Psychological factors affecting a medical condition: ischemic coronary heart disease

Demoralization syndrome among cardiac transplant recipients

AIMS AND OBJECTIVES

To investigate the characteristics and prevalence of demoralisation syndrome among heart transplantation patients in Taiwan.

BACKGROUND

Patients with end-stage heart failure who have undergone cardiac transplantation are at risk of demoralisation syndrome. Demoralisation syndrome has been studied in cancer populations, but our understanding of the syndrome among heart transplant recipients is limited.

DESIGN AND METHODS

The study adopted a cross-sectional design and analysed the baseline data from a longitudinal study with cardiac transplant patients at a heart centre in northern Taiwan. A structured questionnaire, namely the Demoralization Scale-Mandarin Version (DS-MV), was used to assess demoralisation syndrome. Hierarchical regression was applied to determine the predictors of demoralisation. Reporting was consistent with the STROBE checklist.

RESULTS

There were a total of 84 participants with an average age of 51.9 years and a time since heart transplantation of around 4.1 years. Among them, the prevalence of demoralisation syndrome was 35.8%, and 57.1% coped well with stress. In addition, on the DS-MV, participants tended to choose sentences with positive rather than negative wording. Our data showed that cardiac transplant recipients with stress have higher possibility suffering from demoralisation syndrome; poor renal function and those who cannot relive from stress are predictors for loss of meaning.

CONCLUSIONS

Chinese individuals tend to hide their weaknesses; nevertheless, demoralisation syndrome among cardiac transplant recipients, as related to stress status and kidney function, is still remarkable.

RELEVANCE TO CLINICAL PRACTICE

Since demoralisation is preventable, further research on this phenomenon in the cardiac transplant population is warranted and needs to be developed.

Increased arterial stiffness parameters in panic disorder patients in long term treatment period

BACKGROUND

The relationship between mental stress and cardiovascular disease has been shown in several studies. Panic disorder (PD) is also associated with cardiovascular disease due to increased risk of myocardial infarction. The aim of this study is to evaluate the association between arterial stiffness parameters and depression/anxiety scores in patients with PD.

METHODS

The study population consisted of 25 patients with PD and 25 age-sex-matched healthy controls. Depression and anxiety levels were evaluated by Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI), respectively. Determination of arterial stiffness parameters was conducted using a Mobil-O-Graph arteriograph system that detected signals from the brachial artery.

RESULTS

While baseline characteristics were similar between two groups, BDI and BAI scores were significantly higher in patients with PD (p < 0.005). The pulse wave velocity (PWV) and Augmentation Index (AIx) were also significantly higher in patients with PD (p = 0.001, p = 0.006). There was a moderate correlation between PWV and AIx with BAI scores (r = 0.442, p = 0.001, r = 0.441, p = 0.001). AIx was also positively correlated with BDI scores (r = 0.415, p = 0.03).

CONCLUSION

We demonstrated a significant relationship between arterial stiffness parameters and anxiety/depression scores in patients with PD who receive antidepressant treatment.

Platelet activating factors are associated with depressive symptoms in coronary artery disease patients: a hypothesis-generating study

INTRODUCTION

Depression is a frequent complication of coronary artery disease (CAD) with an unknown etiology. Platelet activating factor (PAF) lipids, which are associated with CAD, have recently been linked with novel proposed etiopathological mechanisms for depression such as inflammation, oxidative/nitrosative stress, and vascular endothelial dysfunction.

METHODS AND RESULTS

This hypothesis-generating study investigated the relationships between various PAF species and depressive symptoms in 26 CAD patients (age: 60.6±9.2 years, 69% male, mean Hamilton Depression Rating Scale [HAM-D] score: 11.8±5.2, HAM-D range: 3-20). Plasma PAF analyses were performed using high performance liquid chromatography electrospray ionization mass spectrometry in precursor ion scan. Significant associations between depressive symptom severity (HAM-D score) and a greater plasma abundance of the PAFs phosphocholine (PC) PC(O-12:0/2:0) (r=0.49, P=0.01), PC(O-14:1/2:0) (r=0.43, P=0.03), PC(O-17:3/2:0) (r=0.44, P=0.04), and PC(O-18:3/2:0) (r=0.50, P=0.01) were observed. Associations between those PAFs and HAM-D score persisted after adjusting for age and sex.

