Psychosocial adjustment in patients one year after myocardial infarction

Longitudinal associations between 4-hydroxynonenal and depression in coronary artery disease patients

Depressive symptoms in patients with coronary artery disease (CAD) attenuate the cardiovascular benefits of cardiac rehabilitation (CR). Given that oxidative stress may be an important mechanism underlying depression, this study aimed to understand the longitudinal relationship between lipid peroxidation markers and depression in CAD. Serum levels of early (lipid hydroperoxides, LPH) and late (4‑hydroxy‑2-nonenal, 4-HNE; 8-isoprotane, 8-ISO) lipid peroxidation markers were measured in 120 CAD patients undergoing CR. The Structured Clinical Interview for DSM Axis I Disorders - Depression Module (SCID) was used to diagnose depression at baseline and the Center for Epidemiological Studies Depression Scale (CES-D) was used to measure depressive symptom severity. Multivariate mixed models compared the trajectories of serum LPH, 4-HNE, and 8-ISO between depressed and non-depressed CAD patients undergoing 6 months of CR. Similar models evaluated the associations between serum LPH, 4-HNE, and 8-ISO and CES-D score over the course of CR. Serum 4-HNE decreased less in CAD patients with depression compared to those without. In addition, a decrease in 4-HNE concentrations was significantly associated with a decrease in CES-D scores over 6 months. These findings suggest that 4-HNE may be an important marker of depressive symptoms in CAD and may be involved in its progression.

Depression in patients with coronary heart disease

Approximately 20% of patients with coronary heart disease (CHD) have major depression and 20% have minor depression at any given point in the course of their illness. Depression causes significant psychological and social morbidity, and is a risk factor for further cardiac morbidity and mortality. Although there are many possible biological and behavioral mechanisms, the causal pathways through which depression increases the risk for cardiac events and death are not well understood. Despite the morbidity associated with depression, and the devastating impact it has on the quality of life of patients with CHD, it is underdiagnosed and often left untreated. This article describes screening techniques for use in primary care and cardiology settings, and discusses the safety and efficacy of available treatments for depression in patients with CHD.

Predictors of psychosocial adjustment in people with physical disease

AIMS

The purpose of this paper was to examine the demographic, medical and psychosocial variables that result in the deterioration of psychosocial adjustment in patients with physical disease, the meaning their illness has for them and their coping style.

METHODS

The study was carried out in inpatient clinics of the Istanbul Faculty of Medicine (n = 198). The following evaluation instruments were used: a semi-structured questionnaire, the Psychosocial Adjustment to Illness Scale-Self Report (PAIS-SR), the Meaning of Illness Questionnaire (MIQ), the Hospital Anxiety-Depression Scale, the Multivariate Perceived Social Support Questionnaire and the Ways of Coping Inventory (WCI). Variables to be related with psychosocial adjustment were analysed by using Forward Logistic Regression.

RESULTS

The mean age of patients was 36.9 (SD 12.9) (18-65), 55% of which were women, the average PAIS-SR score was 1.02 (SD 0.41) (0.7-2.26); 47% of the patients had poor adjustment scores. Univariate analysis showed that psychosocial adjustment was affected by having children (p = 0.02), anxiety, depression, locus of control, perceived social support (p < 0.001), information level about their illness and its treatment (p = 0.01), the subscales of WCI [escape-avoidance (p < 0.001), distancing (p = 0.002), planned problem solving (p < 0.001), positive re-appraisal (p = 0.02)]. The psychosocial adjustment of patients with respiratory or infectious illnesses or bone-muscle-skeletal disorders was even less (p = 0.03). All 33 items of the MIQ were found to have a significant impact on psychosocial adjustment (p < 0.001). According to the regression analysis, the best predictors of psychosocial adjustment were: depression (p < 0.001) and the meaning of illness for patient (p < 0.01).

CONCLUSIONS

Having a physical illness is an important stress factor. In providing assistance, a number of factors should be taken into consideration, including how the patient perceives his illness, the impact the illness has on the patient's life, and a determination of the degree of depression being experienced by the patient.

RELEVANCE TO CLINICAL PRACTICE

The study indicated some predictors in the assessment of psychosocial adjustment and care of patients with physical illness. In daily clinical practice, among the patients with physical illness, those with a negative perception of their illness and those who define depression should be given special attention for psychosocial support.

Cognitive performance following fluoxetine treatment in depressed patients post myocardial infarction

BACKGROUND

As depression is a considerable risk factor for an unfavourable course of myocardial infarction (MI), antidepressant treatment of post-MI depression and, inherent to MI status, polypharmacy has become an important issue.

OBJECTIVE

The present study is the first to evaluate cognitive side effects of fluoxetine, as part of a placebo-controlled double-blind trial, in patients with post-first MI depression.

