Associations of type-D personality and depression with somatic health in myocardial infarction patients

How is type D personality associated with the major psychological outcomes in noncardiac chest pain patients?

Noncardiac chest pain (NCCP) may lead many problems on the health-care system. Having type D personality has been shown to adversely affect NCCP patients. This study aimed to determine the psychological comorbidities that type D personality is associated with, in patients with NCCP. The participants of this cross-sectional study were 360 patients diagnosed with NCCP. Patients filled out questionnaires about sociodemographic, behavioral, and clinical factors (severity of pain, somatization, cardiac anxiety, fear of body sensations, depression, and type D personality). Type D personality was more prevalent among female (p < 0.005), and those people having this personality showed lower sleep quality (p = 0.001) and sexual life satisfaction (p < 0.001) and more likely to be smoker (p < 0.001). Type D personality is strongly associated with fear of body sensations (β = 5.92, SE = 1.95, p = 0.003), pain intensity (β = 3.53, SE = 0.98, p < 0.001), depression (β = 2.91, SE = 0.62, p < 0.001), and somatization (β = 1.75, SE = 0.55, p < 0.001). Type D personality and major psychological comorbidities were strongly associated. Physicians should consider that having type D personality can be linked to NCCP in an effort to help patients receive effective psychological consultations.

Prevalence and Correlates of Type D Personality among Survivors following Acute Myocardial Infarction in a Tertiary Care Center in South India

Background  Type D personality, described as a consistent tendency to experience increased levels of social inhibition and negative affectivity, has a robust association with negative outcomes following myocardial infarction (MI). However, little is known about its determinants in our setting. Our aim was to assess the prevalence and correlates of Type D personality among survivors following acute MI (AMI). Methods  Two hundred participants with AMI were recruited over an 18-month period. Type D scale-14 was used to evaluate the presence of Type D personality. Apart from sociodemographic factors, depression, anxiety, stress, coping, personality, quality of life, and perceived social support were assessed using standard measures. Results  Type D personality was present in 24% of samples ( n = 48). In multivariate Poisson regression analysis, younger age (prevalence ratio [PR]: 0.950, 95% confidence intervals [CIs]: 0.927-0.974), high depression (PR: 1.372, 95% CI: 1.216-1.548), and low family support (PR: 0.898, 95% CI: 0.849-0.949) emerged as independent predictors of Type D personality in participants with AMI. Conclusion  Type D personality is seen in a significant proportion of AMI, consistent with global literature. Our findings suggest that among Indian patients with AMI, the presence or absence of Type D personality may represent two distinct subpopulations.

Prevalence of mental disorders among depressed coronary patients with and without Type D personality. Results of the multi-center SPIRR-CAD trial

OBJECTIVE

Type D personality, as with formal mental disorders, is linked to increased mortality in coronary heart disease (CHD). Our aim was to determine the prevalence of mental disorders among depressed CHD patients with and without Type D personality.

METHODS

Depressive symptoms (HADS, HAM-D), Type D personality (DS-14) and mental disorders based on DSM-IV (SCID I and II) were assessed. Results were calculated by Kruskal-Wallis tests, Fisher's exact tests and logistic regression analyses.

RESULTS

570 CHD patients were included (age 59.2±9.5years; male 78.9%, HADS-D depression 10.4±2.5; HAM-D 11.3±6.6; Type D 60.1%). 84.8% of patients with Type D personality and 79.3% of non-Type D patients suffered from at least one mental disorder (p=0.092), while 41.8% of Type D positives and 27.8% of Type D negatives had at least two mental disorders (p=0.001). Patients with Type D personality significantly more often had social phobia [odds ratio (95% confidence interval): 3.79 (1.1 to 13.12); p=0.035], dysthymia [1.78 (1.12 to 2.84); p=0.015], compulsive [2.25 (1.04 to 4.86); p=0.038] or avoidant [8.95 (2.08 to 38.49); p=0.003] personality disorder.

CONCLUSIONS

Type D personality among depressed CHD patients is associated with more complex and enduring mental disorders. This implies higher treatment demands.

TRIAL REGISTRATION

ISRCTN 76240576; NCT00705965.

Effect of neuroticism on risk of cardiovascular disease in depressed persons - a Swedish population-based cohort study

BACKGROUND

The relationship between neuroticism, depression and cardiovascular disease (CVD) is complex and has so far not been studied in depth. The aim of this study was to determine if neuroticism is an effect-modifier in the association between depression and CVD. Data derived from a longitudinal cohort study on mental health, work and relations among adults (20-64 years), including 10,443 individuals. Depression was assessed using the Major Depression Inventory (MDI) and neuroticism by the Swedish Scale of Personality (SSP). Outcomes of cardiovascular disease were register-based from the National inpatient register.

RESULTS

Both depression (OR 1.9 (95%CI 1.4, 2.5)) and high levels of neuroticism (OR 1.2 (95%CI 1.1-1.3)) were associated with increased risk of CVD. The combined effect of depression and neuroticism on the risk of CVD revealed HRs ranging from 1.0 to 1.9 after adjusting for age and gender, socioeconomic position, prevalent hypertension and diabetes. Almost similar associations were seen after further adjustment for lifestyle factors.

CONCLUSION

Neuroticism increased the risk of CVD in depressed persons. We found synergistic interaction between neuroticism and depression status in predicting future risk of CVD.

Chronic Disease and Depression Among Hispanic Americans

Hispanic Americans are the fastest growing minority group in the United States. They face a distinct set of health challenges, resulting in persistent health disparities. Chronic disease self-management programs hold promise in addressing individual-level, behavioral risks factors, such as dietary habits and physical activity patterns. In light of the unique barriers Hispanic men face, including low participation in evidence-based health intervention research, this article argues for a gendered perspective when approaching Hispanic men’s physical and mental health needs. Through the analysis of data collected from male-only focus groups ( N = 3, n = 15) with Hispanic Americans in west central Florida, this study identified that masculine identity is influenced by chronic disease and comorbid depression status. Diagnosis with a chronic disease and/or depression is accompanied by lifestyle adaptations, activity restrictions, and changes in income and health care demands that can undermine traditional notions of Hispanic masculinity. Consequently, masculine identity is associated with self-management strategies in complex ways. Public health interventions aimed at addressing comorbid chronic disease and depression among Hispanic men must take into consideration the role of gender identity and relevant conceptualizations of masculinity in order to better serve this underserved and understudied population.

Inpatient and outpatient costs in patients with coronary artery disease and mental disorders: a systematic review

Background

To systematically review in- and outpatient costs in patients with coronary artery disease (CAD) and comorbid mental disorders.