CONCLUSION

These preliminary findings support the exploration of the PAF lipidome for depressive symptom biomarkers in CAD patients. Patients were recruited as part of the following clinical trial: NCT00981383.

Circadian blood pressure variation in normotensive patients with panic disorder

Nondipper pattern of blood pressure (BP) is associated with cardiovascular risk. In this study, we compared dipper versus nondipper patterns between normotensive patients with panic disorder (PD) and a control group. A total of 25 normotensive patients with PD and 25 controls were enrolled. Twenty-four-hour ambulatory BP monitoring was performed in all patients. At least 10% of sleep-related nocturnal decrease in systolic and diastolic BP was accepted as dipper status, while decreases <10% were defined as a nondipper. Patients with PD had significantly higher incidence of nondipper BP pattern than controls. The reduction of nighttime BP in both systolic and diastolic and mean BP was significantly lower in patients with PD than in the control group (7.6% ± 4.3% vs 13% ± 3.9%, P < .001; 11% ± 7% vs 15% ± 5%, P = .004; 9% ± 5% vs 14% ± 4%, P = .002, respectively). Panic disorder is associated with nondipper BP pattern, causing impaired circadian BP in normotensive settings.

Antioxidant status and its association with elevated depressive symptoms among US adults: National Health and Nutrition Examination Surveys 2005-6

We examined the relationship of elevated depressive symptoms with antioxidant status. Cross-sectional data from the National Health and Nutrition Examination Surveys 2005–6 on US adults aged 20–85 years were analysed. Depressive symptoms were measured using the Patient Health Questionnaire with a score cut-off point of 10 to define ‘elevated depressive symptoms’. Serum antioxidant status was measured by serum levels of carotenoids, retinol (free and retinyl esters), vitamin C and vitamin E. The main analyses consisted of multiple logistic and zero-inflated Poisson regression models, taking into account sampling design complexity. The final sample consisted of 1798 US adults with complete data. A higher total serum carotenoid level was associated with a lower likelihood of elevated depressive symptoms with a reduction in the odds by 37 % overall with each sd increase in exposure, and by 34 % among women (P< 0·05). A dose–response relationship was observed when total serum carotenoids were expressed as quartiles (Q4 (1·62–10·1 μmol/l) v. Q1 (0·06–0·86 μmol/l): OR 0·41; 95 % CI 0·23, 0·76, P< 0·001; P for trend = 0·035), though no significant associations were found with the other antioxidant levels. Among carotenoids, β-carotene (men and women combined) and lutein+zeaxanthins (women only, after control for dietary lutein+zeaxanthin intake and supplement use) had an independent inverse association with elevated depressive symptoms among US adults. None of the other serum antioxidants had a significant association with depressive symptoms, independently of total carotenoids and other covariates. In conclusion, total carotenoids (mainly β-carotene and lutein+zeaxanthins) in serum were associated with reduced levels of depressive symptoms among community-dwelling US adults.

Increased pulse wave velocity in patients with panic disorder: independent vascular influence of panic disorder on arterial stiffness

OBJECTIVE

Acute and chronic mental stress and many psychiatric disorders have been accepted as a cause of cardiovascular disease. Panic disorder, a subtype of anxiety disorder, has been associated with increased risk of fatal myocardial infarction and sudden cardiac death in epidemiological studies. Carotid-femoral pulse wave velocity (CF-PWV) is currently the gold standard measurement of arterial stiffness. CF-PWV is a well-recognized predictor of an adverse cardiovascular outcome with higher predictive value than classical cardiovascular risk factors. The aim of our study is to measure PWV as the surrogate of arterial stiffness and vascular involvement in patients with panic disorder.

