by four measures of intima-media thickening (IMT), than men reporting low to moderate levels of hopelessness. Further analyses revealed significant interactions between hopelessness and initial level of atherosclerosis, such that the effects of high hopelessness on progression were greatest among men who had baseline mean IMT values at or above the median. Moreover, progression was greatest among men reporting high levels of hopelessness at both baseline and follow-up. Traditional coronary risk factors and use of cholesterol-lowering and antihypertensive medications did not account for much variance in the observed relationships. These findings indicate that hopelessness contributes to accelerated progression of carotid atherosclerosis, particularly among men with early evidence of atherosclerosis, and that chronically high levels of hopelessness may be especially detrimental. Additional research is needed to identify the contributory pathways and/or mechanisms underlying these relationships.
There is abundant evidence that depression, anxiety, and anger increase the risk for cardiac events in patients with coronary heart disease. Denollet and Brutsaert1 are to be commended for contributing a generally well-conducted study of psychological predictors of cardiac end points to this rapidly growing literature. They have found that the combination of “negative affectivity” and social inhibition predicts cardiac events independently of established medical risk factors. Prospective studies such as theirs, in which potential confounders are adequately measured and cardiac end points carefully documented, are needed to substantiate the effects of psychological factors on medical outcomes after acute myocardial infarction (MI).
Unfortunately, the authors may have gone beyond their data in asserting that they have identified a personality trait that both predicts cardiac events and explains why such disparate mood states as depression, anxiety, and anger predict cardiac events as well. It is not at all clear that they have substantiated this claim or that it is time to abandon research on depression, anxiety, and anger in favor of this personality trait.
Absent from the authors’ discussion is any reference to an established theory of personality. It is by no means universally accepted among personality theorists that a single trait accounts for every negative mood state (cf Cloninger et al2 ) or that the combination of negative affectivity and social inhibition defines a persistent “distressed personality type.” In this light, it makes more sense to conclude simply that patients with coronary heart disease who are both emotionally distressed and socially inhibited …
The three major theoretical perspectives on the maintenance and persistence of depression in the psychological literature are reviewed. Cognitive theorists, such as Teasdale and Nolen-Hoeksema, focus on how a reciprocal relationship between depressed mood and the individual's processing of, and response to, their symptoms maintains and prolongs the duration of depressive episodes. Interpersonal theorists, such as Lewinsohn and Coyne, hypothesize that the depressed person's interpersonal behavior elicits negative reactions from the social environment, leading to a downward spiral of persistent depression. Finally, recent studies have indicated that individuals who experienced childhood adversity are more susceptible to a chronic course of depression. Although these three perspectives vary somewhat in the degree of support they have accumulated, each exhibits some promise for helping to elucidate the maintenance and persistence of depression. However, much of the available empirical literature suffers from a number of critical limitations, including the lack of clinical samples, longitudinal studies, and adequate attention to confounding variables, such as the severity and duration of depression at baseline and comorbid psychopathology. We conclude by suggesting a number of ways in which cognitive and interpersonal factors and early adversity may interact to maintain and prolong depressive episodes.
Increased research attention is being paid to the negative impact of anger on coronary heart disease (CHD).
This study examined prospectively the association between trait anger and the risk of combined CHD (acute myocardial infarction [MI]/fatal CHD, silent MI, or cardiac revascularization procedures) and of "hard" events (acute MI/fatal CHD). Participants were 12 986 black and white men and women enrolled in the Atherosclerosis Risk In Communities study. In the entire cohort, individuals with high trait anger, compared with their low anger counterparts, were at increased risk of CHD in both event categories. The multivariate-adjusted hazard ratio (HR) (95% CI) was 1.54 (95% CI 1.10 to 2.16) for combined CHD and 1.75 (95% CI 1.17 to 2.64) for "hard" events. Heterogeneity of effect was observed by hypertensive status. Among normotensive individuals, the risk of combined CHD and of "hard" events increased monotonically with increasing levels of trait anger. The multivariate-adjusted HR of CHD for high versus low anger was 2.20 (95% CI 1.36 to 3.55) and for moderate versus low anger was 1.32 (95% CI 0.94 to 1.84). For "hard" events, the multivariate-adjusted HRs were 2.69 (95% CI 1.48 to 4.90) and 1.35 (95% CI 0.87 to 2.10), respectively. No statistically significant association between trait anger and incident CHD risk was observed among hypertensive individuals.
