Fatigue and heart disease. The association between 'vital exhaustion' and past, present and future coronary heart disease

Baseline Characteristics From a New Longitudinal Cohort of Patients With Noncancer Pain and Chronic Opioid Use in the United States

Retrospective cohort studies have consistently observed that long-term prescription opioid use is a risk factor for new major depressive episodes. However, prospective studies are needed to confirm these findings and establish evidence for causation. The Prescription Opioids and Depression Pathways cohort study is designed for this purpose. The present report describes the baseline sample and associations between participant characteristics and odds of daily versus nondaily opioid use. Second, we report associations between participant characteristics and odds of depression, dysthymia, anhedonia, and vital exhaustion. Patients with noncancer pain were eligible if they started a new period of prescription opioid use lasting 30 to 90 days. Participants were 54.8 (standard deviation ± 11.3) years of age, 57.3% female and 73% White race. Less than college education was more common among daily versus nondaily opioid users (32.4% vs 27.3%; P = .0008), as was back pain (64.2% vs 51.3%; P < .0001), any nonopioid substance use disorder (12.8% vs 4.8%; P < .0001), and current smoking (30.7% vs 18.4% P < .0001). High pain interference (50.9% vs 28.4%; P < .0001) was significantly associated with depression, as was having more pain sites (6.9 ± 3.6 vs 5.7 ± 3.6; P < .0001), and benzodiazepine comedication (38.2% vs 23.4%; P < .0001). High pain interference was significantly more common among those with anhedonia (46.8% vs 27.4%; P < .0001), and more pain sites (7.0 ± 3.7 vs 5.6 ± 3.6; P < .0001) were associated with anhedonia. Having more pain sites (7.9 ± 3.6 vs 5.5 ± 3.50; P < .0001) was associated with vital exhaustion, as was back pain (71.9% vs 56.8%; P = .0001) and benzodiazepine comedication (42.8% vs 22.8%; P < .0001). Patients using prescription opioids for noncancer pain have complex pain, psychiatric, and substance use disorder comorbidities. Longitudinal data will reveal whether long-term opioid therapy leads to depression or other mood disturbances such as anhedonia and vital exhaustion. PERSPECTIVE: This study reports baseline characteristics of a new prospective, noncancer pain cohort study. Risk factors for adverse opioid outcomes were most common in those with depression and vital exhaustion and less common in dysthymia and anhedonia. Baseline data highlight the complexity of patients receiving long-term opioid therapy for noncancer pain.

Characteristics of patients with non-cancer pain and long-term prescription opioid use who have used medical versus recreational marijuana

OBJECTIVE

Marijuana use is increasingly common among patients with chronic non-cancer pain (CNCP) and long-term opioid therapy (LTOT). We determined if lifetime recreational and medical marijuana use were associated with more frequent and higher dose prescription opioid use.

DESIGN

Cross-sectional SUBJECTS: Eligible patients (n=1,037), who had a new period of prescription opioid use lasting 30-90 days, were recruited from two midwestern health care systems to a study of long-term prescription opioid use and mental health outcomes. The present cross-sectional analyses uses baseline data from this on-going cohort study.

METHODS

Primary exposures were participant reported lifetime recreational and medical marijuana use versus no lifetime marijuana use. Prescription opioid characteristics included daily versus non-daily opioid use and ≥50 morphine milligram equivalent (MME) dose per day vs. <50 MME. Multivariate, logistic regression models estimated the association between lifetime recreational and medical marijuana use vs. no use and odds of daily and higher dose prescription opioid use, before and after adjusting for confounding.

RESULTS

The sample was an average of 54.9 (SD±11.3) years of age, 57.3% identified as female gender, 75.2% identified as White, and 22.5% identified as Black race. Among all participants, 44.4% were never marijuana users, 21.3% were recreational only, 7.7% medical only and 26.6% were both recreational and medical marijuana users. After controlling for all confounders, lifetime recreational marijuana use, as compared to no use, was significantly associated with increased odds of daily prescription opioid use (OR=1.61; 95%CI:1.02-2.54). There was no association between lifetime recreational or medical marijuana use and daily opioid dose.

CONCLUSION

Lifetime medical marijuana use is not linked to current opioid dose, but lifetime recreational use is associated with more than a 60% odds of being a daily prescription opioid user. Screening for lifetime recreational marijuana use may identify patients with chronic pain who are vulnerable to daily opioid use which increases risk for adverse opioid outcomes. Prospective data is needed to determine how marijuana use influences the course of LTOT and vice versa.

Teachers' perception of aggressive student behavior through the lens of chronic worry and resignation, and its association with psychophysiological stress: An observational study

Aggressive student behavior is considered a leading risk factor for teacher stress. However, teachers' coping styles may affect how they perceive and respond to aggressive student behavior. This study tests whether teachers' perceptions of aggressive student behavior mainly mirror objectively observed aggression in presence of the teacher (as coded by external observers) or whether teachers' perception of aggressive student behavior primarily reflects teachers' avoidant coping styles, such as chronic worry and resignation. Finally, we examine whether observed and teacher-perceived aggression relates to increased vital exhaustion and psychophysiological stress among teachers (i.e., higher hair cortisol concentration). In an ambulatory assessment study, we administered self-reports to 42 Swiss teachers to assess perceived student aggression, chronic worry, resignation, and vital exhaustion. Additionally, four consecutive lessons per teacher were filmed, and aggressive student behavior in presence of the teacher was coded by four trained external observers. The concentration of cortisol was assessed in hair samples. Results showed that teacher-perceived and observed aggression were moderately associated. Observed aggression was related to teacher perceptions to a much lesser extent than teachers' avoidant coping styles, that is, chronic worry and resignation. While teacher-perceived student aggression was associated with teachers' self-reported vital exhaustion, we did not find any significant association with hair-cortisol concentration. Our findings suggest that teachers perceive student aggression through the lens of their coping styles. Teachers' dysfunctional coping styles are associated with an overestimation of student aggression. Teachers' overestimation of student aggression relates to higher levels of vital exhaustion. Therefore, it is crucial to identify and change teachers' dysfunctional coping styles to prevent a vicious cycle of dysfunctional teacher-student interactions.

Physiological and psychological effects of a 12-week home-based telemonitored training in metabolic syndrome

Background

Metabolic Syndrome (MetS) increases the risk of cardiovascular diseases (CVD) and affects around one fourth of the population worldwide. In the prevention and treatment regular exercise trainings are inevitable. Providing personal supervision in out/inpatient care settings for such a large target population challenges the healthcare systems, but using telemonitoring of the home-performed trainings could be a promising and widely available option.