Methods

A comprehensive database search was conducted for studies investigating persons with CAD and comorbid mental disorders (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS). All studies were included which allowed a comparison of in- and outpatient health care costs (assessed either monetarily or in terms of health care utilization) of CAD patients with comorbid mental disorders (mood, anxiety, alcohol, eating, somatoform and personality disorders) and those without. Random effects meta-analyses were conducted and results reported using forest plots.

Results

The literature search resulted in 7,275 potentially relevant studies, of which 52 met inclusion criteria. Hospital readmission rates were increased in CAD patients with any mental disorder (pooled standardized mean difference (SMD) = 0.34 [0.17;0.51]). Results for depression, anxiety and posttraumatic stress disorder pointed in the same direction with heterogeneous SMDs on a primary study level ranging from −0.44 to 1.26. Length of hospital stay was not increased in anxiety and any mental disorder, while studies on depression reported heterogeneous SMDs ranging from −0.08 to 0.82. Most studies reported increased overall and outpatient costs for patients with comorbid mental disorders. Results for invasive procedures were non-significant respectively inconclusive.

Conclusions

Comorbid mental disorders in CAD patients are associated with an increased healthcare utilization in terms of higher hospital readmission rates and increased overall and outpatient health care costs. From a health care point of view, it is requisite to improve the diagnosis and treatment of comorbid mental disorders in patients with CAD to minimize incremental costs.

Decreased physical effort, fatigue, and mental distress in patients with coronary artery disease: importance of personality-related differences

BACKGROUND

Identification of cardio-toxic psychological symptoms in coronary artery disease (CAD) patients is important.

PURPOSE

We examined the association of negative affectivity (NA), social inhibition (SI), and their combination in the distressed (Type D) personality with functional status, fatigue, and mental distress in CAD patients.

METHOD

Following acute coronary syndrome, 690 consecutive CAD patients agreed to participate in this cross-sectional study and were evaluated for clinical characteristics, including left ventricular ejection fraction (LVEF), and for NA, SI, and Type D personality (i.e., NA and SI; DS14 scale) when they entered a cardiac rehabilitation program in Lithuania. Patient-centered outcomes included functional status (bicycle ergometer), symptoms of fatigue (Multidimensional Fatigue Inventory-20), and mental distress (Beck Depression Inventory-II and Hospital Anxiety and Depression Scale).

RESULTS

The reference subgroup (neither NA nor SI) included 34 % of patients; 13 % had NA only, 19 % had SI only, and 34 % had Type D profile. Type D patients had worse functional status, and Type D patients and NA-only patients had higher symptom levels of fatigue and mental distress. In multivariate regression models that included LVEF, clinical characteristics, and depressive symptoms, Type D personality was an independent predictor of decreased exercise capacity (OR = 1.77, 95 % CI 1.06-2.95, p = .03) and decreased motivation for activity (OR = 3.14, 95 % CI 1.73-5.73, p < .001). Type D, NA, and SI were also independent predictors of mental distress.

CONCLUSIONS

Type D personality traits independently predicted poor functional status and worse patient-centered outcomes independently from LVEF and depression. Further studies exploring personality-related differences in cardiovascular outcomes are needed.

Association of psychiatric history and type D personality with symptoms of anxiety, depression, and health status prior to ICD implantation

BACKGROUND

Personality factors and psychiatric history may help explain individual differences in risk of psychological morbidity and poor health outcomes in patients with an implantable cardioverter defibrillator (ICD).

PURPOSE

We examined associations between previous anxiety and depressive disorder, type D personality, anxiety or depressive symptoms, and health status in ICD patients prior to ICD implantation.

METHOD

Patients (N = 278; 83 % men; mean age = 62.2 years ±11) receiving a first ICD from September 2007 through April 2010 at the Medisch Spectrum Twente, The Netherlands completed validated questionnaires before implantation assessing type D personality (14-item Type D Scale), anxiety and depressive symptoms (Hospital Anxiety and Depression Scale), and health status (36-item Short Form Health Survey). History of anxiety or depressive disorder was assessed with the Mini International Neuropsychiatric Interview structural interview.

RESULTS

Previous anxiety or depressive disorder was prevalent in 8 and 19 % of patients, respectively. Type D personality was present in 21 %, depressive symptoms in 15 %, and anxiety in 24 %. In adjusted analyses, type D personality was a dominant correlate of previous depressive disorder (odds ratio (OR) 6.2, p < 0.001) and previous anxiety disorder (OR 3.9, p = 0.004). Type D personality (OR 4.0, p < 0.001), age (OR 1.03, p = 0.043), and gender (OR 2.5, p = 0.013) were associated with anxiety symptoms at baseline. Type D personality (OR 5.9. p < 0.001) was also associated with increased depressive symptoms at baseline. Heart failure and type D personality were related to poorer health status.

CONCLUSION

In ICD patients, prior to ICD implantation, a previous anxiety or depressive disorder, type D personality, and anxiety and depressive symptoms were associated with poorer health status. Type D personality was also independently associated with increased anxiety and depression symptoms.

Type D personality in never-depressed patients and the development of major and minor depression after acute coronary syndrome

BACKGROUND

Type D personality (TDP) has been proposed as a risk factor for the development of depressive symptoms after an acute coronary syndrome (ACS). However, contrasting findings emerged about its predicting power on the onset of depression, since an overlap between TDP and depressive symptoms has been proposed. The present study was aimed to verify whether TDP predicts the development of a depressive disorder in the 6 months after the discharge from hospital.

METHODS

Two hundred fifty consecutive patients were recruited, at the Coronary Intensive Care Unit at the University Hospital of Parma, who were both presenting their first ACS and had no history of depression. The presence and the severity of major (MD) and minor (md) depression were evaluated with the Primary Care Evaluation of Mental Disorders (PRIME-MD) and the Hospital Anxiety and Depression Scale (HADS) respectively. Type D Personality was assessed with the DS14, both at baseline and at 1, 2, 4 and 6 month follow ups.

RESULTS

Out of 250 subjects (81.2% males), MD was diagnosed in 12 patients (4.8%) and md in 18 patients (7.2%). At baseline risk factors for a post-ACS depressive disorder were HADS depression scores, whereas TDP, or its subscales, did not showed any effect.

LIMITATION

The small amount of patients with incidence of depression, due to highly selective inclusion criteria, tempers the reliability of our results.

CONCLUSION

Our data suggests that TDP does not predict the development of depressive disorders in never-depressed patients at their first ACS, when the baseline depression severity was controlled.

The relationship between Type D personality, affective symptoms and hemoglobin levels in chronic heart failure

BACKGROUND

Anemia is associated with poor prognosis in heart failure (HF) patients. Contributors to the risk of anemia in HF include hemodilution, renal dysfunction and inflammation. Hemoglobin levels may also be negatively affected by alterations in stress regulatory systems. Therefore, psychological distress characterized by such alterations may adversely affect hemoglobin in HF. The association between hemoglobin and Type D personality and affective symptomatology in the context of HF is poorly understood.