Proneness to anger places normotensive middle-aged men and women at significant risk for CHD morbidity and death independent of the established biological risk factors.
Negative emotions, such as anger, anxiety, and depression, have emerged as potentially important risk factors for coronary heart disease. The purpose of this article is to consider the nature and function of emotions, to review epidemiological evidence for an association between the three negative emotions and coronary heart disease (CHD), to discuss briefly the mechanisms by which emotions may be linked to CHD, and to consider this evidence in light of theoretical insights provided by mainstream psychological research on emotions.
We collected articles published between 1980 and 1998 on the relationship between each negative emotion and CHD. We also collected review articles or chapters published during the same time period that considered mechanisms by which emotions may increase CHD risk. We used a qualitative approach to review the published literature.
Evidence that anxiety is involved in the onset of CHD is strongest, whereas evidence for an association between anger and CHD is limited but suggestive. Although depression has consistently been linked to mortality following a myocardial infarction, evidence for its role in the onset of coronary disease is quite mixed. Numerous unresolved issues leave our current understanding of the emotion-health relationship incomplete. Psychological theories of emotion are considered to help address gaps in our knowledge.
Growing evidence indicates that negative emotions may influence the development of CHD. The focused and specific consideration of negative emotions and their possible role in the etiology of CHD gives insight into current knowledge and suggests important directions for future research.
Several studies have shown that people who engage in ruminative responses to depressive symptoms have higher levels of depressive symptoms over time, after accounting for baseline levels of depressive symptoms. The analyses reported here showed that rumination also predicted depressive disorders, including new onsets of depressive episodes. Rumination predicted chronicity of depressive disorders before accounting for the effects of baseline depressive symptoms but not after accounting for the effects of baseline depressive symptoms. Rumination also predicted anxiety symptoms and may be particularly characteristic of people with mixed anxiety/depressive symptoms.
Mild to moderate levels of depressive symptoms as characterized by Beck Depression Inventory (BDI) scores of > or =10 are associated with decreased survival after acute myocardial infarction (AMI). We investigated whether lower levels of depressive symptoms are also associated with increased mortality risk after AMI. We prospectively studied 285 patients with AMI who survived to discharge for evidence, at the time of hospitalization, of a DSM-IIIR mood disorder (using a structured clinical interview) and for symptoms of depression (using the BDI). The overall mortality rate at 4 months was 6.7%. Multiple logistic regression (chi-square 35.79, p < or =0.001) revealed that the independent predictors of mortality were: age > or =65 years, left ventricular ejection fraction <35%, diabetes mellitus, and any depression (DSM-IIIR mood disorder or BDI > or =10) present at the time of AMI. Among patients > or =65 years old with left ventricular ejection fraction <35%, the 4-month mortality was 12%. However, in this same group, those with any depression at the time of AMI had a 4-month mortality of 50% (relative risk 4.1, p = 0.01). Among patients aged > or =65 years, the mortality according to BDI scale grouping 0 to 3, 4 to 9, and 10+ was 2.6%, 17.1%, and 23.3%, respectively (p <0.002). Highest mortality rates were observed in patients with most severe depressive symptoms. However, compared with those without depression, higher mortality was also observed at very low levels of depressive symptoms (BDI 4 to 9) not generally considered clinically significant and below the level usually considered predictive of increased post-AMI mortality.
A sense of optimism, which derives from the ways individuals explain causes of daily events, has been shown to protect health, whereas pessimism has been linked to poor physical health. We examined prospectively the relationship of an optimistic or pessimistic explanatory style with coronary heart disease incidence in the Veterans Affairs Normative Aging Study, an ongoing cohort of older men.