Objectives

The aim of this study was to evaluate the physiological and psychological effects of a 12-week home-based physical training program, telemonitored by widely available fitness devices on parameters of MetS patients.

Methods

A total of 55 MetS patients (mean age 49.19 ± 7.93 years) were involved in the study. They were asked to perform 3-5 sessions of exercise activity (min. 150 min) each week for 12 weeks. Trainings were monitored off-line by heart rate sensors, a fitness application and a cloud-based data transfer system. Physiotherapists supervised, coached, and feedback the trainings through an online coach system. We investigated different anthropometric parameters, maximum exercise and functional capacity levels, laboratory parameters, the level of depression, insomnia, vital exhaustion, and wellbeing as well.

Results

The average weekly training time was 152.0 ± 116.2 min. Out of the 55 participants who completed the program, 22 patients (40%) performed the recommended 150 min or more weekly. Patients showed statistically significant changes in: all the measured waist and hip circumferences; 6-min walk distance (6MWD; from 539.69 ± 78.62 to 569.72 ± 79.96 m, p < 0.001); maximal exercise capacity (11.02 ± 2.6 to 12.14 ± 2 MET, p < 0.001), stress-electrocardiogram duration time (13.74 ± 3.29 to 15.66 ± 2.64 min, p < 0.001); body weight (98.72 ± 21.7 to 97.45 ± 21.76 kg, p = 0.004); high-density lipoprotein cholesterol (n = 45, 1.28 ± 0.31 to 1.68 ± 0.36 mmol/L, p < 0.001); fasting plasma glucose (FPG; n = 47, 6.16 ± 1.26 to 5.44 ± 1.31 mmol/L, p = 0.001); glycated hemoglobin A1c (HbA1c; n = 41, 6.22 ± 0.68 to 5.87 ± 0.78%, p = 0.01). Out of the 55 patients who finished the program 38 patients (70%) completed all the psychological questionnaires. We found statistically significant decrease of the overall scores of the Maastricht Vital Exhaustion Questionnaire, from 3.37 ± 2.97 points to 2.63 ± 2.70 points (p < 0.05) and a significant increase of the overall scores of the WHO Wellbeing Scale from 9.92 ± 2.59 points to 10.61 ± 2.76 points (p < 0.05). We have not found any statistically significant changes in the scores of the Beck Depression Inventory and the Athens Insomnia Scale.

Conclusion

A 12-week home-based telemonitored training supported by an affordable, commonly available device system produces positive, statistically significant changes in many core components in MetS patients. Telemonitoring is a cheap method for coaching and feeding back the home-based interventions.

Stress-Related Exhaustion, Polygenic Cognitive Potential, and Cognitive Test Performance - A General Population Study

Background

We investigated whether stress-related exhaustion (chronic or short-term, and co-occurring with depression or not) is related to cognitive performance and whether polygenic cognitive potential modifies these associations.

Methods

The participants were from the Young Finns Study (N = 541-1273). Stress-related exhaustion was assessed using the Maastricht Questionnaire, depressive symptoms with the Beck Depression Inventory, and cognitive performance with subtests of the Cambridge Neuropsychological Test Automated Battery, measuring visuospatial learning, reaction time, sustained attention, and executive function. Cognitive performance and depression were assessed in 2011, and exhaustion in 2001, 2007, and 2011. A polygenic score for cognitive potential was calculated based on a GWAS on intelligence.

Results

High stress-related exhaustion, especially chronic, was associated with slower reaction time. Only clinical levels of depression were related to slower reaction time. Polygenic cognitive potential did not modify these associations. There were no differences in cognitive performance between individuals with co-occurring exhaustion and depression vs. those with only either condition.

Conclusion

Stress-related exhaustion, especially if chronic, seems to relate to slower reactions. Co-occurring exhaustion and depression may not have additive effects on cognitive performance. High polygenic cognitive potential may not protect from or predispose to harmful effects of exhaustion or depression on reaction time.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10608-023-10354-z.

Association between workaholism, vital exhaustion, and hair cortisol concentrations among teachers: A longitudinal study testing the moderation effect of neuroticism

Introduction

Workaholism in teachers is characterized by the willingness to work until exhausted and may be associated with various adverse health outcomes as well as high economic costs. The present study examines the association between workaholism, vital exhaustion (VE), and hair cortisol concentration (HCC) as indicators of chronic stress. In addition, this study explores the moderating role of the personality trait neuroticism on the relationship between workaholism and chronic stress indicators, i.e., VE and HCC.

Methods

Forty-two Swiss teachers (28 females; M _age = 39.66, SD = 11.99) completed questionnaires assessing VE (Maastricht Vital Exhaustion Questionnaire), workaholism (Measure of Coping Capacity Questionnaire), and neuroticism (Big-Five Inventory). Together with VE, HCC was assessed twice, with a one year lag.

Results

Both workaholism and neuroticism were positively associated with VE at both time points but not with HCC. Moderation analyses revealed a positive relationship between workaholism and VE in teachers with high neuroticism, while no such association was observed in teachers with low neuroticism. No associations were found between self-reports and HCC.

Discussion

These findings emphasize the importance of considering individual characteristics when investigating VE. Further research is necessary to investigate the applicability of HCC as a biomarker of chronic stress in the context of work.

Longitudinal Associations Between Core Self-Evaluation, Vital Exhaustion and Hair Cortisol in Teachers and the Mediating Effects of Resignation Tendency

Work-related stress appears to be especially high among teachers. However, most research on teacher stress relies exclusively on teachers' self-reports. Little is known about the physiological correlates of affective stress in teachers. This longitudinal study investigates the relationship between core self-evaluation and adverse psychological and physiological stress outcomes in 42 teachers. Self-report questionnaires were used to assess core self-evaluation, vital exhaustion, and resignation tendency. The concentration of cortisol was assessed using hair samples. One year after the initial measurement, vital exhaustion and hair cortisol were assessed again. Path-analytic mediational models showed that core self-evaluation strongly predicted vital exhaustion, and resignation tendency partially mediated this relationship. However, core self-evaluation did not predict hair cortisol concentration. These findings suggest that core self-evaluation plays a crucial role in preventing vital exhaustion among teachers. A positive core self-evaluation seems beneficial for teachers' primary and secondary appraisal and an essential resource for the long-term prevention of self-reported vital exhaustion.