METHODS

Cognitive performance of 54 depressed patients post first-MI, treated with fluoxetine or placebo was compared. Cognitive performance was tested before and after 9 weeks of treatment using the Visual Verbal Learning Test, Concept Shifting Task, Stroop Colour-Word Test and Letter-Digit-Substitution Test.

RESULTS

The median number of cardiovascular drugs taken by MI patients was 4.9. There were no differences between the fluoxetine and the placebo group on cognitive performance.

CONCLUSION

In sum, there were no negative side effects of fluoxetine compared with placebo on cognition in depressed MI patients, simultaneously treated with cardiac drugs.

Psychosocial Predictors of Death for Low-Risk Patients After a First Myocardial Infarction

PURPOSE

This study aimed to identify whether psychosocial variables predicted mortality 7 years after a first myocardial infarction among patients who did not undergo revascularization.

METHODS

The study population consisted of 222 men aged 30 to 60 years who entered an inpatient rehabilitation program a mean of 7 weeks after a first myocardial infarction. Medical data were obtained from the patients and their physicians at entry to the rehabilitation center and 1 year later. Psychosocial and medical variables were obtained from the patient by questionnaires at entry 1 and 7 years later. Follow-up evaluation was 96% complete. Statistical analyses are reported using odds ratios (OR).

RESULTS

The 7-year mortality rate was 10.4%; the reinfarction rate was 9%; the hospital readmission rate was 32.3%; and 39.2% of the patients underwent a subsequent revascularization procedure, either coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA). The most important psychosocial predictors for death at 7 years identified with logistic regression analyses were lack of partnership (OR, 3.46), anxiety (OR, 1.19), and depression (OR, 1.04). Medical predictors of 7-year mortality were severity of infarction (OR, 2.86) and the number of coronary risk factors (OR, 1.77).

CONCLUSIONS

Survival in a group of low-risk male patients 7 years after a first myocardial infarction was predicted by the following psychological and social variables: lack of partnership, depression, and anxiety. Although it is unknown whether the risk of dying 7 years after an initial myocardial infarction can be reduced by therapeutic interventions, these data reinforce the importance of special attention for patients with these psychosocial characteristics.

Long-term mental health of women after a first acute myocardial infarction11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To compare the long-term psychologic well-being and psychologic distress, after a first acute myocardial infarction (AMI), of women with those of men and those of a normative community sample of women and to examine the relation of sociodemographic, medical, and psychologic variables to the long-term psychologic well-being and psychologic distress of women.

DESIGN

Longitudinal study.

SETTING

Eight medical centers in central Israel.

PARTICIPANTS

Sixty-two women (age range, 30-65y) with documented first AMI.

INTERVENTIONS

Sociodemographic, medical, and psychologic data were collected before hospital discharge (T1). Psychologic well-being and psychologic distress were assessed 5 years after AMI (T2) with the Mental Health Inventory.

MAIN OUTCOME MEASURES

Hierarchical regression was used to examine the relations among the outcome variables, psychologic well-being, and psychologic distress at T2 and the predictors, sociodemographic, medical, and psychologic variables at T1.

RESULTS

Women had less long-term psychologic well-being and more psychologic distress after AMI than did men or the normative sample of women. Depression and concomitant medical problems were related to women's psychologic well-being; depression alone was related to their long-term psychologic distress.

CONCLUSIONS

Women with an AMI are more likely than men to have reduced psychologic well-being and increased psychologic distress. In addition, diminished mental health was related to medical and psychologic pathogenic factors.

Cardiac rehabilitation patient versus proxy quality-of-life perceptions

Spousal perceptions and/or attitudes to their patient partners' capabilities have been shown to affect the effectiveness of the cardiac rehabilitation (CR) process. The purpose of this study was (a) to assess differences between patient and proxy responses to the Medical Outcomes Survey-Short Form 36 (SF36)and (b) suggest how such information may contribute to enhancing rehabitation outcomes. Fifty-eight patients completed the SF36 prior to entering Phase II CR. Patient spouses completed a proxy version of the same questionnaire. The authors found that spouses' perceptions of their patient partners physical functioning (PF) was approximately 10% lower than patients' perceptions of their own PF (p < .04). Implications for the appropriate application of such data are discussed.

Comorbidity of depression with other medical diseases in the elderly

A major factor in the context of evaluating depression in the elderly is the role of medical problems. With aging there is a rapid increase in the prevalence of a number of medical disorders, including cancer, heart disease, Parkinson's disease, Alzheimer's disease, stroke, and arthritis. In this article, we hope to bring clarity to the definition of comorbidity and then discuss a number of medical disorders as they relate to depression. We evaluate medical comorbidity as a risk factor for depression as well as the converse, that is, depression as a risk factor for medical illness. Most of the disorders that we focus on occur in the elderly, with the exception of HIV infection. This review focuses exclusively on unipolar disorder. The review summarizes the current state of the art and also makes recommendations for future directions.

Long-term mental health of men after a first acute myocardial infarction

OBJECTIVE

To evaluate the differential and independent impact of sociodemographic, medical, and psychologic variables assessed at hospital discharge on patients' short- and long-term mental health.