METHODS

Forty-two patients with PD, and 30 control participants were included in the study. Patients with hypertension, diabetes mellitus, or the history of any cardiovascular disease were excluded from study.

RESULTS

Baseline characteristics were not significantly different between the two groups, except carotid-femoral pulse wave velocity (PD vs. control; 7.51±2.02 vs. 6.24±1.09 m/s, p=0.001), heart rate, and smoking status. Additionally, CF-PWV positively correlated with age (r=0.250, p=0.034), heart rate (r=0.284, p=0.017), systolic and diastolic blood pressure (r=0.393, p=0.001 and r=0.286, p=0.015, respectively) significantly. However, only the presence of panic disorder was independently related to PWV (βeta: 0.317, p=0.011) in the multivariate analysis including age, heart rate, smoking status and blood pressure measurements.

CONCLUSION

Increased pulse wave velocity in patients with panic disorder may justify the associated risk as documented in previous studies, and may be useful in identifying the patients with higher risk of future cardiovascular complications.

Is social isolation/alienation confounded with, and non-independent of, emotional distress in its association with early onset of coronary artery disease?

Both emotional distress (ED) and social isolation/alienation (SI/A) have been found to prospectively predict adverse cardiac events, but few studies have tested the confounding/redundancy of these measures as correlates/predictors of outcomes. In this study, 163 patients with documented coronary artery disease (CAD) were interviewed for multiple indices of SI/A and administered the Symptom Checklist 90 - Revised (SCL90R). A spouse or friend provided an independent rating of ED using the spouse/friend version of the Ketterer Stress Symptom Frequency Checklist (KSSFC). The measures of ED and SI/A covaried. All three scales from the KSSFC (depression, anxiety, and "AIAI" - aggravation, irritation, anger, and impatience), and three scales from the SCL90R (anxiety, depression, and psychoticism), were associated with early Age at Initial Diagnosis (AAID) of CAD. Neither three scales derived from the SCL90R (shyness, feeling abused, and feeling lonely) nor the interview indices of SI/A (married, living alone, having a confidant, self description as a lone wolf, and self-description as lonely) were associated with early AAID. Thus, it is concluded that the present results indicate that ED and SI/A are confounded and that, even when tested head-to-head in a multivariate analysis, only ED is associated with AAID.

Screening, diagnosis & monitoring of depression/distress in CHF patients

Objective and validated measures of depression/distress (anxiety and anger) are available and readily usable at the bedside or in clinic. Foremost among these is the Patient's Health Questionnaire--an adaptation of DSM IV criteria for Major Depressive Disorder that permits administration and scoring by nursing or physician personnel, and quantification of the intensity of depression. A score of 10 or greater indicates a need for evaluation/treatment. Because of patient denial/minimization/alexithymia, PHQ negatives should undergo further screening by having a spouse or friend complete a depression/distress rating scale. The only standardized, normed, and validated spouse/friend scale presently available is the Ketterer Stress Symptom Frequency Checklist, which is available by internet.

Psychological Factors Affecting Medical Condition: A New Proposal for DSM-V

The DSM category of "psychological factors affecting medical condition" had virtually no impact on clinical practice. However, several clinically relevant psychosomatic syndromes have been described in the literature: disease phobia, persistent somatization, conversion symptoms, illness denial, demoralization, and irritable mood. These syndromes, in addition to the DSM definition of hypochondriasis, can yield clinical specification in the category of "psychological factors affecting medical condition" and eliminate the need for the highly criticized DSM classification of somatoform disorders. This new classification is supported by a growing body of research evidence and is in line with psychosomatic medicine as a recognized subspecialty.