Exploring High vs. Low Burnout amongst Public Sector Educators: COVID-19 Antecedents and Profiles

The COVID-19 pandemic has had a prolonged impact on many people working in different sectors. This paper focuses on the psychological stress consequences of professionals working in the educational sector in Andalucía (Spain). Using a sample of 340 educators, this empirical paper identifies the antecedents and profiles of those that ended up with burnout vs. those that were able to develop resilience. Results from OLS regressions show that regardless of the origins of stress, the principal determinant of burnout is clearly a lack of support and a perception of an inability to control a situation. Furthermore, results also show that working sources have a higher impact on the configuration of high burnout, while family sources harm those who are more resilient (low burnout).

Vital exhaustion in women with chest pain and no obstructive coronary artery disease: the iPOWER study

BACKGROUND

More than half of women with symptoms suggestive of myocardial ischaemia have no obstructive coronary artery disease (CAD), yet they face a higher risk of cardiovascular mortality and morbidity. Both vital exhaustion (VE) and depression have been linked to adverse cardiovascular prognosis in patients with CAD. We aimed to assess whether symptomatic women with no obstructive CAD are more vitally exhausted compared with asymptomatic women. Furthermore, we investigated the overlap between the constructs of VE and depression.

METHODS

Prevalence and burden of VE was assessed in symptomatic women with no obstructive CAD (n=1.266) and asymptomatic women (n=2.390). Among symptomatic women, we also assessed chest pain characteristics and symptoms of Hospital Anxiety and Depression Questionnaire.

FINDINGS

Median (IQR) VE score was 4 (1-9) and 2 (0-5) in symptomatic and asymptomatic women, respectively (age adjusted, p<0.001). The risk of severe VE was significantly higher in symptomatic women compared with asymptomatic women (OR 3.3, 95% CI 2.5 to 4.4), independent of age and risk factors, and was associated with symptom severity. VE and depression scores were correlated but principal component cluster analysis (PCCA) showed clear distinctiveness between the two constructs.

CONCLUSIONS

Women with chest pain and no obstructive CAD are more vitally exhausted compared with asymptomatic women. PCCA showed that VE is distinct from depression in symptomatic women.

CLINICAL IMPLICATIONS

Mental health screening focusing on depressive symptomatology in women with chest pain presenting with symptoms of mental and physical exhaustion may overlook VE in these patients.

Out of Chaos-Meaning Arises: The Lived Experience of Re-Habituating the Habitual Body When Suffering From Burnout

Sufferers from burnout might experience a sincere bonding to their lost lifeworld, which can result in their holding on to their previous worlds while simultaneously trying to unleash themselves. In this article, four experiential dimensions are presented in discussion with the phenomenological insights provided by Merleau-Ponty. These dimensions are "Trapped in the present body," "the balancing act," "precious moments of joy," and "this is my Lifeworld now." In the rehabilitation process, the participants demonstrated deliberate choices and reflective self-cultivation to adjust to their present situation. The illness seemed to promote a search for meaning-and out of the existential chaos, a "new" habitual body might appear. The study provides invaluable information about the rehabilitation process and the need for humanistic interventions.

Chronic Systemic Inflammation Is Associated With Symptoms of Late-Life Depression: The ARIC Study

OBJECTIVE

The current study examined how the pattern of systemic inflammation in the decades leading up to late-life relates to depression symptoms in older adults.

METHODS

Within the Atherosclerosis Risk in Communities Study, we measured high-sensitivity C-reactive protein (CRP), a nonspecific marker of systemic inflammation, at three visits: 21 years and 14 years before, and concurrent with the assessment of depression symptoms, defined using the 11-item Center for Epidemiologic Studies Depression (CESD) scale. We categorized participants into one of four groups based on their 21-year longitudinal pattern of elevated (≥3 mg/L) versus low (<3 mg/L) CRP (stable low; unstable low; unstable elevated; stable elevated). Analyses excluded participants with suspected depression during midlife.

RESULTS

A total of 4,614 participants were included (age at CESD assessment: 75.5 [SD: 5.1]; 59% female; follow-up time: 20.7 years [SD: 1.0]). Compared to participants who maintained low CRP levels (stable low), participants who had elevated CRP at two of three visits (unstable elevated; ß = 0.09; 95% confidence interval [CI]: 0.02, 0.17) and participants who maintained elevated CRP at all three visits (stable elevated; ß = 0.13; 95% CI: 0.05, 0.21) had greater depression symptoms as older adults, after adjusting for confounders. After excluding participants with late-life cognitive impairment, only participants with stable elevated CRP demonstrated significantly greater late-life depression symptoms. In a secondary analysis, stable elevated CRP was associated with increased risk for clinically significant late-life depression symptoms.

CONCLUSION

Chronic or repeated inflammation in the decades leading up to older adulthood is associated with late-life depression, even in the context of normal cognition.

Kriteriumsbezogene Cut-Off-Werte für Tätigkeitsspielraum und Arbeitsintensität

Zusammenfassung. Cut-Off-Werte ermöglichen eine ökonomische, binäre Beurteilung von Summenscores. Für Beanspruchungsfragebögen, die personenbezogene Merkmale erfragen, sind Cut-Off-Werte häufig vorhanden und in der klinischen Diagnostik unerlässlich. Für die Bewertung von Arbeitsmerkmalen sind Cut-Off-Werte ebenfalls wünschenswert. Bislang fehlen sie jedoch für die Beurteilung von Arbeitsmerkmalen wie Arbeitsintensität und Tätigkeitsspielraum. Zwischen 2006 und 2016 wurden daher in verschiedenen Branchen 801 objektive Arbeitsplatzanalysen durchgeführt, welche eine Unterteilung in gut und schlecht gestalteten Tätigkeitsspielraum sowie gut und schlecht gestaltete Arbeitsintensität nach DIN EN ISO 6385 (2016) ermöglichen. Anhand dieser Unterteilung wurden mit der Receiver-Operating-Characteristics-Analyse Cut-Off-Werte für den subjektiv-bedingungsbezogen Fragebogen zum Erleben von Arbeitsintensität und Tätigkeitsspielraum (FIT; Richter et al., 2000 ) ermittelt. Für den Tätigkeitsspielraum weisen Summenscores ≤ 22 und für die Arbeitsintensität Summenscores ≥ 15 auf eine schlechte Gestaltung des jeweiligen Arbeitsmerkmals hin. Anhand einer weiteren Stichprobe von 1 076 Arbeitenden konnte gezeigt werden, dass Arbeitende mit schlecht gestaltetem Tätigkeitspielraum vital erschöpfter sowie weniger engagiert sind und Arbeitende mit schlecht gestalteter Arbeitsintensität eine höhere Erholungsunfähigkeit sowie vitale Erschöpfung aufweisen.