In 1986, 1306 men completed the revised Minnesota Multiphasic Personality Inventory, from which we derived the bipolar revised Optimism-Pessimism Scale. During an average of 10 years of follow-up, 162 cases of incident coronary heart disease occurred: 71 cases of incident nonfatal myocardial infarction, 31 cases of fatal coronary heart disease, and 60 cases of angina pectoris. Compared with men with high levels of pessimism, those reporting high levels of optimism had multivariate-adjusted relative risks of 0.44 (95% confidence interval = 0.26-0.74) for combined nonfatal myocardial infarction and coronary heart disease death and 0.45 (95% confidence interval = 0.29-0.68) for combined angina pectoris, nonfatal myocardial infarction, and coronary heart disease death. A dose-response relation was found between levels of optimism and each outcome (p value for trend,.002 and.0004, respectively).
These results suggest that an optimistic explanatory style may protect against risk of coronary heart disease in older men.
Although previous research demonstrated an independent link between depression symptoms and cardiac mortality after myocardial infarction (MI), depression was assessed only once, and a dose-response relationship was not evaluated.
We administered the Beck Depression Inventory to 896 post-MI patients during admission and at 1 year. Five-year survival was ascertained using Medicare data. We observed a significant long-term dose-response relationship between depression symptoms during hospitalization and cardiac mortality. Results remained significant after control for multiple measures of cardiac disease severity. Although 1-year scores were also linked to cardiac mortality, most of that impact was explained by baseline scores. Improvement in depression symptoms was associated with less cardiac mortality only for patients with mild depression. Patients with higher initial scores had worse long-term prognosis regardless of symptom changes.
The level of depression symptoms during admission for MI is more closely linked to long-term survival than the level at 1 year, particularly in patients with moderate to severe levels of depression, suggesting that the presumed cardiovascular mechanisms linking depression to cardiac mortality may be more or less permanent for them.
To review and quantify the impact of depression on the development of coronary heart disease (CHD) in initially healthy subjects.
Cohort studies on depression and CHD were searched in MEDLINE (1966-2000) and PSYCHINFO (1887-2000), bibliographies, expert consultation, and personal reference files.
Cohort studies with clinical depression or depressive mood as the exposure, and myocardial infarction or coronary death as the outcome.
Information on study design, sample size and characteristics, assessment of depression, outcome, number of cases, crude and most-adjusted relative risks, and variables used in multivariate adjustments were abstracted.
Eleven studies met the inclusion criteria. The overall relative risk [RR] for the development of CHD in depressed subjects was 1.64 (95% confidence interval [CI]=1.29-2.08, p<0.001). A sensitivity analysis showed that clinical depression (RR=2.69, 95% CI=1.63-4.43, p<0.001) was a stronger predictor than depressive mood (RR=1.49, 95% CI=1.16-1.92, p=0.02).
It is concluded that depression predicts the development of CHD in initially healthy people. The stronger effect size for clinical depression compared to depressive mood points out that there might be a dose-response relationship between depression and CHD. Implications of the findings for a broader bio-psycho-social framework are discussed.
There is consistent evidence that depression symptoms predict long-term mortality following a myocardial infarction, and recent results show a dose-related gradient. The importance of other psychological variables remains unclear.
This study examines the relative importance of depression, anxiety, anger, and social support in predicting 5-year cardiac-related mortality following a myocardial infarction and assesses the role of any common underlying dimensions. The design of this cohort analytic study involves self-reports (Beck Depression Inventory, state scale of the State-Trait Anxiety Inventory, 20-item version of the General Health Questionnaire, Modified Somatic Perception Questionnaire, Anger Expression Scale, Perceived Social Support Scale, number of close friends and relatives, and visual analog scales of anger and stress). The study was conducted in 10 Montreal-area hospitals. The patients included 896 persons who experienced a myocardial infarction, aged 24 to 88 years (232 were women), followed up for 5 years using Medicare records; baseline data were complete for 95.0% of the patients. The intervention was usual care, and the main outcome measure was 5-year cardiac-related mortality.