AIM

To examine the relationship between Type D personality and affective symptomatology with hemoglobin levels at inclusion and 12-month follow-up, controlling for relevant clinical factors.

METHODS

Plasma levels of hemoglobin and creatinine were assessed in 264 HF patients at inclusion and at 12-month follow-up. Type D personality and affective symptomatology were assessed at inclusion.

RESULTS

At inclusion, hemoglobin levels were similar for Type D and non-Type D HF patients (p = .23), and were moderately associated with affective symptomatology (r = -.14, p = .02). Multivariable regression showed that Type D personality (β = -.15; p = .02), was independently associated with future hemoglobin levels, while controlling for renal dysfunction, gender, NYHA class, time since diagnosis, BMI, the use of angiotensin-related medication, and levels of affective symptomatology. Change in renal function was associated with Type D personality (β = .20) and hemoglobin at 12 months (β = -.25). Sobel mediation analysis showed significant partial mediation of the Type D - hemoglobin association by renal function deterioration (p = .01). Anemia prevalence increased over time, especially in Type D patients. Female gender, poorer baseline renal function, deterioration of renal function and a longer HF history predicted the observed increase in anemia prevalence over time, while higher baseline hemoglobin was protective.

CONCLUSION

Type D personality, but not affective symptomatology, was associated with reduced future hemoglobin levels, independent of clinical factors. The relation between Type D personality and future hemoglobin levels was mediated by renal function deterioration.

Type D (distressed) personality and its assessment with the DS14 in Lithuanian patients with coronary artery disease

We examined Type D personality (combination of negative affectivity with social inhibition) and its assessment with the DS14 in 543 Lithuanian coronary patients. Psychometric analyses confirmed the two-factor structure, internal consistency (α = 0.84/α = 0.75), and test-retest reliability (r = 0.69/0.81) of the DS14 negative affectivity and inhibition components. Negative affectivity correlated (r = -0.58) with emotional stability and social inhibition (r = -0.46) with extraversion; correlations with other Big-Five traits ranged between r = -0.11 and -0.19. Type D patients (34%) had a ninefold increased odds of depression (95% confidence interval = 5.01-17.36) and a fivefold increased odds of anxiety (95% confidence interval = 3.47-7.97). These findings support the validity of the Type D construct in Lithuania.

Somatic depression predicts mortality in chronic heart failure: can this be explained by covarying symptoms of fatigue?

OBJECTIVE

Somatic symptoms of depression predict mortality in chronic heart failure (CHF), but symptoms of fatigue that are common to both conditions may confound this association. We therefore examined the contribution of fatigue to the association between somatic depression and increased risk of mortality in patients with CHF.

METHODS

At baseline, 380 consecutive patients with CHF were assessed for symptoms of depression, exertion fatigue, and general fatigue. Demographic and clinical data were obtained from the patients' medical records or the treating cardiologist. The primary end point was mortality after a median follow-up of 2.3 years (range = 0.15-4.76 years).

RESULTS

At follow-up, 63 patients (16.6%) had died. Exertion fatigue (hazard ratio [HR] = 1.04, 95% confidence interval [CI] = 1.01-1.06, p = .003), not general fatigue, was associated with an increased risk of mortality in CHF. Multivariate Cox regression analysis revealed that somatic symptoms of depression (HR = 1.41, 95% CI = 1.05-1.88, p = .02) were independently associated with increased mortality risk and that this association could not be explained by exertion fatigue (HR = 1.02, 95% CI = 0.97-1.05, p = .31).

CONCLUSIONS

The adverse effect of somatic depression on prognosis in CHF was not confounded by exertion fatigue. Behavioral interventions should focus not only on fatigue but also on other somatic manifestations of depression in patients with CHF.

Depression is independently associated with 7-year mortality in patients treated with percutaneous coronary intervention: results from the RESEARCH registry

BACKGROUND

Depression has been associated with poor prognosis in patients with coronary artery disease (CAD), but little is known about the impact of depression on long-term mortality. We examined whether depression was associated with 7-year mortality in patients treated with percutaneous coronary intervention (PCI), after adjusting for socio-demographic and clinical characteristics, anxiety, and the distressed (Type D) personality.

METHODS

The sample comprised a cohort of consecutive PCI patients (N=1234; 72.0% men; mean age 62.0 ± 11.1 years, range [26-90] years) from the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. At baseline (i.e., 6 months post-PCI), patients completed the Hospital Anxiety and Depression Scale (HADS) to assess anxiety and depression and the Type D scale (DS14) to assess Type D personality. The endpoint was defined as all-cause mortality.

RESULTS

The prevalence of depression (HADS-D ≥ 8) was 26.2% (324/1236). After a median follow-up of 7.0 ± 1.6 years, 187 deaths (15.2%) from any cause were recorded. The incidence of all-cause mortality in depressed patients was 23.5% (76/324) versus 12.2% (111/910) in non-depressed patients. Cumulative hazard functions differed significantly for depressed versus non-depressed patients (log-rank X(2)=25.57, p<.001). In multivariable analysis, depression remained independently associated with all-cause mortality (HR=1.63; 95% CI [1.05-2.71], p=.038), after adjusting for socio-demographic and clinical characteristics, anxiety, and Type D personality.

CONCLUSIONS

Depression was independently associated with a 1.6-fold increased risk for 7-year mortality, above and beyond anxiety and Type D personality. Future studies are warranted to further elucidate the potential pathways linking depression to long-term mortality following PCI.

Multi-method analysis of the internal structure of the Type D Scale-14 (DS14)

OBJECTIVE

The Type D Scale-14 (DS14) measures distressed (also, Type D) personality by assessing the medium-level trait negative affectivity that encompasses the low-level traits dysphoria, anxiety, and irritability, and the medium-level trait social inhibition that encompasses the low-level traits social discomfort, reticence, and lack of social poise. The literature discusses three different structural models of the DS14. The goal of this study was to investigate which of the three models best describes the internal structure of the DS14.

METHOD

We used three methods to investigate the internal structure of the DS14 items using data collected in representative samples from the Dutch general population (N=3,181). The methods were exploratory factor analysis, confirmatory factor analysis, and Mokken scale analysis.

RESULTS

Exploratory factor analysis suggested a two-factor structure without evidence of the low-level factors, and the other two methods showed evidence of a three-level structure including the low-level factors.

CONCLUSIONS

A two-factor model with correlated errors for items defining low-level traits adequately describes the data. The results support the three-level hierarchical model as a conceptual model for Type D personality, and support the interpretation of DS14 scores on item subsets representing medium-level traits and low-level traits.