The changes of oxidative stress and human 8-hydroxyguanine glycosylase1 gene expression in depressive patients with acute leukemia

The results of several recent studies indicated that free radicals are involved in the biochemical mechanisms that underlie neuropsychiatric disorders. In the present study, we evaluated changes in oxidative stress and human 8-hydroxyguanine glycosylase1 gene (hOGG1) expression in depressive patients with acute leukemia. Ninety two cases were assessed using the Zung self-rating depression scale (SDS) and multiple-item questionnaires. We measured total antioxidant capacity (T-AOC) and the concentrations of reactive oxygen species (ROS), superoxide dismutase (SOD), malondialdehyde (MDA) and nitric oxide (NO) during a pre-treatment period. The steady-state expression of hOGG1 mRNA transcripts was monitored. The incidence of depression was 47.83%. There was a significant decrease in serum T-AOC and SOD concentrations in depressive patients compared to the control subjects, whereas the opposite was the case for serum concentrations of ROS, NO and MDA. Real-time polymerase chain reaction (PCR) revealed that hOGG1 mRNA expression was greater in depressive patients than in the controls. Person correlation analysis revealed that depression was correlated positively with sex, the course of the disease and hOGG1 mRNA expression; depression was correlated negatively with T-AOC. Based on these results, we conclude that the antioxidant system is impaired in leukemic patients with affective disorders. Therefore, oxidative stress may play an important role in the pathophysiology of depression.

Burnout and risk of cardiovascular disease: evidence, possible causal paths, and promising research directions

Burnout is characterized by emotional exhaustion, physical fatigue, and cognitive weariness, resulting from prolonged exposure to work-related stress. The authors review the accumulated evidence suggesting that burnout and the related concept of vital exhaustion are associated with increased risk of cardiovascular disease and cardiovascular-related events. The authors present evidence supporting several potential mechanisms linking burnout with ill health, including the metabolic syndrome, dysregulation of the hypothalamic-pituitary-adrenal axis along with sympathetic nervous system activation, sleep disturbances, systemic inflammation, impaired immunity functions, blood coagulation and fibrinolysis, and poor health behaviors. The association of burnout and vital exhaustion with these disease mediators suggests that their impact on health may be more extensive than currently indicated.

“Major” Depressive Disorder, Coronary Heart Disease, and the DSM–IV Threshold Problem

Seventy-seven patients with documented coronary heart disease (CHD) were evaluated for demographic/risk factor characteristics, Major Depressive Disorder (MDD) according to the Patient's Health Questionnaire (PHQ - Diagnostic and Statistical Manual IV criteria), and emotional distress by the Symptom Checklist 90-Revised (SCL-90-R). Early age at initial diagnosis for coronary heart disease (AAID) was used as a proxy for disease malignancy because early AAID is a known predictor of early mortality. MDD was unrelated to early AAID despite being strongly associated with all the scales of the SCL-90-R. Several of the SCL-90-R scales were significantly associated with early AAID in the sample as a whole (Depression, Interpersonal Sensitivity, Anxiety, Paranoia, and Psychoticism) and after removal of the patients meeting criteria for MDD (residual N = 54). Our results suggest a new criterion for determining whether depression, or any mental disorder, is "major": onset or aggravation of serious medical illness.

Depressive symptoms and life satisfaction in elderly women are associated with natural killer cell number and cytotoxicity

Well-preserved natural killer (NK) cell cytotoxicity (NKCC) is associated with healthy aging. The objective of the survey was to investigate psychological factors related to NKCC and NK cell populations in elderly women. A cross-sectional study involving 181 participants was conducted using the Japanese version of the 28-item General Health Questionnaire (GHQ) and additional questions assessing psychological status and lifestyle. Spearman's rank test revealed a significant negative correlation between NKCC and the GHQ depression subscale (GHQ-D) scores. Significantly reduced NKCC was found in participants presenting high GHQ-D scores (12 < or = GHQ-D, n = 58) compared with those showing middle (8 < or = GHQ-D < or = 11, n = 55) or low (GHQ-D = 7, n = 68) scores. Adjusting for covariates regarding lifestyle, multiple logistic regression analysis was applied; consequently, significant associations were found between reduced NKCC and high depressive symptoms and between increased NK cell numbers and life satisfaction. These results indicated a clue to longitudinal studies in the future.