The Beck Depression Inventory (P<.001), the State-Trait Anxiety Inventory (P =.04), and the 20-item version of the General Health Questionnaire (P =.048) were related to outcome), but only depression remained significant after adjustment for cardiac disease severity (hazards ratio per SD, 1.46; 95% confidence interval, 1.18-1.79) (P<.001). Exploratory factor analysis revealed 3 underlying factors: negative affectivity, overt anger, and social support. There was also a covariate-adjusted trend between negative affectivity scores and outcome (P =.08). Furthermore, residual depression scores (P =.001) and negative affectivity scores (P =.05) were linked to cardiac-related mortality after adjustment for each other and cardiac covariates.
Negative affectivity and some unique aspect of depression predict long-term cardiac-related mortality following a myocardial infarction independently of each other and cardiac disease severity. Additional research is needed to characterize the mechanisms involved.
The goal of the current study was to examine whether individuals with comorbid Major Depressive Disorder (MDD) and Borderline Personality Disorder (BPD) exhibit greater severity of depressive symptoms than (1) individuals with MDD without BPD and (2) individuals with neither MDD nor BPD. One hundred and forty-one individuals participated in a semi-structured clinical interview assessing MDD and BPD. They also completed measures assessing depressive symptoms, depressogenic attributional style, hopelessness, self-esteem, rumination, and dysfunctional attitudes. In line with hypotheses, individuals with BPD and MDD exhibited higher levels of depressive symptoms and cognitive vulnerability than individuals in the other two groups. In addition, after controlling for the effects of cognitive vulnerability, the effect of group membership on depressive symptoms was reduced, suggesting that the increased severity of depressive symptoms experienced by those with BPD is partially due to their possessing higher levels of cognitive vulnerability to depression.
High prevalence estimates in epidemiological surveys have led to concerns that the DSM system is overly inclusive and that mild cases should be excluded from future DSM editions.
To demonstrate that the DSM-III-R disorders in the baseline National Comorbidity Survey (NCS) can be placed on a severity gradient that has a dose-response relationship with outcomes assessed a decade later in the NCS follow-up survey (NCS-2) and that no inflection point exists at the mild severity level.
The NCS was a nationally representative household survey of DSM-III-R disorders in the 3-year time span 1990-1992. The NCS-2 is a follow-up survey of 4375 NCS respondents (76.6% conditional response rate) reinterviewed in 2000 through 2002. The NCS-2 outcomes include hospitalization for mental health or substance disorders, work disability due to these disorders, suicide attempts, and serious mental illness.
Twelve-month NCS/DSM-III-R disorders were disaggregated into 3.2% severe, 3.2% serious, 8.7% moderate, and 16.0% mild case categories. All 4 case categories were associated with statistically significantly (P<.05, 2-sided tests) elevated risk of the NCS-2 outcomes compared with baseline noncases, with odds ratios of any outcome ranging monotonically from 2.4 (95% confidence interval, 1.6-3.4) to 15.1 (95% confidence interval, 10.0-22.9) for mild to severe cases. Odds ratios comparing mild to moderate cases were generally nonsignificant.
There is a graded relationship between mental illness severity and later clinical outcomes. Retention of mild cases in the DSM is important to represent the fact that mental disorders (like physical disorders) vary in severity. Decisions about treating mild cases should be based on cost-effectiveness not current severity. Cost-effectiveness analysis should include recognition that treatment of mild cases might prevent a substantial proportion of future serious cases.
Psychosocial factors have been reported to be independently associated with coronary heart disease. However, previous studies have been in mainly North American or European populations. The aim of the present analysis was to investigate the relation of psychosocial factors to risk of myocardial infarction in 24767 people from 52 countries.
We used a case-control design with 11119 patients with a first myocardial infarction and 13648 age-matched (up to 5 years older or younger) and sex-matched controls from 262 centres in Asia, Europe, the Middle East, Africa, Australia, and North and South America. Data for demographic factors, education, income, and cardiovascular risk factors were obtained by standardised approaches. Psychosocial stress was assessed by four simple questions about stress at work and at home, financial stress, and major life events in the past year. Additional questions assessed locus of control and presence of depression.
