Research reportType-D personality but not depression predicts severity of anxiety in heart failure patients at 1-year follow-up
Introduction
Chronic heart failure (CHF) is a major health problem, with the incidence and prevalence of this potentially fatal disorder increasing tantamount to an epidemic (Hunt et al., 2005, Davis et al., 2000). Despite an impressive development of various treatment options, CHF is still associated with poor prognosis and functional capacity, frequent (re)hospitalisation, and escalating health costs (Hunt et al., 2005, Krumholz et al., 2002, Krumholz et al., 1997). Importantly, CHF is also associated with increased psychological distress (Schiffer et al., 2005, Gottlieb et al., 2004), and there is an urgent need to focus on this patient-centred outcome and its determinants in CHF (Krumholz et al., 2005).
Depression has received the most attention in CHF, with only few studies focusing on anxiety (Konstam et al., 2005, MacMahon and Lip, 2002). However, there is evidence to suggest that 8–16% of CHF patients suffer from clinically significant anxiety, such as generalised anxiety disorder or panic disorder (Haworth et al., 2005, Griez et al., 2000). Moreover, anxiety in heart patients is frequently under-recognised in clinical practice (Grace et al., 2004). Although anxiety has been linked in some (although not all) studies to prognosis, morbidity, and functional status in CHF (Ingle et al., 2006, Jiang et al., 2004, Clarke et al., 2000, Konstam et al., 1996), few studies have investigated the determinants of anxiety, and all of these have been cross-sectional (Haworth et al., 2005, Dracup et al., 2003, Majani et al., 1999). In these cross-sectional studies, higher New York Heart Association (NYHA) functional class (Haworth et al., 2005, Majani et al., 1999), co-morbid physical conditions (Haworth et al., 2005), and lower perceived control (Dracup et al., 2003) were associated with increased levels of anxiety.
The distressed (type-D) personality may be another important, but overlooked, determinant of anxiety in CHF patients. Type-D patients have elevated scores on two normal and stable personality traits, negative affectivity (tendency to experience negative emotions) and social inhibition (tendency to inhibit self-expression in social interaction) (Denollet, 2005) (Table 1). Type-D personality has been associated with several negative outcomes in patients with cardiac disease, such as worse prognosis (e.g. Denollet et al., 2000, Denollet and Brutsaert, 1998) and impaired quality of life (e.g. Al-Ruzzeh et al., 2005). Type-D personality is also independently associated with an increased risk of depressive symptoms and anxiety in patients with CHF, in patients with an implantable cardioverter defibrillator (ICD), and in coronary patients (van Gestel et al., 2007, Spindler et al., 2007, Schiffer et al., 2005, Pedersen et al., 2004). Increasing our knowledge of the prevalence and determinants of anxiety may enhance secondary prevention and further improve management of CHF (Haworth et al., 2005, MacMahon and Lip, 2002). However, to date no prospective study has directly examined the relationship between type-D personality and anxiety in CHF patients. Hence, the objective of this 1-year follow-up study was to examine whether type-D personality would predict clinically significant anxiety in CHF patients.
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Study population and procedure
Consecutive CHF outpatients visiting the cardiology clinic of the TweeSteden teaching hospital in Tilburg, the Netherlands, were approached for inclusion in the current study. CHF patients with a left ventricular ejection fraction (LVEF) ≤ 40%, younger than 80 years, and pharmacologically stable 1 month preceding inclusion were asked to participate in this study. Patients older than 80 years, with diastolic heart failure, incapable of understanding and reading Dutch, or with cognitive
Patient characteristics
At baseline, 35 patients (23.5%) were classified as type-D and 47 patients (31.5%) as having probable depression (BDI ≥ 10). There were no significant differences (all p > 0.05) between type-D and non type-D patients on baseline characteristics, including medication (Table 2). The mean score was 8.6 ± 6.2 (range 0–34) for self-reported depression and 12.1 ± 9.7 (range 0–47) for anxiety sensitivity.
Prevalence of mild to severe anxiety
The prevalence of clinically significant anxiety at 1-year follow-up in this sample was 11%. A
Discussion
This is the first study examining the relative impact of type-D personality, depressive symptoms, and anxiety sensitivity on severity of anxiety at 1-year follow-up in patients with CHF. We found that type-D personality incurred an almost 6-fold increased risk of clinically significant anxiety at 1-year follow-up, adjusting for depressive symptoms, anxiety sensitivity, and socio-demographic and clinical baseline characteristics, including LVEF, NYHA class and aetiology of CHF. Only type-D
Funding Source
The study was supported by grants from Medtronic and St. Jude Medical. Medtronic and St. Jude Medical had no further role in study design, the collection, analysis and interpretation of the data, the writing of the report and in the decision to submit the paper for publication.
Acknowledgement
The authors wish to thank Eric Hendriks for his assistance in data collection.
References (47)
- et al.
Perceived control reduces emotional stress in patients with heart failure
J. Heart Lung Transplant
(2003) - et al.
The influence of age, gender, and race on the prevalence of depression in heart failure patients
J. Am. Coll. Cardiol.
(2004) - et al.
Panic disorder and ideopathic cardiomyopathy
J. Psychosom. Res.
(2000) - et al.
ACC/AHA 2005 Guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure)
J. Am. Coll. Cardiol.
(2005) - et al.
Psychological outcomes of an outpatient pulmonary rehabilitation program in patients with chronic obstructive pulmonary disease
Respir. Med.
(2006) - et al.
Depression and anxiety in heart failure
J. Card. Fail.
(2005) - et al.
Baseline quality of life as a predictor of mortality and hospitalization in 5025 patients with congestive heart failure
Am. J. Cardiol.
(1996) - et al.
Randomized trial of an education and support intervention to prevent readmission of patients with heart failure
J. Am. Coll. Cardiol.
(2002) - et al.
Effects of depression and anxiety on mortality and quality-of-life 4 months after myocardial infarction
J. Psychosom. Res.
(2000) - et al.
The Hamilton Anxiety Scale: reliability, validity, and sensitivity to change in anxiety and depressive disorders
J. Affect. Disord.
(1988)
The development and modification of temperamental risk for anxiety disorders: prevention of a lifetime of anxiety?
Biol. Psychiatry
Anxiety sensitivity, anxiety frequency and the prediction of fearfulness
Behav. Res. Ther.
History of depression, angina, and quality of life after acute coronary syndromes
Am. Heart J.
Type-D personality predicts chronic anxiety following percutaneous coronary intervention in the drug-eluting stent era
J. Affect. Disord.
Comparing symptoms of depression and anxiety as predictors of cardiac events and increased health care consumption after myocardial infarction
J. Am. Coll. Cardiol.
Sensitivity and specificity of observer and self-report questionnaires in major and minor depression following myocardial infarction
Psychosomatics
Type-D personality and depressive symptoms predict anxiety 12 months post-percutaneous coronary intervention
J. Affect. Disord.
Predictors of poor mid-term health related quality of life after primary isolated coronary bypass grafting surgery
Heart
Confirmatory factor analysis and psychometric properties of the Anxiety Sensitivity Index — revised in clinical and normative populations
Eur. J. Psychol. Assess.
An inventory for measuring depression
Arch. Gen. Psychiatry
Psychosocial factors as predictors of functional status at 1 year in patients with left ventricular dysfunction
Res. Nurs. Health
ABC of heart failure: history and epidemiology
BMJ
Predictors of health status for heart failure patients
Prog. Cardiovasc. Nurs.
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