Association of sociodemographic characteristics, cardiovascular symptoms and psychosocial stressors in elderly depressed patients with coronary artery disease
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ORIGINAL ARTICLE
Association of sociodemographic characteristics, cardiovascular symptoms and psychosocial stressors in elderly depressed patients with coronary artery disease Associação entre características sociodemográficas, sintomas cardiovasculares e estressores psicossociais em idosos deprimidos com doença arterial coronária Miriam Ximenes Pinho1, Osvladir Custodio2, Marcia Makdisse3, Manes Erlichman 4, Jose Antonio Gordillo5, Vera Laet6, Maria José Carvalho7, Antônio Carlos Carvalho8
ABSTRACT Objective: To describe the prevalence of depressive symptoms in elderly patients with coronary artery disease and to compare the clinical and socio-demographic characteristics between depressed and non-depressed patients. The study also investigates the presence of psychosocial stressors in patients with depressive symptoms. Methods: A prospective cross-sectional study of 80 elderly patients with coronary artery disease. Main measures used: Geriatric Depression Scale and interview; echocardiography (ejection fraction); the New York Heart Association Functional Class and the Canadian Cardiovascular Society Functional Class. The statistical analysis was performed by the following: Student t test, chi-square, Fisher exact test and Mann-Whitney test. Results: The prevalence rate of depressive symptoms was 31%. Depressed patients were younger than the non-depressed ones (mean age: 75.5 and 79.3 years, p = 0.019, respectively). The socio-demographic variables (sex, schooling and income) and the clinical variables (previous myocardial infarction, cardiac function, severity of heart failure symptoms and angina) showed no difference between the depressed and non-depressed groups. The psychosocial stressors were predominant (56%), and among them, “problems related to primary support group” was the most frequently reported (92.8%). Physical stressors were found in 46% of participants and among them, the most frequently reported
were unrelated to the cardiac disease. Conclusion: The prevalence rate of depressive symptoms was high in this group of patients, but the objective evaluation of the cardiac function was not associated to depressive symptoms. On the other hand, the patient perception of the cause of their depressive symptoms was mostly related to psychosocial stressors, and problems related to primary support group was the most-endorsed category. Depressed elderly patients have a higher cardiac morbidity and mortality. Our findings suggest that an assessment of the patient’s psychosocial risk factors should be an essential part of the global evaluation of the health status and therapeutic intervention as much as the cardiac function itself. Keywords: Depression; Aged; Life change events; Stress; Coronary arteriosclerosis
RESUMO Objetivo: Avaliar a prevalência de sintomas depressivos em idosos com doença arterial coronária e comparar as características sociodemográficas e clínicas entre deprimidos e não deprimidos, e investigar a presença de eventos estressores no grupo de deprimidos. Métodos: Estudo prospectivo de corte transversal que analisou 80
Estudy carried out at the Departamento de Medicina: Cardiogeriatria, Universidade Federal de São Paulo - UNIFESP - São Paulo (SP), Brazil. 1
Psychologist; Graduate student in Health Sciences, Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil.
2
Psychiatrist, Department of Psychiatry - Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil.
3
Cardiologist; PhD, Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil.
4
Cardiologist, Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil.
5
Cardiologist, Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil.
6
Nurse, Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil.
7
Psychologist, Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil.
8
Full Professor and Coordinator of the Discipline of Cardiology at the Universidade Federal de São Paulo - UNIFESP, São Paulo (SP), Brazil.