DESIGN

Longitudinal study.

SETTING

Eight medical centers in central Israel.

PARTICIPANTS

Male Israeli patients (N = 209; age range: 30-65 y) with documented first acute myocardial infarction (AMI).

INTERVENTION

Subjects were interviewed 3 times, once (T1) before hospital discharge, a second time (T2) at 3 to 6 months after discharge, and a third time (T3) at 5 years post-AMI. Sociodemographic, medical, and psychologic data were elicited at the first interview and completed with medical information in the files. Psychologic well-being and psychologic distress were evaluated by the Mental Health Inventory at the second and third interviews. These 2 outcome variables were compared with normative community data on these aspects of mental health.

MAIN OUTCOME MEASURES

Hierarchical regression was used to examine the relation between the independent variables, sociodemographic, medical, and psychologic variables, and the dependent variables, psychologic well-being and psychologic distress, at T2 and T3.

RESULTS

Depression, perceived health, sense of coherence, social support, and educational level at discharge predicted aspects of mental health 3 to 6 months and 5 years post-AMI. However, only psychologic distress differentiated between the research participants and the normative community sample of men.

CONCLUSIONS

A first episode of AMI appears to increase psychologic distress more than it decreases psychologic well-being both 3 to 6 months and 5 years post-AMI. Educational level and sense of coherence may serve as protective factors, whereas depression may foster vulnerability to distress and impaired psychologic well-being.

Management of Depression in Patients with Comorbid Cardiovascular Disease

Evidence suggests that depression commonly occurs in patients with cardiovascular disease and is associated with a poor prognosis including increased risk of cardiac mortality. Proposed pathophysiologic mechanisms include decreased heart rate variability, altered sympathetic and parasympathetic activity, increased ventricular instability, and abnormal platelet reactivity. Other proposed mechanisms involve the interference of depression with medication adherence and cardiac risk factor reduction. Despite this evidence, depression during cardiovascular disease is commonly unrecognized and inadequately treated. Tricyclic antidepressants (TCA) are efficacious for treating depression in this population but cause serious cardiac side effects and should be avoided in patients with significant cardiovascular disease. More recent studies with bupropion and the selective serotonin reuptake inhibitors (fluoxetine, paroxetine, sertraline) indicate that they are acceptable alternatives to TCAs with regard to cardiac risk in depressed patients with heart disease, although larger studies are needed to validate their safety and efficacy in this special population. There are 3 studies currently being conducted to investigate the effect of antidepressant therapy and/or psychotherapy on cardiac morbidity and mortality in post–myocardial infarction patients with depression and/or low social support. These studies will hopefully answer the long-posed question of whether appropriate treatment of depression can improve cardiac prognosis.

Persistent impaired emotional functioning in survivors of a myocardial infarction?

The quality of life (QoL) of survivors of a myocardial infarction (MI) remains lower than that of their peers long after the acute event. Previous research on this subject has indicated, however, that this difference might lessen somewhat over time for the dimension 'emotional functioning' (as measured by the sickness impact profile (SIP): a generic instrument for QoL). The present study explores this phenomenon further using two instruments that specifically measure emotional functioning i.e. the hospital anxiety and depression scale (HAD) and the heart patients psychological questionnaire (HPPQ). Ninety-nine participants of a large population-based cohort (the Rotterdam study), who had been admitted to the hospital because of an MI in the previous 6-60 months, and 101 reference subjects, without a history of infarction of heart or brain, from the same age and gender-groups, were interviewed twice (at 1- to 3-year time intervals). The results of the present study confirm earlier findings that the emotional functioning (in terms of 'anxiety', 'depression', 'well-being', 'feeling disabled', and 'displeasure') of MI survivors is impaired when compared to their unaffected peers. Moreover, they did not show any improvement in 'anxiety', 'depression', 'well-being' and 'displeasure' over time in the MI survivors. The results did, however, show that the difference between MI survivors and referents became less in time in the dimension 'feeling disabled'. This decrease was partly because MI survivors improved and partly because referents felt more disabled over time. One explanation for this might be that referents (51% aged 70 years and over) had difficulties in adapting emotionally to decreasing levels of physical functioning with increasing age, while the MI survivors tended to adjust to and accept the impairments they had contracted several years earlier.

Coping in spouses of patients with acute myocardial infarction in the early phase of recovery

The purpose of this study was (1) to determine the coping strategies employed by spouses of patients with AMI in the early phase of the crisis, (2) to define the role of age, gender, health perception, time since infarction, spouses' fears, and negative life events in the choice of coping strategies applied, and (3) to test the effect of coping strategies on physical and psychological strain. Fifty-seven spouses participated in the study, 47 were female and 10 were male. Data were collected by structured questionnaires, which were distributed to the spouses from 2 weeks-4 months after the patient's AMI. The researchers found that age, negative life event during the last 12 months, time since infarction, and the spouse's fears influenced the choice of strategies. In the early stage of the crisis, positive reappraisal seems to be a strategy that increased physical strain. Spouses' need for social support in the early stage of the crisis is a factor for health care providers to bear in mind. Besides giving information, empathy, and understanding, health care personnel can try to assist spouses in their efforts to reappraise their situation.