Social and lifestyle determinants of depression, anxiety, sleeping disorders and self-evaluated quality of life in Russia--a population-based study in Arkhangelsk

BACKGROUND

The paper investigates social and lifestyle determinants of depression, anxiety, sleeping disorders and self-evaluated low quality of life in a population sample from the northwest of Russia.

METHODS

Altogether 1968 men and 1737 women aged 18-90 years participated in a population-based study in Arkhangelsk, Russia, in the period 1999-2000. Depression, anxiety, and sleeping disorders were evaluated by a questionnaire with the formulations that have been previously used in population studies in Northern Norway. Alcohol dependence was diagnosed by the Alcohol Use Disorders Identification Test (AUDIT). Quality of life was evaluated by a 10-score Cantril Ladder. A score lower than five was defined as low quality of life. Relations between depression, anxiety, and sleeping disorders and socioeconomic/lifestyle factors were tested by logistic regression analyses.

RESULTS

Women reported significantly higher prevalence of depression, anxiety and/or sleeping disorders than men: 68.7% and 32.3%, respectively. Depression, anxiety, sleeping disorders and low quality of life were positively associated with self-evaluation of nutrition as "poor", low consumption of food, and with low-paid professional status. Depression and sleeping disorders were associated with smoking, hazardous level of alcohol drinking and alcohol dependence. Anxiety and low quality of life were associated with alcohol dependence. Depression, anxiety, sleeping disorders and low quality of life had a strong positive association with circulatory diseases and gastrointestinal diseases, the association remained significant after adjustment for smoking and alcohol variables.

CONCLUSIONS

A considerable part of the examined Russian population experienced depression, anxiety, and sleeping disorders that were strongly positively associated with poor nutrition, low socioeconomic status and adverse health behaviors (alcohol use disorders, smoking).

Psychological distress, physical illness, and risk of coronary heart disease

STUDY OBJECTIVE

The aims of this study are to confirm the association between psychological distress and coronary heart disease (CHD) using an epidemiological community study with hospital admissions data and to examine if any association is explained by existing illness.

DESIGN

Prospective cohort study modelling the association between psychological distress, measured using the 30 item general health questionnaire (GHQ), and hospital admissions data for CHD (ICD 410-414), using proportional hazards modelling adjusted for sociodemographic, CHD risk factors, and angina, bronchitis, diabetes, ischaemia, and stroke.

SETTING

Two suburbs of Glasgow, Renfrew and Paisley, in Scotland.

PARTICIPANTS

6575 men and women aged 45-64 years from Paisley.

MAIN RESULTS

Five year CHD risk in distressed men compared with non-distressed men was 1.78 (95% confidence intervals (CI), 1.15 to 2.75) in age adjusted analysis, 1.78 (95% CI, 1.14 to 2.79) with sociodemographic and CHD risk factor adjustment, and 1.61 (95% CI 1.02 to 2.55) with additional adjustment for existing illness. Psychological distress was unrelated to five year CHD risk in women. In further analysis, compared with healthy, non-distressed men, distressed physically ill men had a greater risk of CHD than non-distressed physically ill men, a relative risk of 4.01 (95% CI 2.42 to 6.66) compared with 2.12 (95% CI 1.35 to 3.32).

CONCLUSION

The association of psychological distress with an increased risk of five year CHD risk in men could be a function of baseline physical illness but an effect independent of physical illness cannot be ruled out. Its presence among physically ill men greatly increases CHD risk.

