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Comparison of Prevalence of Symptoms of Depression, Anxiety ISSUES IN CARDIOVASCULAR NURSING Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly patients with heart failure, myocardial infarction, and a coronary artery bypass graft Debra K. Moser, DNSc, RN, FAAN,a Kathleen Dracup, DNSc, RN,b Lorraine S. Evangelista, PhD, RN,c Cheryl Hoyt Zambroski, PhD, RN,d Terry A. Lennie, PhD, RN,a Misook L. Chung, PhD, RN,a Lynn V. Doering, DNSc, RN,c Cheryl Westlake, PhD, RN,e and Seongkum Heo, PhD, RNf OBJECTIVE: This study sought to compare the prevalence of anxiety, depression, and hostility among 3 clinically diverse elderly cardiac patient cohorts and a reference group of healthy elders. METHODS: This was a multicenter, comparative study. A total of 1167 individuals participated: 260 healthy elders, and 907 elderly cardiac patients who were at least 3 months past a hospitalization (478 heart-failure patients, 298 postmyocardial infarction patients, and 131 postcoronary artery bypass graft patients). Symptoms of anxiety, depression, and hostility were measured using the Multiple Affect Ad- jective Checklist. RESULTS: The prevalence of anxiety, depression, and hostility was higher in patients in each of the car- diac patient groups than in the group of healthy elders. Almost three quarters of patients with heart failure reported experiencing symptoms of depression, and the heart-failure group manifested the greatest per- centage of patients with depressive symptoms. CONCLUSIONS: The high levels of emotional distress common in cardiac patients are not a function of aging, because healthy elders exhibit low levels of anxiety, depression, and hostility. (Heart LungÒ 2010;39:378–385.) egative emotions (ie, depression, anxiety, Although some researchers reported that aging is and hostility) appear to be more common associated with a reduction in anxiety and depres- Namong cardiac patients than among healthy sion levels,1 others documented higher levels of individuals. Whether this phenomenon is related negative emotions in the elderly.2,3 Higher rates of to cardiac disease alone or to the older age of suicide are seen in the elderly, and the distinctive most cardiac patients is unclear. The incidence of stresses of aging (eg, loss of friends and loved cardiac disease increases dramatically with age. ones, and retirement) may contribute to substan- tially higher rates of emotional distress.4 From the aCollege of Nursing, University of Kentucky, Lexington, Kentucky; bSchool of Nursing, University of California at San This argument is not simply academic. Negative Francisco, San Francisco, California; cSchool of Nursing, Univer- emotional states adversely and independently affect sity of California at Los Angeles, Los Angeles, California; dSchool 5-7 e quality of life, adherence to recommended treat- of Nursing, University of South Florida, Tampa, Florida; School of 8-10 11,12 Nursing, California State University, Fullerton, California; and ments, costs of care, and physical outcomes fSchool of Nursing, Indiana University, Indianapolis, Indiana. in patients with coronary heart disease and heart fail- 13-21 Corresponding author: Debra K. Moser, DNSc, RN, FAAN, College ure. The risks engendered by negative emotional of Nursing, University of Kentucky, 527 College of Nursing, states may be equal to, or greater than, those seen Lexington, KY 40536-0232. E-mail: [email protected] with traditional risk factors such as the presence of di- 0147-9563/$ - see front matter Ó 2010 Elsevier Inc. All rights reserved. abetes, smoking, elevated low-density lipoprotein, 5,19 doi:10.1016/j.hrtlng.2009.10.017 and the presence of comorbidities. Despite the 378 www.heartandlung.org SEPTEMBER/OCTOBER 2010 HEART & LUNG Moser et al Psychological distress in cardiac patients importance of negative emotional states to the qual- Multiple affect adjective checklist. The Multiple ity of life, morbidity, and mortality of cardiac patients, Affect Adjective Checklist (MAACL) assesses states clinicians still do not routinely assess for emotional of anxiety, depression, and hostility.24,25 The MAACL distress as a significant risk factor.22,23 One major fac- is a set of 132 positive and negative adjectives repre- tor limiting the application by clinicians of evidence senting each of the 3 emotional states, arranged in regarding negative emotional states is the perception alphabetical order. Subjects read through the adjec- that major confounding factors such as age obscure tives and check all those that reflect how they cur- the impact of cardiac disease on emotional states. rently feel. The instrument is scored by calculating Thus, this study sought to determine the impact of the number of negative adjectives checked, and the cardiac disease on psychological adjustment by number