Coping mediates the association between Type D personality and perceived health in Chinese patients with coronary heart disease

BACKGROUND

Increasing evidence show that Type D personality is a risk factor for morbidity, mortality, and quality of life of patients with coronary vascular disease. Few studies examined coping as a potential behavioral mechanism to explain the harmful effect of Type D personality.

PURPOSE

This study examined the association between Type D personality, coping, and perceived health among Chinese patients with coronary heart disease (CHD).

METHODS

One hundred seventeen CHD patients completed the assessments on Type D personality, coping, perceived severity of CHD, and morale.

RESULTS

There was no difference on severity of coronary artery stenosis between Type D and non-Type D patients. Compared to the non-Type D patients, the Type D patients perceived higher severity of CHD (5.31 ± 2.41 versus 4.45 ± 2.17, p < 0.05) and lower morale (12.67 ± 4.71 versus 15.00 ± 4.43, p < 0.05), and used less confrontation (16.90 ± 5.39 versus 20.88 ± 4.95, p < 0.001) and more acceptance-resignation coping (10.16 ± 3.50 versus 8.35 ± 3.48, p < 0.05). Mediation analyses showed that confrontation coping mediated the association between Type D personality and perceived severity of disease, and acceptance-resignation coping mediated the association between Type D personality and morale after controlling for age, gender, and clinical variables.

CONCLUSION

The Type D patients used maladaptive coping in response to disease. These coping strategies fully mediated the association between Type D personality and perceived health. Implications for integrating coping training into the intervention for patients with a Type D personality are discussed.

Type D personality and health status in cardiovascular disease populations: a meta-analysis of prospective studies

BACKGROUND

Knowledge of the factors associated with individual differences in patient-reported outcomes is essential to identify high-risk patients and improve secondary prevention.

DESIGN

In this meta-analysis, we examined the association between Type D personality and the individual differences in patient-reported physical and mental health status among cardiovascular patients.

METHODS

A computerized search of the literature through PUBMED and PsychINFO (from 1995 to May 2011) was performed and prospective studies were selected that analysed the association between Type D personality and health status in cardiovascular patients. Two separate meta-analyses were performed for the association of Type D personality with physical and mental health status, respectively.

RESULTS

Of all identified studies, ten studies met the selection criteria. The meta-analyses showed that Type D was associated with a two-fold increased odds for impaired physical health status (3035 patients, OR 1.94, 95% CI 1.49-2.52) and a 2.5-fold increased odds for impaired mental health status (2213 patients, OR 2.55, 95% CI 1.57-4.16). There was no significant heterogeneity between the studies on physical health status (Q = 12.78; p = 0.17; I(2 )= 29.59), but there was between those on mental health status (Q = 21.91; p = 0.003; I(2 )= 68.04). Subgroup analyses showed that the association between Type D and mental health status decreased yet remained significant when adjusting for baseline health status.

CONCLUSION

Type D personality was shown to be an independent correlate of impaired patient-reported physical and mental health status in various cardiovascular patient groups. Clinicians should be aware of the association between chronic psychological distress and poor patient-reported outcomes.

Validity of Type D personality in Iceland: association with disease severity and risk markers in cardiac patients

Type D personality has been associated with poor prognosis in cardiac patients. This study investigated the validity of the Type D construct in Iceland and its association with disease severity and health-related risk markers in cardiac patients. A sample of 1,452 cardiac patients completed the Type D scale (DS14), and a subgroup of 161 patients completed measurements for the five-factor model of personality, emotional control, anxiety, depression, stress and lifestyle factors. The Icelandic DS14 had good psychometric properties and its construct validity was confirmed. Prevalence of Type D was 26–29%, and assessment of Type D personality was not confounded by severity of underlying coronary artery disease. Regarding risk markers, Type D patients reported more psychopharmacological medication use and smoking, but frequency of previous mental problems was similar across groups. Type D is a valid personality construct in Iceland, and is associated with health-related risk markers, but not cardiac disease severity.

Testing the effectiveness of a mindfulness-based intervention to reduce emotional distress in outpatients with diabetes (DiaMind): design of a randomized controlled trial

BACKGROUND

Approximately 20-40% of outpatients with diabetes experience elevated levels of emotional distress, varying from disease-specific distress to general symptoms of anxiety and depression. The patient's emotional well-being is related to other unfavorable outcomes, like reduced quality of life, sub-optimal self-care, impaired glycemic control, higher risk of complications, and increased mortality rates. The purpose of this study is to test the effectiveness of a new diabetes-specific, mindfulness-based psychological intervention. First, with regard to reducing emotional distress; second, with respect to improving quality of life, dispositional mindfulness, and self-esteem of patients with diabetes; third, with regard to self-care and clinical outcomes; finally, a potential effect modification by clinical and personality characteristics will be explored.

METHODS/DESIGN

The Diabetes and Mindfulness study (DiaMind) is a randomized controlled trial. Patients with diabetes with low levels of emotional well-being will be recruited from outpatient diabetes clinics. Eligible patients will be randomized to an intervention group or a wait-list control group. The intervention group will receive the mindfulness program immediately, while the control group will receive the program eight months later. The primary outcome is emotional distress (anxiety, stress, depressive symptoms), for which data will be collected at baseline, four weeks, post intervention, and after six months follow-up. In addition, self-report data will be collected on quality of life, dispositional mindfulness, self-esteem, self-care, and personality, while complications and glycemic control will be assessed from medical files and blood pressure will be measured. Group differences will be analyzed with repeated measures analysis of covariance.The study is supported by grants from the Dutch Diabetes Research Foundation and Tilburg University and has been approved by a medical ethics committee.

DISCUSSION

It is hypothesized that emotional well-being, quality of life, dispositional mindfulness, self-esteem, self-care, and blood pressure will improve significantly more in the mindfulness group compared to the control group. Results of this study can contribute to a better care for patients with diabetes with lowered levels of emotional well-being. It is expected that the first results will become available in 2012.

TRIAL REGISTRATION

Dutch Trial Register NTR2145.

The possibility of evidence-based psychiatry: depression as a case

Considering psychiatry as a medical discipline, a diagnosis identifying a disorder should lead to an effective therapy. Such presumed causality is the basis of evidence-based psychiatry. We examined the strengths and weaknesses of research onto the causality of relationship between diagnosis and therapy of major depressive disorder and suggest what could be done to strengthen eventual claims on causality. Four obstacles for a rational evidence-based psychiatry were recognised. First, current classification systems are scientifically nonfalsifiable. Second, cerebral processes are—at least to some extent—nondeterministic, i.e. they are random, stochastic and/or chaotic. Third, the vague or lack of relationship between therapeutic regimens and suspected pathogenesis. Fourth, the inadequacy of tools to diagnose and delineate a functional disorder. We suggest a strategy to identify diagnostic prototypes that are characterised by a limited number of parameters (symptoms, markers and other characteristics). A prototypical diagnosis that may either support or reject particular elements of current diagnostic systems. Nevertheless, one faces the possibility that psychiatry will remain a relatively weak evidence-based medical discipline.