Association of Antidepressant Medication Type With the Incidence of Cardiovascular Disease in the ARIC Study

Background

The association of antidepressant medication type with the risk of cardiovascular disease (CVD) is unclear. We hypothesized that selective serotonin reuptake inhibitors (SSRIs) are associated with lower risks of CVD events relative to tricyclics and other non‐SSRI antidepressants.

Methods and Results

We studied 2027 participants from the ARIC (Atherosclerosis Risk in Communities) study (mean age 63±10 years; 29% men; 78% white) treated with antidepressants at some time between 1987 and 2013. Antidepressant usage was confirmed by participants bringing pill bottles to study visits. CVD events in the study sample were identified, including atrial fibrillation, heart failure, myocardial infarction, and ischemic stroke. Hazard ratios were used to compare CVD events adjusted for sociodemographic and clinical risk factors in SSRIs users (47%) versus non‐SSRI users. Participants were followed from antidepressant initiation up to 2016 for a median of 13.5 years. We identified 332 atrial fibrillation, 365 heart failure, 174 myocardial infarction and 119 ischemic stroke events. CVD risk was similar for SSRIs and non‐SSRI antidepressant users (hazard ratio, 1.10; 95% CI, 0.86–1.41 for atrial fibrillation; hazard ratio, 0.98; 95% CI, 0.77–1.25 for heart failure; hazard ratio, 0.91; 95% CI, 0.64–1.29 for myocardial infarction; and hazard ratio, 1.07; 95% CI, 0.70–1.63 for ischemic stroke).

Conclusions

SSRI use was not associated with reduced risk of incident CVD compared with non‐SSRI antidepressant use. These results do not provide evidence supporting the use of SSRIs compared with tricyclics and other non‐SSRI antidepressants in relation to CVD risk.

Do Implicit Motives Influence Perceived Chronic Stress and Vital Exhaustion?

Vital exhaustion (VE) results from the experience of chronic stress. However, research on stress types and their relation to VE is rare. Moreover, the role of implicit motives in these processes has not yet been investigated. Analysis included 101 vitally exhausted men aged 40-65 years. Participants provided self-report data on their experience of chronic stress and social support. Subtypes of work-related and social stress were positively associated with VE. Implicit affiliation and achievement motives were linked to social support and chronic stress, and indirectly to VE. Moreover, they moderated the relationship between stress and exhaustion. In conclusion, implicit motives are key factors in the stress process: They are involved in an individual's experience of stress and stress-related consequences for mental health.

Vital exhaustion and sudden cardiac death in the Atherosclerosis Risk in Communities Study

OBJECTIVE

Vital exhaustion (VE), a construct defined as lack of energy, increased fatigue and irritability, and feelings of demoralisation, has been associated with cardiovascular events. We sought to examine the relation between VE and sudden cardiac death (SCD) in the Atherosclerosis Risk in Communities (ARIC) Study.

METHODS

The ARIC Study is a predominately biracial cohort of men and women, aged 45-64 at baseline, initiated in 1987 through random sampling in four US communities. VE was measured using the Maastricht questionnaire between 1990 and 1992 among 13 923 individuals. Cox proportional hazards models were used to examine the hazard of out-of-hospital SCD across tertiles of VE scores.

RESULTS

Through 2012, 457 SCD cases, defined as a sudden pulseless condition presumed due to a ventricular tachyarrhythmia in a previously stable individual, were identified in ARIC by physician record review. Adjusting for age, sex and race/centre, participants in the highest VE tertile had an increased risk of SCD (HR 1.48, 95% CI 1.17 to 1.87), but these findings did not remain significant after adjustment for established cardiovascular disease risk factors (HR 0.94, 95% CI 0.73 to 1.20).

CONCLUSIONS

Among participants of the ARIC study, VE was not associated with an increased risk for SCD after adjustment for cardiovascular risk factors.

Does vital exhaustion increase the risk of type 2 diabetes? A prospective study

BACKGROUND

There is evidence that both stress and depression have a causal relationship with type 2 diabetes suggesting that vital exhaustion (VE) too could be a risk factor. The association between VE and type 2 diabetes has, however, not been investigated prospectively.

AIM

To prospectively investigate whether VE is associated with an increased risk of type 2 diabetes in a Danish population.

METHODS

A prospective cohort study based on the Copenhagen City Heart Study (1991-1993). The degree of VE was measured among 9075 participants without type 1 or 2 diabetes at baseline. To detect type 2 diabetes in the follow-up period, two different approaches were used: In the first substudy, type 2 diabetes was defined based on blood samples and questionnaires from a follow-up study in 2001-2003 (N=4708). The second substudy was register-based, and the study population was linked to the Danish Hospital Discharge Register to detect registrations with type 2 diabetes until 2014.

RESULTS

A high degree of VE was associated with an increased risk of developing type 2 diabetes in both substudies. In the first substudy, the OR for developing type 2 diabetes was 2.56 (95% CI, 1.53; 4,29, P<0,001) among the quartile of participants reporting the highest degree of VE. In the second substudy, the OR was 1.31 (95% CI, 0.99; 1.72, P=0.053) for this group.

CONCLUSION

The results indicate that VE may be a useful measure in clinical practice in order to discover individuals at risk of type 2 diabetes.

Vital Exhaustion and Coronary Heart Disease Risk: A Systematic Review and Meta-Analysis

OBJECTIVE

The construct of vital exhaustion has been identified as a potential independent psychological risk factor for incident and recurrent coronary heart disease (CHD). Despite several decades of research, no systematic review or meta-analysis has previously attempted to collate the empirical evidence in this field. The purpose of this study was to review and quantify the impact of vital exhaustion on the development and progression of CHD.

METHODS

Prospective and case-control studies reporting vital exhaustion at baseline and CHD outcomes at follow-up were derived from PubMed, PsycINFO (1980 to July 2015; articles in English and published articles only), and bibliographies. Information on aim, study design, sample size, inclusion and exclusion criteria, assessment methods of psychological risk factors, and results of crude and adjusted regression analyses were abstracted independently by two authors.

