Depression, faith-based coping, and short-term postoperative global functioning in adult and older patients undergoing cardiac surgery

Abstract

Objectives

This prospective study examined how preoperative depression and faith-based coping, assessed preoperatively and postoperatively, affected short-term postoperative global functioning (SPGF) following a major cardiac surgery.

Methods

We recruited 481 patients (male, 58%; mean age=62 years, range=35–89) 2 weeks before surgery for three sequential psychosocial interviews using standardized instruments. Of them, 426 completed the second interview, and 335 completed the postoperative follow-up.

Results

Multiple regression analyses showed that depression predicted poor SPGF, controlling for age, preoperative illness impact, and two noncardiac chronic conditions. Preoperative positive religious coping contributed to better SPGF, controlling for preoperative depression and other confounders. However, postoperatively assessed prayer coping was associated with poor SPGF.

Conclusion

Research should distinguish the longitudinal protection of generally adaptive faith-based coping styles from the increased usage of such coping for immediate distress, mobilized by crisis.

Introduction

Major cardiac surgery is a life-altering event for many middle-aged and older people [1], [2]. Over the past two decades, the number of cardiac procedures increased by nearly 70% in the United States. Early mobilization and discharge after cardiac surgery have been recommended for these patients [3]. Clinically, this change has considerably enhanced the surgical outcome for most of them. At-home recovery, however, depends on overall postoperative functional status. The purpose of this prospective study was to examine the effect of preoperative depression and faith-based coping, assessed preoperatively and postoperatively, on short-term postoperative global functioning (SPGF) of middle-aged and older patients undergoing major cardiac operations. In particular, we intended to distinguish the longitudinal effect of general religious coping styles on SPGF from the associated role of cross-sectionally assessed use of prayer for coping after surgery, as a stress-mobilized reaction.

The significance of this SPGF investigation lies in the need to bridge several gaps in the literature. First, in the area of psychosomatic research, SPGF following major cardiac surgery has been underinvestigated or underreported in the United States. Outside of the United States, a retrospective study of 329 elderly participants (age >70 years) showed that preoperative chronic conditions, such as hypertension and cerebrovascular disease or stroke, had negative effects on long-term functional status [4]. In addition, very old patients (age >75 years) tended to have higher mortality and morbidity and poor health improvement and quality of life 1 year after surgery [5]. Basic biological and psychosocial function is commonly assessed by activities of daily living (ADL) in gerontological research [6]. Yet, these scales have been rarely used for testing SPGF in the cardiac literature.

Second, the mental health comorbidity of cardiac diseases, such as depression and anxiety, has caught increasing attention in cardiac procedure research. In recent years, a mountain of evidence has shown that depression predicts poor postoperative outcomes regarding both mental health and cardiac events [7]. Preoperative depression varied across studies between 7.5% and 47%, depending on the instruments used [8], [9]. Symptom levels remained stable before and after surgery [8], [10], [11], which even predicted mental status 1 year later [12]. Follow-up research found that depression was a major risk factor for postoperative readmission, new cardiac events, poorer quality of life, and especially cardiac events, coronary catheterization or angioplasty, and major cardiac events after catheterization [7], [13], [14], [15], [16], [17], [18]. A current study has associated acute distress immediately prior to cardiac surgery with higher levels of postoperative depression and anxiety [19]. Sparse information, however, is available concerning how preoperative mental health symptoms may affect SPGF that could influence long-term outcomes of cardiac surgery.

Finally, in the past decade, there has also been a growing interest among medical and psychosomatic researchers in the role of faith in health outcomes. Faith-driven involvement has been linked to better physical and psychological health [20], [21] and even decreased mortality among medically ill older patients [22], [23]. The protective role of faith has been more clearly established for cardiovascular diseases in contrast to cancer [21], but only a handful of research has investigated patients undergoing cardiac surgery. Oxman et al. [24] found that lack of religious strength and comfort was a risk factor for postoperative mortality in older cardiac patients. Ai et al. [25] indicated that patients who pursued prayer postoperatively had lower levels of distress 1 year after surgery. In another follow-up study, they linked the use of prayer for coping with preoperative optimal expectations, that have been made evident as protectors of health, including cardiovascular health [26], [27]. The potential influence of faith on SPGF, a measure with clinical significance, is yet to be determined.

For some important reasons, however, the findings concerning the faith effect on health have not always been consistent [28]. An obvious, first reason lies in the fact that various aspects of faith-based involvement may have different influences on outcomes under varied circumstances. For instance, a recent publication related stronger religious beliefs to fewer complications and shorter hospital stays but linked attendance at religious services with longer hospitalization and more complications [29]. In addition, negative religious coping styles (defined as an insecure relationship with God and an ongoing religious struggle) have been associated with deleterious effects on health, whereas positive religious coping styles (defined as a secure relationship with God and a sense of spiritual connectedness) had beneficial, but weaker, effects [30], [31]. An earlier report on this patient sample found that preoperative positive religious coping styles contributed to reduced short-term postoperative depression and anxiety, whereas preoperative distress was linked with negative religious coping styles that, in turn, predicted more postoperative mental health symptoms (i.e., depression and anxiety) [32]. Because depression is debilitating, it would be interesting to examine how these general religious coping styles affect SPGF in these patients.

Another less obvious, second reason is underinvestigated, which has to do with the clarified temporal nature of faith measures, namely, the longitudinally or cross-sectionally assessed role of faith factors. Most studies on the faith–health connection have only addressed the above first reason but failed to pay a deliberate attention to this second one. Clearly, there is the need to distinguish the overtime effects of general faith-based coping styles from the increased use of faith for coping with stress during adversity.

Theoretically and empirically, researchers have indicated that a crisis can mobilize an individual's pursuit of spiritual support from a higher power [33], [34]. For some time, therefore, faith-based involvement appeared to be associated with distress, especially in a cross-sectional design [35]. A two-step statistical analysis in an earlier retrospective study showed that the use of prayer in cardiac patients increased with depression 1 month after surgery, although prayer was also related to better mental health 1 year later [25]. As the function of the temporal nature of assessment, these different associations of faith factors with outcome measures must be verified through a prospective design. To illuminate this second reason, the present study was designed to distinguish the longitudinal effect of preoperatively used, general faith-based coping styles from a cross-sectional interference of faith-based coping, likely mobilized by stress or, in our case, poor SPGF.

To meet the above gaps in the literature and to clarify the second reason in the mixed findings regarding the faith–health linkage, this study aimed to answer two research questions:

• How do preoperative mental health symptoms (i.e., depression and anxiety) influence SPGF following major cardiac surgery, controlling for established risk and protective factors (i.e., age, preoperative functioning and well-being, chronic conditions such as hypertension, stroke, and social support)?

• How does trait faith-based coping, assessed longitudinally as preoperative general positive and negative styles of religious coping, contribute to SPGF, controlling for state faith-based coping, assessed cross-sectionally as the use of prayer to cope with cardiac surgery, along with significant mental health symptoms and other confounders?

With regard to the first question, we hypothesized that SPGF would increase with preoperative mental health symptoms, preoperative illness impact, and other risk factors, based on the literature. With regard to the second question, we expected preoperative positive and religious negative coping styles to influence SPGF in opposite ways, and postoperatively assessed prayer coping to increase with poor SPGF as a stress-related mobilizor.