Is type-D a stable construct? An examination of type-D personality in patients before and after cardiac surgery

OBJECTIVE

Type-D personality-negative affectivity and social inhibition-are related to poor prognosis in cardiovascular diseases. At present, little is known about type-D personality and its stability before and after cardiac surgery.

METHODS

One hundred twenty-six patients recommended for coronary bypass and/or valve surgery were examined at pre-surgery and 6 months post-surgery to investigate the stability of type-D (14-item Type-D Scale) and its relationship to anxiety, depression (Hospital Anxiety and Depression Scale) and quality of life (Short Form 12).

RESULTS

Preoperatively, 26% were assessed to have type-D, while only 11% fulfilled type-D criteria both pre- and post-surgery. Patients were assessed and identified as belonging to one of the four type-D groups: Stable type-D (11%), non-type-D (61%), type-D pre (15%), and type-D post (13%). In comparison to the stable non-type D group, the stable type-D reported more symptoms of anxiety, depression, lower physical quality of life post-surgery, and lower mental quality of life both pre- and post-surgery. When compared to the population at large, stable type-D had more symptoms of depression pre-surgery, and more anxiety as well as lower physical and mental quality of life pre- and post-surgery.

CONCLUSION

Type-D diagnosis changed in nearly 60% of the cases post-surgery. Only those patients with stable type-D exhibited a relationship to emotional distress, such as anxiety and depression and reduced quality of life. Additional research on the critical cut-off scores and stability of type-D as it relates to critical life events would likely enhance our ability to more effectively diagnose and treat patients who are at high risk for insufficient coping.

Symptom dimensions of post-myocardial infarction depression, disease severity and cardiac prognosis

BACKGROUND

Individual symptoms of post-myocardial infarction (MI) depression may be differentially associated with cardiac prognosis, in which somatic/affective symptoms appear to be associated with a worse cardiovascular prognosis than cognitive/affective symptoms. These findings hold important implications for treatment but need to be replicated before conclusions regarding treatment can be drawn. We therefore examined the relationship between depressive symptom dimensions following MI and both disease severity and prospective cardiac prognosis.

METHOD

Patients (n=473) were assessed on demographic and clinical variables and completed the Beck Depression Inventory (BDI) within the first week of hospital admission for acute MI. Depressive symptom dimensions were associated with baseline left ventricular ejection fraction (LVEF) and prospective cardiac death and/or recurrent MI. The average follow-up period was 2.8 years.

RESULTS

Factor analysis revealed two symptom dimensions--somatic/affective and cognitive/affective--in the underlying structure of the BDI, identical to previous results. There were 49 events attributable to cardiac death (n=23) or recurrent MI (n=26). Somatic/affective (p=0.010) but not cognitive/affective (p=0.153) symptoms were associated with LVEF and cardiac death/recurrent MI. When controlling for the effects of previous MI and LVEF, somatic/affective symptoms remained significantly predictive of cardiac death/recurrent MI (hazard ratio 1.31, 95% confidence interval 1.02-1.69, p=0.038). Previous MI was also an independent predictor of cardiac death/recurrent MI.

CONCLUSIONS

We confirmed that somatic/affective, rather than cognitive/affective, symptoms of depression are associated with MI severity and cardiovascular prognosis. Interventions to improve cardiovascular prognosis by treating depression should be targeted at somatic aspects of depression.

Psychometric properties of the Type D scale (DS14) in Norwegian cardiac patients

The combination of negative affectivity (NA) and social inhibition (SI) - the Type D Personality - is associated with poor outcomes in coronary artery disease (CAD) patients. A Norwegian translation of the standard instrument measuring Type D (DS14) was tested on 432 CAD patients receiving coronary revascularization treatment. Factor analysis produced two factors with high inter-item reliability, indicating that the Norwegian DS14 has acceptable psychometric properties. Eighteen percent were classified as Type D, lower than has been reported elsewhere. Type D was associated with anxiety, depression, and passive coping. NA correlated positively with depression, anxiety, and passive coping. SI correlated positively with depression and anxiety, and negatively with active coping. The prevalence of Type D was higher among women, and negatively correlated with time since treatment. The variation in Type D prevalence among studies needs further elucidation as does the predictive power of continuous scoring of the Type D trait.

Psychological distress and mortality in systolic heart failure

BACKGROUND

Depression, anxiety, and type D ("distressed") personality (tendency to experience negative emotions paired with social inhibition) have been associated with poor prognosis in coronary heart disease, but little is known about their role in chronic heart failure. Therefore, we investigated whether these indicators of psychological distress are associated with mortality in chronic heart failure.

METHOD AND RESULTS

Consecutive outpatients with chronic heart failure (n=641; 74.3% men; mean age, 66.6+/-10.0 years) filled out a 4-item questionnaire to assess mixed symptoms of anxiety and depression and the 14-item type D scale. End points were defined as all-cause and cardiac mortality. After a mean follow-up of 37.6+/-15.6 months, 123 deaths (76 due to cardiac cause) were recorded. Cumulative hazard functions for elevated anxiety/depression symptoms differed marginally for all-cause (P=0.06), but not cardiac, mortality (P=0.43); type D personality was associated with neither all-cause mortality (P=0.63) nor cardiac mortality (P=0.87). In multivariable analyses, neither elevated anxiety/depression symptoms nor type D personality was associated with all-cause mortality (hazard ratio [HR]=1.18; 95% CI, 0.76 to 1.84; P=0.45 and HR=1.09; 95% CI, 0.67 to 1.77; P=0.73, respectively) or cardiac mortality (HR=1.13; 95% CI, 0.63 to 2.04; P=0.65 and HR=1.16; 95% CI, 0.62 to 2.18; P=0.67). In secondary analyses, a 1-point increase in anxiety/depression (range, 0 to 16) was associated with an 8% increase in risk for all-cause mortality (HR=1.08; 95% CI, 1.01 to 1.15; P=0.02).

CONCLUSIONS

Neither elevated anxiety/depression symptoms nor type D personality was associated with an increased risk for all-cause or cardiac mortality. Future studies with adequate power and a longer follow-up duration are needed to further elucidate the role of psychological distress in chronic heart failure.

Association between type D personality, depression, and oxidative stress in patients with chronic heart failure

OBJECTIVE

To examine whether markers of oxidative stress differ as a function of Type D personality, depression, and chronic heart failure (CHF) etiology. Type D (distressed) personality and depression are related to poor cardiac prognosis. Because patients with CHF are characterized by increased oxidative stress, this may be a candidate mechanism responsible for the adverse prognosis in emotionally distressed patients with CHF.