Depression and ischemic heart disease

Major depression is a common comorbidity associated with ischemic heart disease (IHD). There is growing evidence that psychological stress in general and depression in particular predispose to cardiovascular disease. Persons who have mental stress during daily life are at twice the risk of myocardial ischemia, and patients with post-myocardial infarction depression have higher mortality rates than nondepressed controls. These data suggest a psychophysiologic mechanism underlying the vulnerability of depressed patients to IHD. Clinical studies have demonstrated that depression is associated with a much higher risk of both cardiovascular morbidity and mortality, which could be caused by platelet activation. Physicians should maintain a heightened level of clinical suspicion for depression and depressive disorders in persons with IHD, particularly those individuals who are recovering from an acute ischemic event, such as myocardial infarction. Furthermore, depression may complicate the recovery of IHD, but in most cases depression can be effectively treated with antidepressant agents.

Myocardial infarction, spouses' reactions and their need of support

The purpose of this study was to investigate the impact of myocardial infarction (MI) on survivor's spouses in terms of fears and symptoms during the patient's recovery period. In addition the researchers sought to evaluate the influence of the support by the health care professionals on spouses' adjustment. A total of 57 Finnish spouses participated in the study. Of the spouses 47 were female and 10 were male. Data were collected using a structured questionnaire distributed to the spouses at a rehabilitation session at 2 weeks-4 months after the MI. Topics covered included fears, emotional and physical symptoms and the spouses' experience of the sufficiency of the support that they had received from health care professionals during the patient's recovery. Data were analysed using quantitative methods including descriptive statistics and multivariate methods. Fears and symptoms were classified using factor analyses. For fears two factors emerged which were named: disease-related fears and personal fears. In respect of symptoms experienced by the spouse three factors emerged: one which describes emotional distress, one which describes dysfunction and one describing spouses' own vulnerability. The significantly most intensively experienced fears by the spouses were the disease-related fears followed by the personal fears. The most frequently reported symptom was dysfunction followed by emotional distress and vulnerability. In regression analysis emotional distress was predicted by personal fears, support from the health care professionals, the shock reaction, spouse's own health and time after MI. Dysfunction was predicted by spouse's own health and personal fears whereas vulnerability was predicted by spouse's own health and support from the health care professionals. Study findings show that in the planning of the care of patients with MI it is important to attend to the reactions and needs of spouses. Their resources are required for optimal rehabilitation of the patient.

Psychosocial adjustment in patients after a first acute myocardial infarction: the contribution of salutogenic and pathogenic variables. Israel Study Group on First Acute Myocardial Infarction

OBJECTIVE

To ascertain the differential and independent impact of sociodemographic, medical, and psychologic variables assessed at patients' hospital discharge on these patients' psychosocial adjustment in several domains of life 3 to 6 months later.

DESIGN

Two-hundred ninety Israeli male patients, aged 30 to 65 years, with a documented first acute myocardial infarction (AMI) were interviewed once before discharge and again 3 to 6 months postinfarct. Sociodemographic, medical, and psychologic data were elicited at the first interview and completed from medical information in the hospital files. Psychosocial adjustment in seven significant life domains was evaluated by the Psychosocial Adjustment to Illness Scale-Self-Report Version (PAIS-SR) at the second interview. Hierarchical regression analysis was used to examine the relation between the sociodemographic, medical, and psychologic variables at discharge to psychosocial adjustment in the different life domains 3 to 6 months later.

RESULTS

Psychologic variables, such as depression, sense of coherence, and social support, and the sociodemographic variable of educational level at discharge predicted a relatively substantial amount of variance in psychosocial adjustment in most PAIS-SR-measured life domains. Low to moderate relations were found between such medical variables as Killip class, heart disease before AMI, other medical conditions, and perceived health before first AMI and psychosocial adjustment in specific life domains. The results also raised the possibility that part of the impact of the medical variables at discharge on psychosocial adjustment 3 to 6 months later may have been mediated by the psychologic variables. The centrality of the psychologic and domestic life domains to psychosocial adjustment in post-AMI patients was also suggested by the results.

CONCLUSIONS

Both external and internal pathogenic (depression) and health proneness variables (sense of coherence and social support) at discharge predict psychosocial adjustment in most life domains 3 to 6 months after AMI.