Corresponding author: Miriam Ximenes Pinho – R. dos Otonis, 897 - Vila Clementino - CEP 04025-002 - São Paulo (SP), Brazil - Tel.: 11 5549-9064 - e-mail:
[email protected] Funding source: Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), process number 02/13855-0. Received on Aug 03, 2006 - Accepted on Sep 25, 2006
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Pinho MX, Custodio O, Makdisse M, Erlichman M, Gordillo JA, Laet V, Carvalho MJ, Carvalho AC
pacientes idosos coronariopatas, por meio dos instrumentos: Escala de Depressão em Geriatria e entrevista; ecocardiografia (fração de ejeção); Classificação funcional da New York Heart Association e Classificação Funcional da Canadian Cardiovascular Society. A análise estatística foi realizada por meio dos testes t de Student, qui-quadrado, exato de Fisher e Mann-Whitney. Resultados: A prevalência de sintomas depressivos foi de 31%. Os pacientes deprimidos eram mais jovens que os não deprimidos (média: 75,5 e 79,3 anos, p = 0,019, respectivamente). Não houve diferença entre os grupos de deprimidos e não deprimidos em relação às variáveis sociodemográficas, sexo, escolaridade e renda; e nem em relação às variáveis clínicas (infarto prévio, função cardíaca, gravidade dos sintomas da insuficiência cardíaca e angina). Os principais eventos estressores relatados foram os psicossociais (56%), dentre esses, “problemas relacionados com o grupo primário de apoio” foi o estressor predominante (92,8%). Estressores físicos foram relatados em apenas 46% dos casos, sendo mais freqüentes os estressores não relacionados a doença cardíaca. Conclusão: A prevalência de sintomas depressivos foi alta nesse grupo de pacientes, a avaliação objetiva da função cardíaca não esteve associada com o quadro depressivo. Por outro lado, na percepção dos pacientes deprimidos avaliados, a depressão esteve relacionada com maior freqüência aos estressores psicossociais, com ênfase nos problemas relacionados com o grupo primário de suporte. Idosos deprimidos apresentam um risco aumentado de morbimortalidade. Nossos achados sugerem que avaliar os fatores de risco psicossocial tem uma importância tão significativa para a avaliação geral da saúde dos pacientes e intervenção terapêutica quanto a avaliação do funcionamento cardíaco. Descritores: Depressão; Idoso; Acontecimentos que mudam a vida; Estresse; Arteriosclerose coronária
INTRODUCTION Depression and depressive symptoms are often associated to coronary heart disease (CHD)(1-2). About 20% of patients with CHD display severe depression or major depressive episode, the same proportion of depression observed among the patients with myocardial infarction(1,3-4). Depression is also associated to worsening of the functional scores and of the self-assessment of health status and quality of life scores (5-7) , aside from increasing the cost of health care(8). In patients with cardiovascular diseases, especially after acute myocardial infarction, depression is associated with increased risk of fatal and non-fatal events (8-9) . Barefoot et al. (10) demonstrated that patients with CHD and severe depression had an 84% greater risk of cardiovascular death than those not depressed. Being exposed to several stressful life events has been associated to the appearance of different psychopathological disorders including depression(11-13). In a study involving depressed elderly patients, the death of the partner or of other family member was the most frequently identified stressor(14). Other recent einstein. 2006; 4(4):321-326
studies, aside from the contribution of psychosocial factors, discuss the possible causal relation between these in triggering cardiac events(15-17). Geriatric depression is little acknowledged, especially, in general hospitals, long-term care facilities and primary care units. It often occurs in the presence of physical disorders that may have similar manifestations to those observed in depression (for instance, tiredness, fatigue and reduced libido). In the elderly, the diagnosis may be additionally confounding when they complain of irritability, anxiety, cognitive problems and somatic symptoms, rather than of depressive or sad mood(18-19). The present study assessed the prevalence of depressive symptoms in CHD outpatients and compared the socio-demographic and clinical characteristics between the depressed and nondepressed individuals. It further investigated the presence of stressful events in the population with depressive symptoms.
METHODS This is a cross-sectional study carried out at the Geriatric Cardiology Outpatient Clinic of a University Hospital. The study protocol was approved by the institutional ethics committee and all participants signed an informed consent. Sample Eighty CHD patients with 65 years of age or older were consecutively selected by a cardiologist. CHD was defined when one or more of the following criteria were present: a. History of angina pectoris with stress EKG showing ST depression > 2 mm and/or imaging test (stress myocardial scintigraphy or echocardiogram) consistent with myocardial ischemia and/or coronary angiogram with > 50% stenosis in at least one main epicardial artery; or b. History of acute myocardial infarction confirmed by at least two of the World Health Organization criteria: suggestive clinical features, EKG changes and increased serum markers of myocardial injury (CK-MB and/or troponins); or c. History or percutaneous coronary intervention or of myocardial revascularization surgery. Patients with severe physical ailment or cognitive loss hampering the ability to answer the questionnaire or with communication problems, unresolved by adaptive devices (hearing loss, aphasia) were excluded. Instruments and procedures The instruments were applied after the routine medical visit to the patients who agreed to take part in the study.