RESULTS

Thirteen prospective (n = 52,636) and three case-control (cases, n = 244; controls, n = 457) studies assessed vital exhaustion and could be summarized in meta-analyses. The pooled adjusted risk of CHD in healthy populations was 1.50 (95% confidence interval [CI] = 1.22-1.85) for prospective studies, and 2.61 (95% CI = 1.66-4.10) for case-control studies using hospital controls. Risk of recurrent events in patients with CHD was 2.03 (95% CI = 1.54-2.68). The pooled adjusted risk of chronic heart failure in healthy populations was 1.37 (95% CI = 1.21-1.56), but this was based on results from only two studies.

CONCLUSIONS

Vital exhaustion is associated with increased risk of incident and recurrent CHD.

Social gradient in the metabolic syndrome not explained by psychosocial and behavioural factors: evidence from the Copenhagen City Heart Study∗

BACKGROUND

Psychosocial stressors may mediate the effect of social status on the metabolic syndrome (MS). The paper explores this hypothesis in a random sample of the general population.

DESIGN

A total of 3462 women and 2576 men aged 20-97 years from the Copenhagen City Heart Study.

METHODS

An MS index was defined from the seven components: waist-hip ratio, high-density lipoprotein (HDL)-cholesterol, triglycerides, systolic blood pressure (SBP), blood glucose, C-reactive protein (CRP) and fibrinogen. Social status was measured by educational level. Psychosocial factors included fatigue and depression, perceived stress, social network and cohabitation. Behavioural factors were smoking, alcohol and physical activity.

RESULTS

There was an inverse social gradient in the prevalence of the seven components of the MS. The age-adjusted odds ratio (OR) (95% confidence interval) for occupying the most disadvantaged quintile, comparing highest with lowest educational level, were for men and women, respectively: waist-hip ratio 0.48 (0.34-0.69) and 0.48 (0.33-0.69); HDL-cholesterol 0.61 (0.45-0.84) and 0.46 (0.33-0.64); triglycerides 0.71 (0.51-0.98) and 0.37 (0.25-0.53); SBP 0.64 (0.44-0.92) and 0.76 (0.50-1.15); blood glucose 0.57 (0.41-0.80) and 0.55 (0.38-0.78); CRP 0.53 (0.37-0.74) and 0.44 (0.31-0.63), and fibrinogen 0.50 (0.35-0.70) and 0.56 (0.38-0.82). The pooled OR for having an MS index score of 3 or more was 0.32 (0.24-0.42) for highest versus lowest educational level. A higher fatigue and depression score in both sexes and a lack of social support in men were associated with the MS, as were smoking, low alcohol consumption and a lack of physical activity. However, OR for educational level were not affected by adjustment for the psychosocial or behavioural factors.

CONCLUSIONS

There is a strong inverse social gradient in the prevalence of the MS, which is not explained by psychosocial or major behavioural factors.

Childbearing History and Self-Reported Well-Being in Later Life

The authors examined how numbers of live births and pregnancy losses affected the self-rated health and depressive symptoms of women aged 50 years and older, contrasting African Americans and Whites. The authors used data from Atherosclerosis Risk in Communities, a large, prospective study with substantial minority representation. They tested hypotheses that childbearing-history variables would influence self-rated well-being among older women and that perceived social support would mediate the associations. The authors also tested whether these associations would be stronger among older African American versus White women. The results suggest that the impact of child-bearing history is greater among older African American than White women. Pregnancy loss worsened depressive symptoms and self-rated health among African American women; the effect was reduced by social-support variables. High parity was associated with worse self-rated health among African American women, mediated by social support. Having no live births was not associated with diminished well-being among older women of any race.

Denial of Depression as an Independent Correlate of Coronary Artery Disease

A number of psychosocial measures were tested as correlates of coronary artery disease (CAD) in 122 males with positive coronary angiograms and 56 males with no manifest history of atherosclerotic disease who were selected to approximate the patients' age and socio economic status. Only denial of depression as indexed by spouse/friend-minus-self scores on the Ketterer Stress Symptom Frequency Checklist and number of unprovoked nocturnal awakenings were independently and positively related to CAD severity in multivariate regression analyses which controlled for jointly associated cardiac risk factors and commonly used cardiovascular medications. Denial of depression and unprovoked nocturnal awakening appear to be independent correlates of coronary artery disease.

Women's exhaustion and coronary artery atherosclerosis progression: The Stockholm Female Coronary Angiography Study

OBJECTIVE

Vital exhaustion (VE) has been associated with incident and recurrent cardiac events. The present study investigated the impact of VE on coronary atherosclerosis progression for 3 years. We further aimed to detect the relative importance of the VE subcomponents, fatigue, and depressed mood.

METHODS

103 women (age range, 30-65 years) who had experienced an acute coronary event underwent quantitative coronary angiography at baseline and again after 3 years. VE and subcomponents were assessed using the Maastricht Questionnaire.

RESULTS

VE correlated significantly with coronary artery diameter change for 3 years (r = -0.239, p = .015). When analyzed in quartiles, women of the highest VE level showed the most pronounced coronary artery luminal diameter narrowing (mean = 0.21 mm, 95% confidence interval [CI] = 0.15-0.27), women in the third quartile were intermediate (mean = 0.11 mm, 95% CI = 0.05-0.17), and women within the two lower quartiles showed no significant change. High levels of the depressed mood and fatigue subscales were also associated with coronary artery diameter narrowing (mean = 0.19 mm, 95% CI = 0.12-0.26, p = .003; and mean = 0.17 mm, 95% CI = 0.08-0.26, p = .03, respectively). However, the associations were attenuated when both variables were entered into the model simultaneously: 0.17 mm (95% CI = 0.09-0.25, p = .05) and 0.14 mm (95% CI = 0.03-0.25, p = .67), respectively.

CONCLUSIONS

VE was associated with accelerated coronary atherosclerosis progression in relatively young women who had experienced an acute coronary event. This association was mainly driven by depressed mood.

Vital exhaustion and somatic depression: the same underlying construct in patients with myocardial infarction?

OBJECTIVE

To test whether vital exhaustion overlaps more with somatic/affective depression than with cognitive/affective depressive symptoms and evaluate the risk of recurrent cardiovascular events associated with these constructs.