Family stress management following acute myocardial infarction: an educational and skills training intervention program

Although the experience of acute myocardial infarction (AMI) is a family affair, little has been available to guide stress and distress reduction efforts focusing on all members of the family compared to the somewhat larger literature addressing stress management interventions with cardiac patients. This article provides a conceptual background for a specific behavioral therapy approach to family stress management in dealing with the sequelae of AMI for all family members with the goal of reducing morbidity for all family members as they cope with ongoing survivorship issues. The family intervention program is described and its pilot implementation discussed. Evaluation of the pilot suggests that an individually tailored focus for that subset of families at higher risk for elevated persistent distress may be the most cost-effective use of such a family intervention program.

Depression and coronary heart disease: a review for cardiologists

Major depression is a common comorbid condition in patients with coronary heart disease (CHD). Although mild emotional distress may be a normal reaction to myocardial infarction or other manifestations of CHD, major depression should not be considered a normal reaction, nor should it be ignored. Major depression is a debilitating comorbid disorder that can seriously complicate recovery and increase the risks of further cardiac morbidity and mortality. Fortunately, it is one that can be successfully treated in the majority of cases. The purpose of this review is to present the evidence for the negative prognostic effects of depression in cardiac patients and to discuss methods for assessing and treating depression in these patients.

Psychological rehabilitation after myocardial infarction: multicentre randomised controlled trial

OBJECTIVE

To evaluate rehabilitation after myocardial infarction.

DESIGN

Randomised controlled trial of rehabilitation in unselected myocardial infarction patients in six centres, baseline data being collected on admission and by structured interview (of patients and spouses) shortly after discharge and outcome being assessed by structured interview at six months and clinical examination at 12 months.

SETTING

Six district general hospitals.

SUBJECTS

All 2328 eligible patients admitted over two years with confirmed myocardial infarction and discharged home within 28 days.

INTERVENTIONS

Rehabilitation programmes comprising psychological therapy, counselling, relaxation training, and stress management training over seven weekly group outpatient sessions for patients and spouses.

MAIN OUTCOME MEASURES

Anxiety, depression, quality of life, morbidity, use of medication, and mortality.

RESULTS

At six months there were no significant differences between rehabilitation patients and controls in reported anxiety (prevalence 33%) or depression (19%). Rehabilitation patients reported a lower frequency of angina (median three versus four episodes a week), medication, and physical activity. At 12 months there were no differences in clinical complications, clinical sequelae, or mortality.

CONCLUSIONS

Rehabilitation programmes based on psychological therapy, counselling, relaxation training, and stress management seem to offer little objective benefit to patients who have experienced myocardial infarction compared with previous reports of smaller trials.

Depression and long-term mortality risk in patients with coronary artery disease

Previous research has established that patients with coronary artery disease (CAD) have an increased risk of death if they are depressed at the time of hospitalization. Follow-up periods have been short in these studies; therefore, the present investigation examined this phenomenon over an extended period of time. Patients with established CAD (n = 1,250) were assessed for depression with the Zung Self-Rating Depression Scale (SDS) and followed for subsequent mortality. Follow-up ranged up to 19.4 years. SDS scores were associated with increased risk of subsequent cardiac death (p = 0.002) and total mortality (p < 0.001) after controlling for initial disease severity and treatment. Patients with moderate to severe depression had a 69% greater odds of cardiac death and a 78% greater odds of mortality from all causes than nondepressed patients. Increased risk was not confined to the initial months after hospitalization. Patients with high SDS scores at baseline still had a higher risk of cardiac death > 5 years later (p < 0.005). Compared with the nondepressed, patients with moderate to severe depression had an 84% greater risk 5 to 10 years later and a 72% greater risk after > 10 years. Patients with mild depression had intermediate levels of risk in all models. The heightened long-term risk of depressed patients suggests that depression may be persistent or frequently recurrent in CAD patients and is associated with CAD progression, triggering of acute events, or both.

A long-term follow-up study of patients with ischaemic heart disease versus patients with nonspecific chest pain

Ninety consecutive patients who were admitted to hospital with acute chest pain were followed-up five years later. At the time of the original admission, all of the patients received a detailed physical and psychiatric evaluation. Seventy-one patients were diagnosed as having ischaemic heart disease, and 19 were diagnosed as having nonspecific chest pain. Patients with nonspecific pain were younger, consumed greater amounts of alcohol, smoked more than their organic counterparts, and were more likely to suffer from psychiatric disorder. The five-year assessment was carried out using a self-report questionnaire. Of the original 71 patients with ischaemic heart disease, 14 had died; 43 questionnaires were returned, 80.2% of the original sample. Sixteen (84.9%) of the patients with nonspecific pain were followed up; none had died. Both groups were predominantly male. The patients with nonspecific pain still smoked more than the patients with ischaemic heart disease, and they had significantly more symptoms of anxiety. The overall prevalence of psychiatric morbidity remained high, however, in both groups. Patients who had psychiatric illness at the time of the original assessment were more anxious at follow-up and more likely to complain of chest pain than those who had been well. Patients with nonspecific chest pain continued to seek treatment on a regular basis from their general practitioners either for chest pain or for other symptoms, but few were in frequent contact with hospital services. The possible preventive effects of psychiatric intervention at an earlier stage in both groups of patients needs to be investigated.