Association of sociodemographic characteristics, cardiovascular symptoms and psychosocial stressors in elderly depressed patients with coronary artery disease
Geriatric Depression Scale - GDS Patients with depression were identified through the GDS, which is one of the most used instruments to assess depressive disorders in the elderly. The 15 items short version (GDS-15) was chosen because it is easy to apply, the cutoff point 5/6 being used to differentiate no case/ case, respectively(20). Definition of stressful events The life situations reported as being associated to triggering the depressive state were considered as stressful events. Such situations were reported by the depressed patients themselves (GDS score ³ 6) when asked to answer the question: “Is there a reason for you to feel this way?” The stressful events were classified into physical and psychosocial stressors. Complaints related to health problems (angina/AMI, dizziness, dyspnea, motor limitation, malignancies) were considered as physical stressors. Psychosocial stressors included complaints regarding the required emotional demands when there was death in the family, marital and family disputes, separations, dependent family member living in the same household and financial problems(21). The stressful events were classified into four categories, according to the source of stress. The psychosocial stressors were categorized in problems with the primary support group and financial problems. The physical stressors were categorized in complaints related to the cardiac disease and complaints unrelated to the cardiac disease. Cardiac function assessment Cardiac function was assessed by means of the left ventricle ejection fraction (LVEF) measured in thoracic echocardiogram. Patients with LVEF smaller than or equal to 40% were considered severely impaired. Regarding the severity of heart failure symptoms, the patients were categorized into four groups according to the New York Heart Association (NYHA), as follows: class I: patients with no dyspnea in usual physical activities; class II: patients with mild limitation of physical activity; class III: patients with important limitation of physical activity; and class IV: patients unable to perform any activity without discomfort(22). Regarding the severity of anginal symptoms, the patients were classified into four groups, by means of the functional assessment of the Canadian Cardiovascular Society (CCS) as: class I - asymptomatic in usual physical activities, class II - with slight limitation, class III - with important limitation of the usual activities and class IV - angina at rest(23).
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STATISTICAL ANALYSIS Data analysis was performed with the Statistical Package for Social Sciences(24). The chi-square test was used for sample analysis and for the comparison of discrete variables between the depressed and non-depressed groups; in the case of the Cochrane recommendation violation, the Fisher exact test was used. In the case of discrete ordinal and continuous variables, the MannWhitney test was used. The level of significance adopted was 5% (p < 0.05). RESULTS Among the 80 patients studied, 31% had depressive symptoms. The socio-demographic and clinical characteristics of the 80 patients are depicted in table 1. The proportion of men and women was the same (x2 = 0.200; p = 0.655). The mean age of the patients was 78 years, standard deviation of 6.232, and the age range was 66-92 years. Most had from one to four years of schooling (x2 = 39.70; p < 0.001). There was no preponderance of any socioeconomic class in the sample (x2 = 2.9; p = 0.407). Most of them (58.7%) had an income between one and four minimal wages. The proportion of patients with previous myocardial infarction (61.25%) and heart failure (92.5%) was high. Regarding the severity of heart failure symptoms, most of the patients (85%) were in functional class I or II (NYHA). Regarding angina, most (85%) were in class I (CCS). The LVEF was assessed in 85% of patients and of these, 87% had the ejection fraction greater than 40%. The comparison between the groups with or with no depression is depicted in table 2. The depressed patients were younger (75.52 ± 6.59 years) than the non-depressed ones (79.25 ± 5.752 years). There were no differences regarding sex (x2 = 1.928; p = 0.1650) and schooling (p = 0.789). There were no differences regarding history of previous myocardial infarction or not (x2 = 1.311; p = 0.252), severity of symptoms of heart failure (p = 0.777), of angina status (p = 0.867) and ejection fraction results (p = 0.690). The distribution of depressed patients according to reported stressful events is depicted in table 3. Psychosocial stressors predominated (56%), among these, complaints related to problems with the primary support group was the main one (92.8%). Health problems, considered as physical stressors, were reported by 44% of the depressed patients and the most mentioned category in this group was of
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Table 1. Description of the socio-demographic and clinical characteristics of 80 patients participanting in the study Variables Sex male female Age (years) 66-75 76-85 >85 Schooling No schooling 1-4 years 5-8 years > 8 years Family income (nº MW)* ≤1 MW 1-2 MW 3-4 MW ³5 MW Previous infarction Yes No LVEF > 40% ≤ 40% FC NYHA I II III IV No past history of HF** FC CCS I II III/IV * MW = minimum wage.