METHODS

The Beck Depression Inventory (BDI) and the Maastricht Questionnaire (MQ) were administered to 528 patients hospitalized with myocardial infarction (MI). Principal component analyses (PCAs) were performed to assess the structure of the BDI, the MQ, and both combined. Univariate and multivariate (adjusting for age, sex, left ventricular ejection fraction, Killip Class, and history of MI) Cox proportional hazard regression analyses were used to examine the risk of recurrent cardiovascular events associated with the subscales of the MQ and of both questionnaires together.

RESULTS

PCA on the MQ yielded only one dimension. Per-standard-deviation increase in total MQ score, the multivariate hazard ratio was 1.37 (confidence interval [CI] = 1.15-1.64, p < .001). PCA on the items of MQ and BDI together yielded two dimensions: a somatic/affective and a cognitive/affective dimension. All but two of the items of the MQ loaded on the somatic/affective dimension. The multivariate hazard ratio for recurrent events associated with a 1-standard deviation increase in the somatic/affective dimension was 1.39 (CI = 1.11-1.73, p = .004), which was higher than the risk associated with the cognitive/affective dimension (1.02, CI = 0.82-1.27, p = .83).

CONCLUSIONS

Vital exhaustion and somatic/affective depression strongly overlap and may cover the same underlying construct that increased the risk of new cardiovascular events.

The predictive value of fatigue for nonfatal ischemic heart disease and all-cause mortality

OBJECTIVE

To investigate whether fatigue predicts nonfatal ischemic heart disease (IHD) and all-cause mortality in middle-aged men.

METHODS

The study population consisted of 5216 middle-aged men born in the Copenhagen metropolitan area in 1953. At baseline, men free of angina pectoris and previous IHD were asked if they felt fatigued. Information on IHD diagnosis and all-cause mortality was register based. The Cox proportional hazard model was used to test the association at 4-year follow-up.

RESULTS

Fatigue was associated with hospitalization for nonfatal IHD (hazard ratio [HR] = 1.98, 95% confidence interval [CI] = 1.09-3.61) and all-cause mortality (HR = 3.99, 95% CI = 2.27-7.02). These associations became nonsignificant in multivariable-adjusted models (HR = 1.57, 95% CI = 0.82-3.01 and HR = 1.90, 95% CI = 0.95-3.80). Imputation of missing data did not modify conclusions. Fatigue was a strong independent predictor of first hospitalization for nonfatal IHD among nonsmoking men (HR = 6.00, 95% CI = 2.00-18.04), and the fatigue-by-smoking status interaction was significant (p = .04). Findings should be interpreted with caution because of the small number of participants with IHD (n = 21, 1.5%). Compared to nonfatigued nonsmokers, both fatigued nonsmokers and fatigued smokers had higher hazard of dying (HR = 4.99, 95% CI = 1.31-19.09 and HR = 3.74, 95% CI = 1.32-10.57, respectively), although the fatigue-by-smoking status interaction was not significant (p = .12).

CONCLUSIONS

Fatigue is a potential risk indicator for IHD and mortality. Further research is needed to establish the role of smoking and other life-style characteristics.

[Depression. An underestimated risk for the development and progression of coronary heart disease]

The aim of this article is to provide an overview on depression as a risk factor for the onset and follow-up of cardiovascular disease (CVD). In brief, the current state of psychobiological mechanisms bridging the gap between affective states and somatic consequences are presented. Four meta-analyses dealing with depression as a CVD risk factor in apparently healthy populations with >100,000 participants included, extracted an adjusted effect estimator of 1.60-1.90. Depressed subjects present with an unhealthier lifestyle (nutrition, smoking, physical activity). Three major psychobiological pathways directly acting on the circulatory system are under discussion: (1) hyperregulation of the autonomic nervous system (e.g., increased mean heart rate, increased heart rate responses, impaired heart rate variability), (2) overshooting stress responses of the endocrine system with impaired feedback mechanisms (e.g., for cortisol release), and (3) the immune system with dysregulated release of acute phase proteins and proinflammatory cytokines, all involved in a bidirectional crosstalk with the patient's affective state and leading to platelet activation and flow mediated endothelial (dys-)function. Nonadherence and adverse side effects of medications also contribute to the lethal properties of depression in CVD.

Relationships among stress measures, risk factors, and inflammatory biomarkers in law enforcement officers

Law enforcement officers suffer higher morbidity and mortality rates from all causes than the general population. Cardiovascular disease (CVD) accounts for a significant portion of the excess illness, with a reported prevalence as high as 1.7 times that of the general population. To determine which occupational hazards cause this increased risk and morbidity, it is imperative to study law enforcement officers before they retire. The long-range goal of our research is to reduce the incidence of CVD-related illness and death among aging law enforcement officers. The purpose of the present study was to measure pro- and anti-atherogenic inflammatory markers in blood samples from law enforcement officers (n = 71) and determine what types of occupation-related stress correlate with differences in these markers. For each outcome variable of interest, we developed separate regression models. Two groups of potential predictors were examined for inclusion in the models. Selected measures of stress were examined for inclusion in the models, in addition to general covariates, such as gender, ethnicity, years in law enforcement, and body mass index. Our results revealed statistically significant relationships between several physiologic variables and measures of stress.

Patterns and predictors of recovery from exhaustion in older adults: the cardiovascular health study

OBJECTIVES

To estimate the likelihood of, and factors associated with, recovery from exhaustion in older adults.

DESIGN

Secondary analysis of a cohort study.

SETTING

Six annual examinations in four U.S. communities.

PARTICIPANTS

Four thousand five hundred eighty-four men and women aged 69 and older.

MEASUREMENTS

Exhaustion was considered present when a participant responded "a moderate amount" or "most of the time" to either of two questions: "How often have you had a hard time getting going?" and "How often does everything seem an effort?"

RESULTS

Of the 964 participants who originally reported exhaustion, 634 (65.8%) were exhaustion free at least once during follow-up. When data from all time points were considered, 48% of those who reported exhaustion were exhaustion free the following year. After adjustment for age, sex, race, education, and marital status, 1-year recovery was less likely in individuals with worse self-rated health and in those who were taking six or more medications or were obese, depressed, or had musculoskeletal pain or history of stroke. In proportional hazards models, the following risk factors were associated with more persistent exhaustion over 5 years: poor self-rated health, six or more medications, obesity, and depression. Recovery was not less likely in participants with a history of cancer or heart disease.

CONCLUSION

Exhaustion is common in old age but is dynamic, even in those with a history of cancer and congestive heart failure. Recovery is especially likely in seniors who have a positive perception of their overall health, take few medications, and are not obese or depressed. These findings support the notion that resiliency is associated with physical and psychological well-being.