Secondary prevention of coronary heart disease: patient beliefs and health-related behaviour

OBJECTIVE

Coronary heart disease (CHD) is a leading cause of illness and death in Western society. The present study was designed to evaluate the utility of illness perceptions and medication beliefs in predicting secondary preventive behaviour among patients with CHD. An extended version of Leventhal's self-regulatory model (SRM) was used as a theoretical framework for this study [Leventhal H, Nerenz DR, Steele DJ. Illness perceptions and coping with health threat. In: Baum A, Taylor SE, Singer JE, editors. Handbook of psychology and health, Volume IV: social psychological aspects of health. Hillsdale (NJ): Erlbaum, 1984. pp. 219-52; Horne R, Weinman J. Self-regulation and self-management in asthma: exploring the role of illness perceptions and treatment beliefs in explaining non-adherence to preventer medication. Psychol Health 2002;17(1):17-32].

METHOD

Medical and demographic data were gathered from the medical charts of 1611 patients with established CHD from 35 randomly selected general practices. Self-report data about patients' lifestyles (diet, exercise, smoking, alcohol consumption and medication adherence) and information on illness and medication beliefs were provided from postal questionnaire (1084 patients responded; 69% response rate). The relationship between patients' beliefs and their secondary preventive behaviour was examined using regression analyses.

RESULTS

Illness perceptions appeared to be only weak predictors of smoking, exercise, diet, alcohol consumption and medication adherence, accounting for about 2% of the variance in these behaviours. Medication beliefs were moderately related to medication adherence, accounting for about 7% of the variance in scores. A strong belief in the necessity of one's medication and a lower level of concern about one's medication were associated with higher levels of adherence.

CONCLUSIONS

An illness perception approach did not prove helpful in predicting secondary preventive behaviour among this group of patients. However, beliefs about medications appear to be reasonable predictive of medication adherence.

Anger, Anxiety, and Depression as Risk Factors for Cardiovascular Disease: The Problems and Implications of Overlapping Affective Dispositions

Several recent reviews have identified 3 affective dispositions--depression, anxiety, and anger-hostility--as putative risk factors for coronary heart disease. There are, however, mixed and negative results. Following a critical summary of epidemiological findings, the present article discusses the construct and measurement overlap among the 3 negative affects. Recognition of the overlap necessitates the development of more complex affect-disease models and has implications for the interpretation of prior studies, statistical analyses, prevention, and intervention in health psychology and behavioral medicine. The overlap among the 3 negative dispositions also leaves open the possibility that a general disposition toward negative affectivity may be more important for disease risk than any specific negative affect.

Interrater Reliability, Prevalence, and Relation to ICD-10 Diagnoses of the Diagnostic Criteria for Psychosomatic Research in Consultation-Liaison Psychiatry Patients

The Diagnostic Criteria for Psychosomatic Research (DCPR) have been proposed by an international group of psychosomatic investigators as an operationalized tool for the assessment of psychological distress in medical patients. The aims of the present study were to evaluate interrater reliability, the distribution of DCPR syndromes, and their relationship with ICD-10 diagnostic categories. One hundred consecutive patients who were referred for psychiatric consultation in a university general hospital consented to assessment for DCPR syndromes as elicited in a joint interview conducted by two researchers. The results showed excellent interrater agreement, with kappa values for the 11 DCPR syndromes ranging from 0.69 to 0.97. More patients met criteria for one or more of the DCPR (87%) than for an ICD-10 diagnosis (75%). Four DCPR syndromes were particularly prevalent: demoralization, alexithymia, illness denial, and type A behavior. DCPR criteria appear to be a useful, reliable, and promising approach in the assessment and description of psychological distress in medical patients. They may serve as a focus of intervention studies in this population.

What's “Unstable” in Unstable Angina?