N
%
38 42
47 58
27 41 12
33 51 15
22 42 11 5
27 52 13 6
18 25 22 15
22 31 27 18
49 31
61 38
59 9
86.7 13.2
30 38 6 0 6
37 47 7.5 0 7.5
68 12 0
85 15 0
** HF = heart failure.
Table 2. Description of the socio-demographic and clinical variables of 80 patients divided according to presence of depressive symptoms, and the results of chi-square test, Fisher’s exact test and Mann-Whitney test and their respective p values Variables
With depressiveWithout depressive symptoms* symptoms (n = 25/ 31.25%) (n = 55/ 68.75%) p Sex male female 9 (36)16 (64) 29 (52)26 (47) 0.1650 Age (years) 79.25 ± 5.752 75.52 ± 6.590 0.019 Schooling (1-4 years) 14 (56) 28 (50.9) 0.789 Family income (MW)** 3.08 ± 2.10 3.31 ± 2,43 0.697 Previous infarction 13 (52) 36 (65.4) 0.252 LVEF (‘‡0,40) 15 (60) 44 (80) 0.690 FC NYHA I, II 22 (88) 46 (83.6) 0.777 FC CCS I, II 25 (100) 55 (100) * GDS score ³ 6. ** MW = Minimum wage.
health problems unrelated to the heart condition (63.6%).
DISCUSSION The estimated prevalence of depressive symptoms among outpatient elderly individuals with coronary heart disease was high (31%). This is in accordance with other studies that showed a greater prevalence of depressive manifestations when milder depression is accounted for(7,25-26). The GDS scale, utilized to assess the presence of depressive symptoms, is a screening instrument of quick and easy application, which may be particularly useful in outpatients. It does not diagnose depression although it helps identifying possible “cases”. Regarding the clinical characteristics of the studied population, most of the subjects had clinically stable health, consistent with outpatients. Low schooling and income levels (about 80% of the elderly of the sample had up to four-year schooling and had incomes of up to four minimal wages) are consistent with the national elderly population average(27). In the present study, among the socio-demographic characteristics, only age was associated to depression (p = 0.019). Those with a greater number of depressive symptoms were younger, which is similar to what was found in other studies, however the association between age and depression in the elderly was clearly established(28). Although no difference existed regarding sex, income and schooling, some studies reported this association(29-30). The low schooling and income levels found in the sample were uniformly distributed, and may have contributed for the absence of difference between the groups. Sample size may have been insufficient for showing statistically significant differences regarding the sex. As to stressful events, the most frequently reported by the patients were psychosocial stressors compared to physical stressors (56% vs. 44%). Among the psychosocial stressors, “problems related to the primary
Table 3. Distribution of depressed patients (GDS e•6) according to reported stressful events Type of stressor Psychosocial stressors
Physical stressors
Categories Problems related to primary support group
Financial problems Related to a cardiac disease Unrelated to cardiac disease
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Stressful events Marital disputes Family disputes Dependent family member Death of a child (children) Death of a partner Death of partner and child Separation Bankruptcy Dyspnea/dizziness Angina/infarction Motor limitation Malignancies
n (25) 3 2 2 2 2 1 1 1 1 3 5 2
Total n (%) 13 (92.8)
Total n (%) 14 (56)
1 (7.2) 4 (36.4)
11 (44%)
7 (63.6)
Association of sociodemographic characteristics, cardiovascular symptoms and psychosocial stressors in elderly depressed patients with coronary artery disease
support group” (due to marital and family disputes, death of a family member, separation, dependent family member and financial problems) was the most often identified category among the depressed ones (92.8%). Several studies attributed a role of psychosocial stressors in the worsening of physical health, including CHD and the occurrence of mental disorders (11,13-18). Highly tense, long lasting situations, such as financial problems or family disputes, are associated to several psychopathological disorders ranging from anxiety symptoms to specific disorders of severe depression among others(12). According to Neri(31), one of the basic functions of the network of relationships and social support for the elderly is to give and to get emotional and material support services and information so that they may preserve their self-esteem and self-image, important mechanisms in the