Sex differences in the combined effect of chronic stress with impaired vascular endothelium functioning and the development of early atherosclerosis: the Cardiovascular Risk in Young Finns study

Background

The syndrome of vital exhaustion (VE), characterized by fatigue and irritability, may contribute to an increased risk of atherosclerosis. The aim of the study was to explore sex differences in the interactions of VE with endothelial dysfunction and VE with reduced carotid elasticity, the important contributors to the development of early atherosclerosis, on preclinical atherosclerosis.

Methods

The participants were 1002 women and 719 men aged 24-39 examined in the Cardiovascular Risk in Young Finns study. Vital exhaustion was measured using the Maastricht Questionnaire. Preclinical atherosclerosis was assessed by carotid intima-media thickness (IMT), endothelial function was measured by brachial flow-mediated dilatation (FMD), and arterial elasticity by carotid artery compliance (CAC) using ultrasound techniques.

Results

We found a significant CAC x VE interaction for IMT only for the men. Our results imply that high VE level significantly related to high IMT levels among the men with low CAC, but not among the women with low CAC or among the women or men with high CAC. No significant FMD x VE interactions for IMT for the women or men were found.

Conclusions

High VE may exert an effect on IMT for men with impaired arterial elasticity. The results suggest that high vitally exhausted men with reduced arterial elasticity are at increased risk of atherosclerosis in early life and imply men's decreased stress coping in relation to stressful psychological coronary risk factors.

Fatigue in older adults: an early indicator of the aging process?

The aim of this paper is to give an overview of research on fatigue in older adults, with a focus on fatigue as an early indicator of the aging process. Fatigue is a strong predictor of functional limitations, disability, mortality, and other adverse outcomes in young-old and old-old populations, between men and women, and in different geographic localities. Several biological, physiological and social explanations are proposed: fatigue may be seen not only as a self-reported indicator of frailty, defined as a physiologic state of increased vulnerability to stressors, which results from decreased physiologic reserves and even dysregulation of multiple physiologic systems, but also this state may be accelerated because of the cumulative impact of social, mental and biological factors throughout life.

Depression and related psychological factors in heart disease

In this article we review the role of depression and other related psychological factors in heart disease. The prevalence of heart disease in patients with depression is high, and epidemiological links between depression and heart disease are evident in studies of community samples, psychiatric patients, and heart disease patients. We also describe the links between heart disease and related psychological factors-including vital exhaustion, Type A behavior pattern, anger and hostility, and Type D personality-and summarize proposed mechanisms that may link negative affects with heart disease. Finally, we review treatment of depression in heart disease, including evidence from several large clinical trials.

The impact of Type D personality on health-related quality of life in tinnitus patients is mainly mediated by anxiety and depression

OBJECTIVE

To evaluate the impact of Type D personality on health-related quality of life (HRQoL) and self-reported tinnitus-related distress in chronic tinnitus patients and whether this relationship is mediated by indicators of psychological distress (i.e., vital exhaustion, anxiety, and depression).

MATERIALS AND METHODS

Using a cross-sectional study design, 265 consecutive tinnitus patients were asked to complete the Hospital Anxiety and Depression Scale, the Maastricht Questionnaire, the Type D Scale (DS14), the Short-Form Health Survey 36, and the Tinnitus Reaction Questionnaire.

RESULTS

The prevalence of Type D was 35.5%. Type D patients were significantly more anxious, depressed, and vitally exhausted, and experienced more impaired HRQoL and increased tinnitus-related distress compared with non-Type D patients. Structural equation modeling showed that Type D personality directly increased symptoms of depression and anxiety, but not vital exhaustion. Type D was also a direct predictor of poor mental and physical HRQoL and increased tinnitus-related distress, although this influence was mainly mediated by symptoms of depression and anxiety. Anxiety, depression, and vital exhaustion had a direct influence on HRQoL and self-reported tinnitus-related distress, with a higher impact on mental HRQoL (R2 = 0.74) compared with physical HRQoL (R2 = 0.33). Vital exhaustion was a predictor of HRQoL and self-reported tinnitus-related distress; however, its influence was moderated by enhanced levels of anxiety and depression.

CONCLUSION

Tinnitus patients with a Type D personality were more likely to be anxious and depressed and to experience poor HRQoL and increased self-reported tinnitus-related distress, with the impact of Type D mainly being mediated by symptoms of anxiety and depression, although Type D also exerted a direct influence on these outcomes. These findings underline that to reduce the impact of tinnitus on HRQoL and self-reported tinnitus-related distress, treatment should be directed toward reducing anxiety and depression, especially in patients with a Type D personality.

The personality trait of neuroticism is strongly associated with long-term morbidity in testicular cancer survivors

BACKGROUND

Neuroticism is a personality trait expressing nervousness and insecurity. Associations between neuroticism and morbidity in long-term cancer survivors have hardly been explored. The aim of this study was to explore associations between neuroticism and somatic and mental morbidity and lifestyle issues in long-term survivors of testicular cancer (TCSs).

MATERIAL AND METHODS

All Norwegian TCSs treated between 1980 and 1994 (n = 1 814) were invited to this cross-sectional study. Among them 1 428 (79% response rate) delivered valid data. Neuroticism was self-rated on an abridged version of the Eysenck Personality Inventory. Information was collected by mailed questionnaires. The associations of neuroticism and self-reported variables were tested with multivariate logistic regression analyses.

RESULTS

Neuroticism was significantly associated with presence of somatic complaints, reduced physical function, neurotoxic side-effects (tinnitus, hearing impairment, peripheral neuropathy, and Raynaud's Phenomenon), self-esteem, concerns about not being able to father children, sexual problems, hazardous alcohol use, daily use of medication, use of sedatives and hypnotics, recent visits to a general practitioner, and seeing a psychologist/ psychiatrist after ended cancer treatment. Poor self-rated health, higher number of negative life events, economical problems and problems getting loans granted showed significant associations with neuroticism.

DISCUSSION

Neuroticism in TCSs at long-term follow-up is significantly associated with somatic and mental morbidities, and several aspects of unhealthy lifestyle. High levels of neuroticism should be considered in TCSs expressing multiple complaints and concerns at follow-up consultations. Assessment of neuroticism may be clinically important in order to offer appropriate interventions to prevent and manage morbidity in TCSs.