The role of emotional distress (e.g., anger, depression, and anxiety) in anginal chest discomfort (ACD) may have been underestimated. The authors review the empirical studies in this area, which are inconsistent with the standard theory on the ischemia-angina relationship; summarize the substantial evidence indicating a strong and consistent cross-sectional/prospective epidemiological association of emotional distress and ischemia/ACD; review the distress-targeted, interventional evidence confirming a causal relationship (i.e., reduced chest discomfort and health system utilization), thus confirming clinical utility of such interventions; and explore the possible mechanisms that might account for the relationship between emotional distress and chest discomfort. Substantial clinical benefit may be achieved by aggressively detecting and treating emotional distress in ACD patients.

Depressive symptoms are independently correlated with lipid peroxidation in a female population: comparison with vitamins and carotenoids

OBJECTIVE

Lipid peroxidation (LPO) is involved in oxidative tissue injuries. The present investigation examined the association between LPO and psychological depressive symptoms.

METHODS

A cross-sectional study was conducted on 66 female volunteers aged 38-70. Lipid peroxides (LOOH) in serum were evaluated by hemoglobin-methylene blue (Hb-MB) method; additionally, serum antioxidants were also detected. To assess depressive symptoms, the Center for Epidemiologic Studies Depression (CES-D) Scale and a subscale in the 28-item General Health Questionnaire (GHQ) were applied.

RESULTS

LOOH concentration displayed a significant positive correlation with CES-D and GHQ depression scores. Multiple regression analysis was performed in which LOOH concentration served as a dependent variable and CES-D scores and antioxidants as independent variables. Consequently, CES-D scores demonstrated significant positive correlation with LOOH.

CONCLUSIONS

The positive relationship between depressive symptoms and LPO in a female population may support the hypothesis that LPO may affect depressive symptoms.

Men deny and women cry, but who dies? Do the wages of "denial" include early ischemic coronary heart disease?

OBJECTIVES

In this study patients with documented ischemic coronary heart disease (ICHD; prior MI or CAD per catheterization) were tested for the association of various measures of emotional distress with Age at Initial Diagnosis.

METHODS

The measures were chosen because of a published track record at predicting mortality in this population. Females were oversampled to achieve equivalent numbers of each sex (n=50), and thus equivalent statistical power. In a subset of patients (38 males and 32 females), Spouse/Friend Ketterer Stress Symptom Frequency Checklists (KSSFCs) were received.

RESULTS

Females reported more depression and anxiety than males. However, spouses or friends reported more anger for males. Denial (spouse/friend minus self-ratings) was greater in males for all three scales of the KSSFC (Anger, P=.005; Depression, P=.024; Anxiety, P=.001). Although females showed the same trend, self and spouse or friend ratings of distress were significantly associated with Age at Initial Diagnosis only in males. When split at the sample mean on the Spouse/Friend KSSFC AIAI (Anger) scale, Age at Initial Diagnosis occurred 14.2 years earlier in males.

CONCLUSIONS

Use of a significant other in assessing psychosocial/emotional distress in males may confer greater accuracy, and therefore predictive power for clinical endpoints.

Stress influences the level of negative affectivity after forehead cold pressor pain

The purpose of this study was to investigate simultaneously a stress manipulation and an experimental pain manipulation to determine how stress and pain interact to influence negative affectivity. One hundred healthy subjects completed a counterbalanced repeated measure crossover design in which stress (speech task) versus a nonstress control condition (magazine reading) was manipulated. Each session was immediately followed by a 2-minute forehead cold pressor task. Measures of affectivity (Positive Affect Negative Affect Schedule), pain ratings, cardiovascular measures (systolic blood pressure, diastolic blood pressure, heart rate), and salivary cortisol were obtained during each session. Regression analysis showed that the stress manipulation influenced the level of anger and that change in anger predicted post-pain negative affectivity independently of the contribution of maximum pain (model R(2) =.31), with 45% of the total model variance accounted for by change in anger and 17% of the total model variance accounted for by maximum pain intensity. In the nonstress condition only level of pain intensity was an independent predictor of negative affectivity (model R(2) =.16), with 69% of the total model variance accounted for by maximum pain intensity. These results show that stress significantly amplifies post-pain negative mood beyond that accounted for by the level of pain intensity alone.