of positive adjectives not checked. Higher comparing the prevalence of depression, anxiety, scores indicate that a respondent has higher levels and hostility in 3 elderly cardiac patient groups (ie, of the given emotion. Respondents receive separate outpatients with heart failure, patients after a myocar- scores for anxiety, depression, and hostility. Standard dial infarction, and patients after a coronary artery thresholds for anxiety, depression, and hostility were bypass graft) with that of a group of healthy elders. established at scores of 7, 11, and 7, respectively. This instrument measures the intensity of symptoms of METHODS anxiety, depression, and hostility, and is not used to render a clinical diagnosis. Nonetheless, this instru- In this multicenter, comparative study, data ment was chosen for this project because of its clini- from 3 outpatient cohorts of community-dwelling cal utility and ease of comparison among sites, and cardiac patients and a group of community- because dysphoric symptoms, even in the absence dwelling elders without known cardiac disease of a clinical diagnosis, were shown to exert a negative were compared in terms of anxiety, depression, impact on outcomes.18,26 The MAACL has been used and hostility. A multicenter design was used to in- extensively in research, and its sensitivity, reliability, crease clinical diversity and heterogeneity in the and validity were repeatedly demonstrated.24,25,27 Re- sample, to enhance generalizability. liability was confirmed in this study with the calcula- tion of Cronbach’s a in each sample for each subscale Participants of the MAACL. In each of the 4 groups and each of the After approval by our respective Institutional 3 subscales, Cronbach’s a was >.85. Review Boards, cardiac patients were recruited from outpatient clinics at academic medical centers Data analysis in the Western, Midwestern, and Southern United Non-normally distributed data were transformed States, and a cohort of elders without cardiac dis- for a better approximation of normal distribution, us- ease was recruited from senior centers. All partici- ing log transformations as needed. Data were pooled pants gave written, informed consent. Cardiac for all sites, because no differences in outcomes were patients who met the following inclusion criteria evident among sites. Analysis of variance was used to were enrolled: (1) at least 3 months past a hospitali- compare mean anxiety, depression, and hostility zation; (2) community-dwelling; (3) age $ 60 years; scores among the cardiac-patient and healthy elder (4) no cognitive impairment (ie, patients unable to groups. This provided an unadjusted comparison of converse appropriately or diagnosed with dementia the means. We adjusted for baseline age, gender, eth- or Alzheimer’s disease); and (5) a confirmed diagno- nicity, marital status, educational level, and comor- sis. Elders without cardiac disease were community- bidities, using subsequent analysis of covariance dwelling, had no cognitive impairments, were aged models. When a significant difference was found, $60 years, and were free of known cardiac disease. post hoc testing using Bonferroni comparisons iden- tified specific group differences. All analyses were Measurement conducted using SPSS software, release 13.0 (SPSS, Inc., Chicago, IL). All tests for statistical significance Data on sociodemographic characteristics were were 2-tailed, and a =.05. collected from all participants by an interview and questionnaire. Clinical data were collected about patients by patient interview and medical-record re- RESULTS view. Anxiety, depression, and hostility were mea- A total of 1167 individuals participated in this sured in participants using the Multiple Affect study: 907 cardiac patients, and 260 healthy elders. Adjective Checklist. In the cardiac-patient group, 478 heart-failure HEART & LUNG VOL. 39, NO. 5 www.heartandlung.org 379 Psychological distress in cardiac patients Moser et al patients, 298 postmyocardial infarction patients, The percentage of cardiac patients in each group and 131 postcoronary artery bypass graft patients exceeding the threshold for anxiety was 37% to were enrolled. Given our age criterion for enrollment 44%, compared with only 17% among healthy elders in the study, there were no differences in age among (Fig 1). With regard to depression, 63% of heart-fail- the 4 groups. As expected, however, given the typical ure patients exceeded the threshold for depression, cardiac profiles seen in the community, there were compared with 56% of postmyocardial infarction a number of differences in baseline characteristics patients, 53% of postcoronary artery bypass graft among groups (Table I). patients, and only 33% of healthy elders. A total of 62% of postcoronary artery bypass graft
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