Chronic stress and the development of early atherosclerosis: moderating effect of endothelial dysfunction and impaired arterial elasticity

This study aims to explore the interactive effect of vital exhaustion (VE) and endothelial dysfunction on preclinical atherosclerosis, assessed by carotid intima-media thickness (IMT). Furthermore, interaction between VE and carotid elasticity is examined. Participants were 1,596 young healthy adults from the Cardiovascular Risk in Young Finns study. Endothelial dysfunction was measured by brachial flow-mediated dilatation (FMD), and carotid elasticity by carotid artery compliance (CAC). Significant interactions between FMD and VE, and between CAC and VE, for IMT were found in participants with the very lowest FMD and CAC. Thus, VE may be harmful if the endothelium is not working properly.

Vitality and recurrent event risk in acute myocardial infarction survivors

Background

Low vitality, characterized by fatigue and lack of energy, is common among survivors of acute myocardial infarction (AMI) and has been shown to be associated with increased risk of primary and secondary cardiac events. The goal of this study was to determine whether an association between vitality and recurrent cardiac events (nonfatal MI, cardiac death) among acute MI survivors persists after controlling for possible physiological and psychological confounders.

Design and methods

Incident AMI survivors ( n = 1328) from Erie and Niagara (New York) county hospitals were enrolled and followed up to 9 years. Vitality was measured by the Short Form-36 on a 0–100 scale approximately 4 months post-AMI. Cox proportional hazards models were developed to assess the vitality-recurrent event association controlling for traditional cardiovascular disease risk factors, index MI severity, and psychological correlates of vitality.

Results

Low-vitality individuals at baseline were more likely females, of higher BMI, smoking, diabetic, less physically active, and to have worse depression scores. Vitality was not strongly associated with MI severity markers. Lower vitality scores were associated with increased risk of recurrent cardiac events: adjusted hazard ratios (95% CI) for vitality scores 51–79, 21–50, and ≤ 20 (compared with ≥ 80) were 1.2 (0.8, 1.8), 1.4 (0.9, 2.2), and 2.9 (1.5, 5.4), respectively ( Ptrend = 0.005).

Conclusion

Low vitality was associated with increased risk of recurrent cardiac events among AMI survivors after controlling for physiological and psychological confounders. Mechanistic links with vitality should be sought as interventional targets.

Vital exhaustion and retinal microvascular changes in cardiovascular disease: atherosclerosis risk in communities study

OBJECTIVE

To determine if vital exhaustion, a measure of negative emotion, is associated with microvascular changes in the retina. Negative psychological factors, such as depression, have been implicated in the development of cardiovascular disease. Whether this link is mediated by macrovascular or microvascular disease is unknown.

METHODS

We performed a population-based, cross-sectional study of 10,364 White and African Americans aged 48 to 73 years. Vital exhaustion scores were determined from the Maastricht questionnaire and categorized into quartiles. Retinopathy signs and retinal vascular caliber were graded from retinal photographs following standardized protocols.

RESULTS

After adjusting for age, gender, race, study center, education, smoking, blood pressure, diabetes, and other risk factors, higher vital exhaustion scores (highest versus lowest quartiles) were associated modestly with the presence of retinopathy (odds ratio [OR] = 1.27; 95% Confidence Interval [CI] = 1.01-1.59), particularly retinal hemorrhages (OR = 1.71; 95% CI = 1.20-2.44), and with generalized retinal venular widening (OR = 1.19; 95% CI = 1.03-1.38). Analyzing vital exhaustion as a continuous variable did not change the pattern of the associations.

CONCLUSIONS

Middle-aged people with vital exhaustion may be more likely to have retinopathy signs that have been identified as risk predictors of cardiovascular events. Further research is needed to explore the possible adverse effects of negative emotion on the microcirculation.

Effects of mindfulness-based stress reduction intervention on psychological well-being and quality of life: is increased mindfulness indeed the mechanism?

Background

Although several studies have reported positive effects of mindfulness-based stress reduction (MBSR) intervention on psychological well-being, it is not known whether these effects are attributable to a change in mindfulness.

Purpose

The aim of this study is to compare the effects of MBSR to a waiting-list control condition in a randomized controlled trial while examining potentially mediating effects of mindfulness.

Methods

Forty women and 20 men from the community with symptoms of distress (mean age 43.6 years, SD = 10.1) were randomized into a group receiving MBSR or a waiting-list control group. Before and after the intervention period, questionnaires were completed on psychological well-being, quality of life, and mindfulness.

Results

Repeated measures multiple analysis of variance (MANCOVAs) showed that, compared with the control group, the intervention resulted in significantly stronger reductions of perceived stress (p = 0.016) and vital exhaustion (p = 0.001) and stronger elevations of positive affect (p = 0.006), quality of life (p = .009), as well as mindfulness (p = 0.001). When mindfulness was included as a covariate in the MANCOVA, the group effects on perceived stress and quality of life were reduced to nonsignificance.

Conclusion

Increased mindfulness may, at least partially, mediate the positive effects of mindfulness-based stress reduction intervention.

Effects of a stress management program on vital exhaustion and depression in women with coronary heart disease: a randomized controlled intervention study

OBJECTIVES

Psychosocial factors, including depression and vital exhaustion (VE) are associated with adverse outcome in coronary heart disease (CHD). Women with CHD are poor responders to psychosocial treatment and knowledge regarding which treatment modality works in them is limited. This randomized controlled clinical study evaluated the effect of a 1-year stress management program, aimed at reducing symptoms of depression and VE in CHD women.

DESIGN

Patients were 247 women, < or =75 years, recruited consecutively after a cardiac event and randomly assigned to either stress management (20 2-h sessions) and medical care by a cardiologist, or to obtaining usual health care as controls. Measurements at; baseline (6-8 weeks after randomization), 10 weeks (after 10 intervention sessions), 1 year (end of intervention) and 1-2 years follow-up.

RESULTS

For VE, intention to treat analysis showed effects for time (P < 0.001) and time x treatment interaction (P = 0.005), reflecting that both groups improved over time, and that the decrease of VE was more pronounced in the intervention group. However, the level of VE was higher in the intervention group than amongst controls at baseline, 22.7 vs. 19.4 (P = 0.036) but it did not differ later. The change in depressive symptoms did not differ between the groups.

CONCLUSIONS

CHD women attending our program experienced a more pronounced decrease in VE than controls. However, as they had higher baseline levels, due to regression towards the mean we cannot attribute the decrease in VE to the intervention. Whether the program has long-term beneficial effects needs to be evaluated.