process of adaptation to the physical and emotional losses. The social networks made by significant friends and family would reduce the negative impact of stressful events and the absence of such support has been associated with illnesses, death and mental disorders in the elderly(32-33). In the sample analyzed, the depressive symptoms were perceived as due to problems with the primary support group, the quality of the family relationships was considered insufficient or inadequate to give the emotional and/or material support needed for individual well-being. Among the physical stressors, those unrelated to the heart disease were more prevalent than those related to it and were found in 63.6% of the answers. Some studies have demonstrated a clear association between heart disease, especially CHD, with depressive manifestations(14,8-10) . Many studies considered psychosocial stressors as important risk factors for the occurrence of depressive disorders among ill elderly subjects(2,4,6,14-17). It is expected that in this age group, such stressors have a greater impact because of frequent functional losses due to comorbidities rendering incapacity and greater dependency, in addition to the cumulative losses due to death of friends and family members, retirement, low income and the progressive loss of socially valued roles. Since the present study was conducted in outpatients with periodic follow-up and with stable heart disease, the psychosocial and physical factors due to co-morbidities may have had greater importance than heart disease itself.
CONCLUSION In the population assessed composed of outpatient elderly subjects with chronic coronary heart disease, the prevalence of depression was high. Complaints regarding
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psychosocial stressors were more prevalent than those regarding physical stressors and, among the latter, those unrelated to the heart condition predominated, suggesting that when heart disease is stable, the identification of psychosocial risk factors is as important in the general assessment of the patient’s health and therapeutic intervention as the assessment of cardiac function.
SCOPE AND LIMITATIONS OF THE STUDY Some methodological limitations exist in this study and must be taken into account when interpreting the results. Firstly, the sample is constituted by patients with chronic coronary heart disease, mostly stable, and it is likely that in patients with acute CHD, depression has a greater role in the genesis of depressive disorders. Secondly, the assessment of negative life events (stressors) was done only in the depressed subjects, and thus the frequency of such events among the non-depressed subjects is not known; comparisons among the groups are thus not possible. Thirdly, the scale used to measure depression may not have been sensitive enough to detect all positive cases as well as it may have included negative cases in the sample. Further studies might include, in addition to a screening scale, a standardized clinical interview to confirm the diagnosis of depression. ACKNOWLEDGEMENTS To the whole team of the Geriatric Cardiology of the Cardiology discipline of Escola Paulista de Medicina, for their support in this study. REFERENCES 1. Gonzales MB, Snyderman TB, Colket JT, Arias RM, Jiang JW, O’Connor CM et al. Depression in patients with coronary artery disease. Depression. 1996;4(2):57-62. 2. Musselman DL, Evans DL, Nemeroff CB. The relationship of depression to cardiovascular disease: epidemiology, biology and treatment. Arch Gen Psychiatry. 1998;55(7):580-92. 3. Carney RM, Freedland KE, Rich MW, Jaffe AS. Depression as a risk factor for cardiac events in established coronary heart disease: a review of possible mechanisms. Ann Behav Med. 1995;17(2):142-9. 4. Glassman AH, Shapiro PA. Depression and the course of coronary artery disease. Am J Psychiatry. 1998;155(1):4-11. 5. Steffens DC, O’connor CM, Jiang WJ, Pieper CF, Kuchibhatla MN, Arias RM et al. The effect of major depression on functional status in patients wih coronary artery disease. J Am Geriatr Soc. 1999;47(3):319-22. 6. Ruo B, Rumsfeld JS, Hlatky MA, Liu H, Browner WS, Whooley MA. Depressive symptoms and health-related quality of life: the heart and soul study. JAMA. 2003;290(2):215-21. 7. Xavier FMF, Ferraza MPT, Argimon I, Trentini CM, Poyares D, Bertollucci PH et al. The DSM-IV ‘Minor depression’ disorder in the oldest-old: prevalence rate,
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