METHODS

Serum levels of xanthine oxidase (XO), inducible heat shock protein (Hsp)70, and deoxyribonucleic acid damage marker 8-OHdG were measured in 122 patients, and effects of Type D, depression, and etiology were assessed.

RESULTS

CHF patients with Type D personality had lower levels of Hsp70 than non-Type D patients (6.48 ng/mL versus 7.85 ng/mL, p = .04, d = 0.26), and in case of an ischemic etiology, higher levels of XO (13.57 ng/mL versus 9.84 ng/mL, p = .01, d = 0.98). There were no significant univariate differences for depression. When adding depression as an additional independent variable in the Type D analysis, the effect of Type D personality remained significant (F = 5.460, p = .02) and was independent of depression (F = 0.942, p = .33). The ratio of XO to Hsp70 was significantly higher in Type D patients with CHF as compared with non-Type D patients (6.14 versus 2.83, p = .03, d = 0.39), independent of etiology class.

CONCLUSION

CHF patients with Type D personality are characterized by an increased oxidative stress burden, apparent in the decreased antioxidant levels and an increased oxidative stress ratio.

Increased anxiety and depression in Danish cardiac patients with a type D personality: cross-validation of the Type D Scale (DS14)

Background

Type D personality is an emerging risk factor in cardiovascular disease. We examined the psychometric properties of the Danish version of the Type D Scale (DS14) and the impact of Type D on anxiety and depression in cardiac patients.

Method

Cardiac patients (n = 707) completed the DS14, the Hospital Anxiety and Depression Scale, and the Eysenck Personality Questionnaire. A subgroup (n = 318) also completed the DS14 at 3 or 12 weeks.

Results

The two-factor structure of the DS14 was confirmed; the subscales negative affectivity and social inhibition were shown to be valid, internally consistent (Cronbach’s α = 0.87/0.91; mean inter-item correlations = 0.49/0.59), and stable over 3 and 12 weeks (r = 0.85/0.78; 0.83/0.79; ps < 0.01). Type D was an independent associate of anxiety (β, 0.49; p < 0.01) and depression (β, 0.47; p < 0.01) in univariable linear regression analysis and remained a significant independent associate of anxiety (β, 0.26; p < 0.01) and depression (β, 0.17; p < 0.01) in adjusted analyses.

Conclusions

The Danish DS14 was shown to be a valid and reliable measure associated with increased symptoms of anxiety and depression independent of socio-demographic and clinical risk factors. The DS14 may be used in research and clinical practice to identify high-risk patients.

Risk of ventricular arrhythmia after implantable defibrillator treatment in anxious type D patients

OBJECTIVES

We sought to examine the combination of adverse psychological factors (anxiety, depression, and distressed or Type D personality) as a predictor of ventricular arrhythmias in patients with implantable cardioverter-defibrillators (ICDs).

BACKGROUND

Little is known about the role of psychological factors and their clustering in the occurrence of life-threatening arrhythmias.

METHODS

In this prospective study, 391 patients with an ICD (81% men, age 62.3 +/- 10.4 years) completed anxiety, depression, and Type D personality scales at the time of implantation. The end point was occurrence of ventricular arrhythmia, defined as appropriate ICD therapies, in the first year after implantation.

RESULTS

Ventricular arrhythmias occurred in 19% (n = 75) of patients. Increased symptoms of depression (p = 0.81) or anxiety (p = 0.31) did not predict arrhythmias. However, anxious patients with a Type D personality had a significantly increased rate of ventricular arrhythmias (21 of 71; 29.6%) as compared with other ICD patients (54 of 320; 16.9%; hazard ratio [HR]: 1.89; 95% confidence interval [CI]: 1.14 to 3.13; p = 0.013). When controlled for the effects of sex, age, ischemic etiology, left ventricular dysfunction, prolonged QRS duration, and medication, anxious Type D patients (HR: 1.72; 95% CI: 1.03 to 2.89; p = 0.039) and secondary prevention patients (HR: 1.91; 95% CI: 1.14 to 3.20; p = 0.014) were at increased risk of ventricular arrhythmias.

CONCLUSIONS

Personality modulated the effect of emotional distress; anxiety predicted a 70% increase in risk of arrhythmia in Type D patients but not in other patients. Anxious Type D patients may be identified and offered additional behavioral support after ICD implantation.

Positive affect and negative affect correlate differently with distress and health-related quality of life in patients with cardiac conditions: validation of the Danish Global Mood Scale

OBJECTIVE

The Global Mood Scale (GMS), assessing negative affect (NA) and positive affect (PA), is sensitive to tapping treatment-related changes in patients with cardiac conditions. We examined the psychometric properties of the Danish GMS and the influence of NA and PA on distress and health-related quality of life (HRQL).

METHOD

A mixed group of patients with cardiac conditions (n=502) completed the GMS, the Hospital Anxiety and Depression Scale, the Type D Scale, and the 36-item Short-Form Health Survey.

RESULTS

The two-factor model of the Danish GMS was confirmed, and the scale was shown to be valid, internally consistent (Cronbach's alpha NA/PA=.93/.85), and stable over 3 weeks (Pearson's r NA/PA=.82/.80). Unadjusted multiple linear regression analyses showed NA (beta=0.67, P<.001), PA (beta=-0.17, P=.001), and the interaction effect NA x PA (beta=-0.17, P=.015) to be associated with anxiety and depressive symptoms (NA:beta=0.99, P<.001; PA:beta=-0.12, P=.004; NA x PA:beta=-0.43, P<.001), as well as with physical HRQL (NA:beta=-0.37, P<.001; PA:beta=0.17, P=.001; NA x PA: beta=-0.27, P<.001) and mental HRQL (NA:beta=-0.72, P<.001; PA:beta=0.27, P=.004; NA x PA:beta=0.23, P<.001). When adjusting for demographic and clinical characteristics, only NA (beta=0.26, P=.003) was associated with anxiety, whereas NA (beta=0.75, P<.001) and NA x PA (beta=-0.34, P=.002) were associated with depressive symptoms. For physical HRQL, PA (beta=0.21, P=.03) and NA x PA (beta=-0.36, P=.005) remained significant, whereas NA (beta=-0.38, P<.001) and PA (beta=0.21, P=.002) remained significant for mental HRQL.

CONCLUSION

The Danish GMS is a psychometrically sound measure of affect in patients with cardiac conditions. Future studies should examine changes in both PA and NA and their impact on health outcomes.