Early programmes of high and low intensity exercise and quality of life after acute myocardial infarction

OBJECTIVE

To determine whether a group programme of light exercise could improve quality of life in patients after acute myocardial infarction to the same extent as a high intensity exercise training programme.

SETTING

Australian teaching hospital.

PATIENTS

224 men from a consecutive series of 339 men under 70 admitted to a coronary care unit with transmural acute myocardial infarction.

INTERVENTION

Patients were randomly allocated in hospital to a group programme lasting eight weeks of either high intensity exercise training or light exercise.

MAIN OUTCOME MEASURES

Physical working capacity based on metabolic equivalents achieved from treadmill exercise tests at entry, after 11 weeks, and after one year. Quality of life based on self report scores of anxiety, depression, denial, and wellbeing and interview assessments of activities and psychosocial adjustment at entry, after four months, and after one year.

RESULTS

The two groups were well matched at entry. At 11 weeks the mean results of treadmill testing were 10.7 (95% confidence interval 10.20 to 11.20) metabolic equivalents for exercise training and 9.7 (9.26 to 10.14) for light exercise (t = 2.85, df = 181, p = 0.005). Apart from this small temporary benefit in mean physical working capacity, there were no significant differences between groups. Improvement in occupational adjustment score from baseline to four months was greater after exercise training than after light exercise, but at one year repeated measures analysis of variance showed no significant effects of treatment or interaction between treatment and time point.

CONCLUSION

The effects on quality of life of a low cost programme of light exercise are similar to those obtained from a high intensity exercise training programme.

Association between physical and psychological morbidity in the Whitehall II Study

Mechanisms for the association between psychiatric disorder measured by the General Health Questionnaire and subjective and objective indices of physical illness are examined among 6900 male and 3414 female civil servants aged between 35 and 55 yr from the cross-sectional results of the Whitehall II Study. It was hypothesized that the association between physical illness and psychiatric disorder might be because psychiatric disorder was either secondary to the pain and disability of physical illness, or related to the somatic presentation of psychiatric disorder, or to common causes of both physical and psychiatric illness. Overall health status, and self-reported physical symptoms were strongly associated with psychiatric disorder. Angina in men and severe chest pain in men and women were significantly associated with psychiatric disorder, but electrocardiographic abnormalities were not. Established risk factors for physical illness: alcohol intake in women and men and smoking habit in men were related to psychiatric disorder. Fibrinogen was related to self reported physical symptoms but not psychiatric disorder. The association between psychiatric disorder and self-reported physical symptoms is most likely explained by somatisation and plaintive set. However, psychiatric disorder is likely to be secondary to the pain and disability of conditions such as angina.

A population survey of ischaemic heart disease and minor psychiatric disorder in men

Associations between ischaemic heart disease and psychiatric morbidity in hospital recruited samples may be confounded by differential referral of patients with co-morbidity. Associations of angina, past history of myocardial infarction, blood pressure, and electrocardiographic evidence of ischaemia with psychiatric disorder can best be examined in community samples as reported here in 2204 middle-aged men from the Caerphilly Collaborative Study. There was a strong association between past history of myocardial infarction, non-specific chest pain, Angina Grade II and psychiatric disorder measured by the 30-item General Health Questionnaire. Electrocardiographic evidence of ischaemia alone was not significantly associated with psychiatric disorder. It is suggested that non-specific chest pain is a symptom of psychiatric disorder; conversely in severe angina psychiatric disorder is secondary to the pain, restricted activity and threat to life which angina implies.

Psychosocial adjustment of patients arriving early at the emergency department after acute myocardial infarction

The psychosocial functioning of patients arriving at the emergency department with an acute myocardial infarction early enough to be candidates for treatment with thrombolytic agents was compared with that of those arriving later. Patients who arrived within 3 hours were significantly more anxious when assessed 1 week after admission and had a consistently worse pattern of psychosocial adjustment 3 months after hospital discharge than did those who arrived later. The implications of these findings for efforts to improve early arrival at the emergency department, as well as for medical and psychosocial outcomes after acute myocardial infarction, were considered.

Depression and acute myocardial infarction: a review and reinterpretation

Depression is widely accepted as occurring in response to acute myocardial infarction (AMI), and to be an important determinant of recovery. A review of the literature reveals that three categories of patients with depressive symptomatology may be identifiable. First, many patients show depressive symptoms before admission with AMI; these may intensify during hospitalisation. For these patients, the depressive symptoms may contribute etiologically to the onset of AMI or derive from a common source along with AMI. The second group constitute patients with a history of AMI, and who on readmission with chest pain or suspected AMI are more likely to report depressive symptoms. The third group of patients are non-depressed first time admissions for AMI. These patients appear to show transient depressive reactions, much of which it is argued, occurs as a reaction to hospitalisation and not to AMI per se. This review considers the theoretical context whereby depressive symptoms may arise from the same circumstances that generate the coronary heart disease which underlies AMI, and links this to the generation of helplessness and cardiopathic processes.