People with myocardial infarction (cases) reported higher prevalence of all four stress factors (p<0.0001). Of those cases still working, 23.0% (n=1249) experienced several periods of work stress compared with 17.9% (1324) of controls, and 10.0% (540) experienced permanent work stress during the previous year versus 5.0% (372) of controls. Odds ratios were 1.38 (99% CI 1.19-1.61) for several periods of work stress and 2.14 (1.73-2.64) for permanent stress at work, adjusted for age, sex, geographic region, and smoking. 11.6% (1288) of cases had several periods of stress at home compared with 8.6% (1179) of controls (odds ratio 1.52 [99% CI 1.34-1.72]), and 3.5% (384) of cases reported permanent stress at home versus 1.9% (253) of controls (2.12 [1.68-2.65]). General stress (work, home, or both) was associated with an odds ratio of 1.45 (99% CI 1.30-1.61) for several periods and 2.17 (1.84-2.55) for permanent stress. Severe financial stress was more typical in cases than controls (14.6% [1622] vs 12.2% [1659]; odds ratio 1.33 [99% CI 1.19-1.48]). Stressful life events in the past year were also more frequent in cases than controls (16.1% [1790] vs 13.0% [1771]; 1.48 [1.33-1.64]), as was depression (24.0% [2673] vs 17.6% [2404]; odds ratio 1.55 [1.42-1.69]). These differences were consistent across regions, in different ethnic groups, and in men and women.
Presence of psychosocial stressors is associated with increased risk of acute myocardial infarction, suggesting that approaches aimed at modifying these factors should be developed.
This article presents a reanalysis of an earlier study that reported a nonsignificant relation between the 50-item Cook-Medley Hostility Scale (CMHS) and survival in a sample of coronary patients. Since publication of those results, there have been significant developments in the measurement of hostility that suggest that an abbreviated scale may be a better predictor of health outcomes. This study examined the ability of the total CMHS and an abbreviated form of the CMHS (ACM) to predict survival in a sample of patients with documented coronary artery disease (CAD) with increased statistical power.
Nine hundred thirty-six patients (83% were male; mean age = 51.48) with CAD who were followed for an average of 14.9 years. The ACM consisted of the combination of the cynicism, hostile attribution, hostile affect, and aggressive responding subscales that were identified in an earlier study (Barefoot et al. [1989]) by a rational analysis of the item content. The relation between hostility and survival was examined with Cox proportional hazard models (hazard ratios [HRs] based on a two standard deviation difference).
Controlling for disease severity, the ACM was a significant predictor for both CHD mortality (HR = 1.33, p <.009) and total mortality (HR = 1.28, p <.02). The total CMHS was only a marginally significant predictor of either outcome (p values < 0.06).
The results of this study suggest that hostility is associated with poorer survival in CAD patients, and it may be possible to refine measures of hostility in order to improve prediction of health outcomes.
Observational studies indicate that psychologic factors strongly influence the course of coronary artery disease (CAD). In this review, we examine new epidemiologic evidence for the association between psychosocial risk factors and CAD, identify pathologic mechanisms that may be responsible for this association, and describe a paradigm for studying positive psychologic factors that may act as a buffer. Because psychosocial risk factors are highly prevalent and are associated with unhealthy lifestyles, we describe the potential role of cardiologists in managing such factors. Management approaches include routinely screening for psychosocial risk factors, referring patients with severe psychologic distress to behavioral specialists, and directly treating patients with milder forms of psychologic distress with brief targeted interventions. A number of behavioral interventions have been evaluated for their ability to reduce adverse cardiac events among patients presenting with psychosocial risk factors. Although the efficacy of stand-alone psychosocial interventions remains unclear, both exercise and multifactorial cardiac rehabilitation with psychosocial interventions have demonstrated a reduction in cardiac events. Furthermore, recent data suggest that psychopharmacologic interventions may also be effective. Despite these promising findings, clinical practice guidelines for managing psychosocial risk factors in cardiac practice are lacking. Thus, we review new approaches to improve the delivery of behavioral services and patient adherence to behavioral recommendations. These efforts are part of an emerging field of behavioral cardiology, which is based on the understanding that psychosocial and behavioral risk factors for CAD are not only highly interrelated, but also require a sophisticated health care delivery system to optimize their effectiveness.
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