The relationship between type D personality and chronic heart failure is not confounded by disease severity as assessed by BNP

Psychological factors, like Type D personality (i.e., the tendency to experience negative emotions and to inhibit emotional distress) have been linked to impaired health outcomes. Criticism on the role of psychological factors in cardiac disease has postulated that such constructs may be confounded by disease severity. Hence, we examined whether Type D personality is associated with brain natriuretic peptide (BNP), a sensitive marker of disease severity in chronic heart failure (CHF), in 202 consecutive CHF outpatients. No differences in logBNP levels were found between Type D and non-Type D patients (t(200) = -1.03, p = .30). After adjusting for demographic and clinical confounders, Type D personality remained unassociated with logBNP levels (β=.04, p = .55), whereas older age (β = .27, p<.001), being prescribed beta-blockers (β = .15, p = .02), lower left ventricular ejection fraction (β = -.38, p<.0001), and kidney dysfunction (β = .17, p = .01) were associated with higher logBNP. To conclude, Type D personality was not associated with BNP in CHF outpatients, whereas clinical variables were associated with BNP. These findings oppose the suggestion that Type D personality is confounded by indicators of disease severity.

Depression and Type D personality represent different forms of distress in the Myocardial INfarction and Depression - Intervention Trial (MIND-IT)

BACKGROUND

We investigated whether depressive disorder and Type D personality refer to different forms of distress in the Myocardial INfarction and Depression - Intervention Trial (MIND-IT).

METHOD

A total of 1205 myocardial infarction (MI) patients were screened at 3, 6, 9 and 12 months post-MI; those with a Beck Depression Inventory (BDI) score 10 underwent the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Patients completed the DS14 measure of Type D personality at 12 months and were stratified to one of four subgroups: depressed/Type D, depressed/non-Type D, non-depressed/Type D, or non-distressed.

RESULTS

Two hundred and six (17%) patients were diagnosed with depression and 224 (19%) with Type D. Only 7% (n=90) had both forms of distress, and 60% of Type D patients were free of depression in the first year post-MI. Type D moderated the relationship between depressive and cardiac disorder. Depressed patients without Type D had the worst clinical status (left ventricular dysfunction, heart failure, Killip class 2) as compared to other patients, whereas depressed patients with a Type D personality did not differ in clinical status from non-distressed patients. Contrasting 'pure' Type D and depression subgroups showed that Type D patients without depression were less likely to have left ventricular dysfunction [odds ratio (OR) 0.47, 95% confidence interval (CI) 0.35-0.65, p<0.0001] than depressed patients without Type D.

CONCLUSIONS

Depression and Type D refer to different forms of distress in post-MI patients; most Type D patients display non-psychiatric levels of distress and Type D moderates the relationship between depressive and cardiac disorder. Different depression/Type D subgroups may be involved in the prediction of cardiac prognosis.

Normative data of the SF-12 health survey with validation using postmyocardial infarction patients in the Dutch population

OBJECTIVE

To gain Dutch population norms for the Short Form-12 (SF-12), a generic health status questionnaire, in a random sample of the general population and to validate these in postmyocardial infarction (MI) patients.

METHODS

2,301 respondents from the general population and 459 post-MI patients completed the Short Form-36 (SF-36), which was used to calculate SF-12 scores.

RESULTS

The SF-12 summary scores correlated highly with SF-36 summary scores, demonstrating that these scores explain the same amount of variance in health status. Significant sex differences (P < .001) existed for both the physical component summary (PCS) and the mental component summary (MCS). Multivariate analysis of variance showed a main effect of age in oblique (PCS-12: P < .001; MCS-12: P < .001) and orthogonally rotated PCS scores (PCS-12_uc: P < .001; MCS-12_uc: P = .07). As expected, post-MI patients reported statistically significant and clinically relevant poorer mental (P < .001) and physical functioning (P < .001). Differences were less pronounced for MCS and PCS derived from orthogonal rotation data. When controlling for covariates, MI did not significantly affect PCS-12_uc anymore in orthogonally rotated data, while PCS-12_uc was affected by fewer covariates compared with PCS-12.

CONCLUSIONS

This study presents Dutch population norms for the SF-12 in a large random population sample obtained from both oblique and orthogonal PCA rotation methods, revealing systematic differences between the results based on these two methods. Furthermore, this study demonstrates the discriminative validity of the SF-12 by showing that post-MI patients differ significantly from the normative population on PCS-12 scores.

Overlap and distinctiveness of psychological risk factors in patients with ischemic heart disease and chronic heart failure: are we there yet?

OBJECTIVE

Growing evidence supports the importance of psychological factors in the etiology and progression of cardiovascular disease (CVD). However, this research has been criticized due to overlap between psychological constructs. We examined whether psychological questionnaires frequently used in cardiovascular research assess distinct constructs in a mixed group of ischemic heart disease (IHD) and chronic heart failure (CHF) patients.

METHODS

565 patients with CHF (n=118) or IHD (n=447) completed the Type D scale (DS14), Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory (BDI), and State Trait Anxiety Inventory (STAI). Pearson product moment correlations were computed to determine the interrelatedness between psychological constructs. Principal component analyses (PCA) were conducted on both scale scores and items to determine higher-order constructs and distinctiveness of psychological questionnaires.

RESULTS

Two higher-order constructs were identified, namely negative affect and social inhibition. PCA on all 69 items showed that anxiety, depression, negative affectivity, and social inhibition were distinct constructs. The original structure of the DS14 was confirmed, whereas items of the HADS and BDI loaded more diffusely; items of the STAI reflected two different components.

CONCLUSION

The use of multiple questionnaires in cardiac patients is justified, as the higher order construct negative affect comprised different facets. Social inhibition was also shown to be a distinct construct, indicating that it may timely for cardiovascular research to look at the role of inhibition in addition to negative emotions. Future studies are warranted to determine whether these findings are replicable in other cardiac samples and to specify the unique prognostic value of these psychological facets.

Type D personality and depressive symptoms are independent predictors of impaired health status in chronic heart failure

OBJECTIVE

To examine whether Type D personality exerts a stable, independent effect on health status in CHF over time, adjusted for depressive symptoms.

SUBJECTS

CHF outpatients (n = 166; 75% men; mean age 66 years) completed the Type D Scale and Beck Depression Inventory (baseline) and the Minnesota Living with Heart Failure Questionnaire and Short-Form Health Survey (baseline and 12 months).

RESULTS

There was a general improvement in disease-specific physical (p = .029) and mental (p < .001) health over time, but Type D patients scored significantly lower on both outcomes (p < or = .001). The interaction effects Type D x time were not significant, indicating stability of the personality effect. Type D patients also scored significantly lower on all generic physical (p values between .001 and .04) and mental (all p values < or = .01) health status subdomains; these effects were also stable over time. Type D was an independent predictor of disease-specific mental health (p < .001), social functioning (p = .04), role emotional functioning (p < .001), bodily pain (p = .05), and general health (p = .04), adjusted for depressive symptoms, baseline health status and clinical characteristics. Depressive symptoms was an independent predictor of role physical functioning and bodily pain.