Myocardial infarction and patients' wives

When a patient has a myocardial infarction (MI), all aspects of marital function are affected. Soon after the MI, patients' wives experience psychological distress that decreases with time. Illness behaviors among the MI patients' wives increase, and aggressive and sexual impulses are often inhibited. Many families experience changes in members' work status after the husband has an MI, and wives are faced with increased chores. Marital interaction also changes. Dysfunctional marital relationships are associated with a poor psychosocial outcome. Additionally, spousal factors such as dependency are also likely to affect patients. Intervention strategies are best directed to wives at risk for problems.

Wives' responses to counselling early after myocardial infarction

Self-ratings of anxiety and depression were studied over six months in 60 wives of first time myocardial infarction patients. Couples were randomly assigned to either a treatment group, where they received a simple programme of education and psychological support in addition to routine care, or to a control group, where they received routine care only. All wives completed the Hospital Anxiety and Depression scale and a battery of visual analogue scales measuring anxiety on a range of topics related to recovery from a heart attack. Wives in the treatment group reported statistically significantly less anxiety than controls. This effect was sustained for six months after the counselling. It is concluded that a simple programme of in hospital counselling is efficacious and should be routinely offered to the wives of coronary patients.

A randomized controlled trial of in-hospital nursing support for first time myocardial infarction patients and their partners: effects on anxiety and depression

This study monitored and compared levels of anxiety and depression reported by first myocardial infarction (MI) male patients and their partners, throughout the patients' hospital stay. An independent variable of a programme of supportive-educative counselling provided by a coronary care nurse was introduced to determine whether it significantly affected reactions. Sixty couples were randomly assigned to one of two groups: (a) the treatment group (in which they received the systematic programme of nursing support in addition to routine care), or (b) the control group (in which they received routine care but no other intervention). Anxiety and depression were measured by the Hospital Anxiety and Depression (HAD) scale at 24 hours and 5 days after the patient's admission to hospital. At 5 days there were statistically significant differences between both groups with respect to the HAD scale mean scores. These findings strongly suggest that a simple programme of in-hospital couple counselling, provided by a coronary care nurse, statistically significantly reduces anxiety and depression in first MI male patients and anxiety in their partners.

Quality of life in postmyocardial infarction patients in relation to drug therapy

Quality of life (QL) was assessed in relation to drug therapy in 539 patients who were still alive five years after myocardial infarction (MI), and the interaction between drug therapy and QL was investigated. The patients originally participated in a double-blind trial that evaluated the effect of early administration of the beta blocker metoprolol. A cardiac follow-up questionnaire (CFQ) and the Nottingham Health Profile (NHP) were answered by 82%. In the CFQ, sel-fassessed cardiac symptoms, medication (diuretics, digitalis, antiarrhythmics, long-acting nitrates, beta blockers, psychoactive drugs), smoking habits, and work status were described. NHP described QL within the sections of mobility, energy, pain, sleep, emotional reactions, and social isolation. The independent relation between morbidity, drugs, and QL was analyzed multivariately. Apart from symptoms of angina pectoris and dyspnoea, anxiety resulted in impaired QL. A relation between diuretics and decreased QL was found, but no indications of adverse effects of the beta blocker metoprolol.

Support of wives of myocardial infarction patients

Seventy-six wives of patients suffering a first myocardial infarction were studied by questionnaire 6 weeks after their husbands went home. Despite the routine provision of support and information to spouses during their husband's stay in hospital, a high proportion reported physical and emotional symptoms of stress. The majority of wives felt they were poorly informed about myocardial infarction, had not had enough opportunity to ask the experts questions, and had received most support from relatives. The reasons for these findings are discussed and suggestions for early and systematic nursing intervention are made in an attempt to reduce stress and prevent the development of unhealthy patterns of behaviour.

Major depressive disorder in coronary artery disease

Depression has been reported to be common in patients with coronary artery disease (CAD), using a variety of criteria for the diagnosis of depression. However, many studies have relied solely on the presence of symptoms such as a dysphoric mood and fatigue in making a diagnosis of depression. Both fatigue and dysphoric mood are also associated with medical illnesses, and psychiatric diagnoses based on such nonspecific symptoms may lack the specificity necessary to predict the need for psychiatric treatment. To assess the incidence of depression likely to require and respond to psychiatric treatment, 50 patients documented to have CAD by coronary angiography underwent psychiatric diagnostic interviews. Current research-based criteria (DSM-III) were used to make diagnoses of major depressive disorder. In addition, the applicability of a brief screening inventory the (Beck depression inventory) for detecting the presence of depression in these patients was tested. Nine patients (18%) met criteria (DSM-III) for major depressive episode. Depression was not related to the extent of CAD, age or use of beta blockers. There was a relation between depression and smoking. Only 2 of the 9 depressed patients had been diagnosed previously and were being treated for depression. When a score of greater than or equal to 10 on the Beck depression inventory was used to distinguish patients with depression, it had moderate sensitivity (78%) and specificity (90%) for the identification of depression.

Psychological effects of stomas--II. Factors influencing outcome

Sixteen patients with a moderate or severe anxiety and/or depression one year after stoma surgery were compared with 52 patients who had made a good psychiatric adjustment. Factors that were associated with an increased risk of psychiatric morbidity included a previous psychiatric history, postoperative physical symptoms and complications, inadequate advice and personality traits of neuroticism, anxiety and obsessionality.

A randomized control trial of cardiac rehabilitation

A randomized trial using controls tested whether psycho-social rehabilitation of acute myocardial infarction (MI) patients would improve significantly their return to work rate and assessed the importance of various psychological, social, occupational, socio-demographic, and medical factors in facilitating or impeding rapid return to work. Eighty-nine patients were assigned randomly to participate in an experimental cardiac rehabilitation program (rehab care), and 91 patients were controls who received conventional hospital rehabilitation (usual care). By the first follow-up interview at three months, patients assigned to experimental treatment were significantly less distressed psychologically and less dependent on family support than controls (P = 0.04 and P = 0.05, respectively). By the final follow-up interview at 13 months, there was a marginally significant difference in favor of the experimental group in the frequency of reported deterrents to work resumption (P = 0.07). However, the intervention did not result in a statistically significant difference in the return to work rate (P greater than 0.10). In each group, 88% were back at work by approximately the first year after infarction. In addition, the two groups were similar in the amount of time patients remained out of the workforce (median days rehab care = 75, usual care = 81; P greater than 0.10). A multi-stage data analysis procedure utilizing the Cox regression technique indicated that while several independent variables had significant univariate associations with the length of time patients convalesced, outcome was most influenced by the patient's initial cardiological status and clinical course, by the patterns of family support, and by the several variables measuring the presence of obstacles to resuming work. Our findings suggest that rehabilitation programs intervening on multiple levels (psychological, social, occupational, and physical) may best meet the needs of chronically ill cardiac patients. Results indicate that implementing measures addressing the patient's general psycho-social adjustment to MI may improve existing programs.

Teaching and adaptation of patients with myocardial infarction

The role of teaching in facilitating adaptation were examined in 60 patients with myocardial infarction (MI) of working age (under 65 years). Recovery of three different patient groups were followed for one year at three times: at discharge and three months and one year after it. Data for evaluating the effects of the teaching program on the patients and their close relatives were collected by questionnaires from the patients at discharge and by interviewing the patients three months after discharge. Information on patients' recovery during the first year after MI was collected from patients' records. Impact of teaching was prominent on several outcome measures. Patients' knowledge of illness and care increased, they also perceived having received more information and support. The time devoted to exercise increased after myocardial infarction and amount of butter used on bread decreased in the follow-up state. No impact was observed on the outcome variables measuring patient's use of alcohol and smoking. Some of the impacts at the early stages of the convalescence were not lasting. After one year of MI patients had partly returned to their old life styles, for example some patients had resumed the smoking habit. Teaching of close relatives improved only slightly.

A programme for developing nurses' skills and nursing practice

In this paper we describe a programme for developing nursing care for patients with myocardial infarction (MI) and report some results of a study in which applicability and effectiveness of this programme were evaluated. To investigate how the programme influenced nursing practice, nurses' readiness (knowledge, skills, motivation, accountability) to provide care for MI patients was followed for 2 years. Data for the evaluation were collected by questionnaires from three categories of nurses, by analysing nursing documents before and 1 and 2 years after the programme started, and by keeping a continuous diary. This programme made an impact on many variables that measure changes in nursing practice and nurses' readiness to provide care. The implications of this programme for nursing practice, research, education and administration are discussed.

Coping with myocardial infarction: a model with clinical applications, a literature review

Following a myocardial infarction any residual symptoms are likely to remind the patient of a possible fatal outcome and be detrimental to successful rehabilitation. Negative psychological attitudes need to be identified early. Intervention to improve the mental state should be introduced to restore self-confidence.

The effects of education and group discussion in the post myocardial infarction patient

An education and group discussion program administered to a randomly selected group of post myocardial infarction subjects failed to produce any differences in a large number of behavioral and psychological measures. These included smoking behavior, health status, social and recreational status, family and marital life and vocational activities, as well as measures of anxiety, depression, and health locus of control. Treated subjects were slower to return to work than controls and were less likely to have returned to work by the end of the study. More individuals in the treatment group were receiving compensation and this may have been a factor in delaying return to work. Since the majority of our subjects had a very optimistic attitude toward their eventual recovery, there was limited room for improvement. We suggest that cardiac rehabilitation be directed only at those patients with "negative" attitudes, and with more than usual anxiety and depression.