CONCLUSIONS

Type D personality and depressive symptoms were independent predictors of impaired health status in CHF.

Type D personality and cardiac mortality in patients with chronic heart failure

BACKGROUND

Clinical predictors of cardiac mortality in chronic heart failure (CHF) are established, but less is known about chronic psychological predictors. Therefore, we examined the prognostic value of Type D personality (tendency to experience negative feelings and inhibit self-expression) in CHF patients.

METHODS AND RESULTS

Consecutive systolic CHF outpatients (n=232) filled in the Type D Scale (DS14) at baseline. Socio-demographic and clinical data were obtained from the medical record/cardiologist. The primary endpoint was total cardiac mortality (follow-up=30.7+/-11.1 months). Late (>6 months) cardiac mortality was the secondary endpoint. Type D patients had a higher incidence of total cardiac mortality (15/48=31.3%) as compared to non Type D patients (32/184=17.4%), OR=2.16;95%CI:1.05-4.43, p=.04. Type D personality was a near significant independent predictor of total cardiac mortality (OR=1.40;95%CI:0.93-4.29, p=.08), and a significant independent predictor of late cardiac mortality, adjusting for sex, age and left ventricular ejection fraction (OR=2.34;95%CI:1.05-5.26, p=.04).

CONCLUSIONS

Type D personality was a near-significant independent predictor of total cardiac mortality, and a significant independent predictor of late cardiac mortality, adjusting for socio-demographics and disease-severity. These findings suggest that Type D personality, a chronic psychological risk factor, is of importance in long-term prognosis in CHF.

Type D personality in Poland: Validity and application of the Polish DS14

Type D personality (increased negative emotions paired with emotional non-expression) is an emerging risk indicator in cardiovascular disease (CVD), associated with poor patient-centered outcomes, mortality and morbidity. Little is known about the cross-cultural utility of the construct, as it has primarily been used in the Western European setting. We applied the Type D Scale to a large sample of healthy and CVD patients to validate the DS14 in Poland. DS14 was used in the sample comprised 1154 persons, healthy and CVD. The internal consistency of the Polish version of the DS14 was good with Cronbach's alpha of 0.86 for negative affectivity (NA) and 0.84 for social inhibition (SI). The 2-factor structure of the DS14 was confirmed both with exploratory and confirmatory factor analysis. Both of the DS14 subscales were internally consistent and stable over time. Using the standardized cut-off ≥10 for both NA and SI to identify those with a Type D personality, the prevalence was 72.1% in CVD patients and 34.8% in healthy. The Type D personality construct, as assessed with the DS14, seems to be applicable to the Polish setting, as the Polish DS14 was shown to be a psychometrically sound instrument.

Type D patients report poorer health status prior to and after cardiac rehabilitation compared to non-type D patients

BACKGROUND

Type D personality is an emerging risk factor in coronary artery disease (CAD). Cardiac rehabilitation (CR) improves outcomes, but little is known about the effects of CR on Type D patients.

PURPOSE

We examined (1) variability in Type D caseness following CR, (2) Type D as a determinant of health status, and (3) the clinical relevance of Type D as a determinant of health status compared to cardiac history.

METHODS

CAD patients (n = 368) participating in CR completed the Type D Scale, the Short-Form Health Survey 36 pre- and post-CR, and the Hospital Anxiety and Depression Scale pre-CR, to assess health status and depressive and anxious symptomatology, respectively.

RESULTS

The prevalence of Type D decreased from 26.6% to 20.7% (p = 0.012) following CR, but Type D caseness remained stable in 81% of patients. Health status significantly improved following CR [F(1,359) = 17.48, p < 0.001], adjusting for demographic and clinical factors and anxious and depressive symptoms. Type D patients reported poorer health status [F(1,359) = 10.40, p = 0.001], with the effect of Type D being stable over time [F(1,359) = 0.49, p = 0.48]. Patients with a cardiac history benefited less from CR [F(1,359) = 5.76, p = 0.02]. The influence of Type D on health status was larger compared to that for cardiac history, as indicated by Cohen's effect size index.

CONCLUSIONS

Type D patients reported poorer health status compared to non-Type D patients pre- and post-CR. In the majority of patients, CR did not change Type D caseness, with Type D being associated with a stable and clinically relevant effect on outcome. These high-risk patients should be identified in clinical practice and may require adjunctive interventions.

Comparing Type D personality and older age as correlates of tumor necrosis factor-alpha dysregulation in chronic heart failure

Tumor necrosis factor-alpha (TNF-alpha) and its soluble receptors 1 (sTNFR1) and 2 (sTNFR2) have been shown to be implicated in the pathogenesis of chronic heart failure (CHF). Ageing is accompanied by increased plasma levels of pro-inflammatory cytokines. We hypothesized that Type D personality (joint tendency to experience negative emotions and to inhibit self-expression) and age may have similar pro-inflammatory effects in the context of CHF. Participants in this study were 130 consecutive outpatients with CHF (76% men); there were 70 relatively younger (<or=59 years) and 60 relatively older (>or=60 years) patients. They all completed the 14-item Type D Scale (DS14); 43 patients (33%) had a Type D personality. A multivariate model of cytokine levels indicated an independent overall effect of both older age [F(1,128)=9.11, p=.003] and Type D personality [F(1,128)=8.28, p=.005]. Stratifying patients in age/personality subgroups showed that younger non-Type D patients had the lowest and older Type D patients the highest sTNFR1 and sTNFR2 levels (986+/-318 vs 1661+/-1128 pg/ml and 1838+/-777 vs 2823+/-1439 pg/ml, p<.0001). Importantly, the mean sTNFR1 level in younger Type D patients (1359+/-660 pg/ml) was equivalent to that in older non-Type D patients (1360+/-440 pg/ml, p=.99) who were on average 18 years older. Younger Type D and older non-Type D patients also had similar sTNFR2 levels (2406+/-1329 vs 2448+/-812 pg/ml, p=.88). Only older Type D patients had a higher mean TNF-alpha level as compared to patients who were younger or who were not Type D (5.4+/-2.9 vs 3.9+/-2.4 pg/ml, p=.008). A logistic regression model including sex, severity of CHF, systolic heart failure and ischemic etiology indicated that the combined risk category of older age or Type D was independently associated with substantially increased sTNFR1 and sTNFR2 levels. Hence, Type D personality was associated with increased TNF-alpha activity. This disease-promoting effect of Type D matched the pro-inflammatory effect of ageing.