Epidemiology of comorbid coronary artery disease and depression

This article reviews the epidemiology of comorbid coronary artery disease and unipolar depression. Both major depression and subsyndromal depressive symptoms will be considered; unless otherwise specified, the term depression will be used to designate all depressive states, including major depressive disorder, minor depression, dysthymia, and other subsyndromal forms of depression. While 17% to 27% of patients with coronary artery disease have major depression, a significantly larger percentage has subsyndromal symptoms of depression. Patients with coronary artery disease and depression have a twofold to threefold increased risk of future cardiac events compared to patients without depression, independent of baseline cardiac dysfunction. The relative risk for the development of coronary artery disease conferred by depression in patients initially free of clinical cardiac disease is approximately 1.5, independent of other known risk factors for coronary disease. In the discussion, special attention will be paid to the interactions of both gender and age with depression and coronary artery disease risk. Scrutiny of the role of confounding risk factors is presented, such as global burden of comorbid medical illness and modification of traditional risk factors, which may, in part, mediate the effect of depression on coronary artery disease.

"It's like an explosion in your life...": lay perspectives on stress and myocardial infarction

Psychological difficulties are common after myocardial infarction (MI). These difficulties are most often represented to patients through cardiac rehabilitation services and the literature offered to patients after MI as being related to "stress" and its management. However, no research has examined what MI patients understand by the term "stress" or how congruent lay views of stress are with those evident in the professional literature. The aim of the study reported here was to examine post-MI patients' views of stress, its functioning and relationship to their MI. As patients' views of stress were sought, qualitative interviews were used. A philosophical approach was taken (critical realism) that recognizes the legitimacy of both professional and lay perspectives. Data were generated in 44 semistructured interviews with 14 MI patients who were interviewed 48 hours, 1 week, 1 month and 3 months after hospital admission. While participants described their experiences after MI as being difficult, to convey this they used everyday terms such as fear, fright and worry. Rather than viewing stress as being a consequence of their MI, they perceived it to be a common cause of heart problems. Many considered stress as having a more influential role than other risk factors, such as smoking and diet. They expressed a wide variety of sophisticated and diverse views of stress and its functioning. Each of these views placed different weighting on the roles of social, personal and situational factors in contributing to the stressful reaction. Parallels were apparent between these lay accounts and theories of stress developed in the professional literature.

Behavioral medicine in the prevention and treatment of cardiovascular disease

Cardiac behavioral medicine is the application of behavioral and psychosocial principles to the prevention and treatment of heart disease. Most biomedical cardiovascular risk factors (e.g., high blood lipids, high blood pressure, diabetes) require behavioral and medical interventions. Other risks, including obesity, high-fat eating pattern, smoking, and inactivity, clearly require lifestyle change. Behavioral medicine screening and intervention have been applied to psychosocial risk factors such as depression, hostility, and social isolation. Appropriate assessment of risk factors is essential because research has demonstrated successful prevention of heart disease and reduction of morbidity and mortality in patients with existing disease. Behavioral interventions have been beneficial in improving cardiac outcomes by enhancing compliance with medication taking and dietary/exercise recommendations. Future needs include the study of psychosocial factors in women and ethnic minorities with heart disease and the integration of behavioral medicine with newer medical technologies designed to detect subclinical biomarkers of heart disease.

Chest pain and the treatment of psychosocial/emotional distress in CAD patients

Treatment of psychosocial/emotional distress as a strategy for diminishing chest pain in such patients remains entirely unutilized in standard care. Sixty-three patients with known or suspected CAD were entered in an aggressive lifestyle modification program. Patients completed the Symptom Checklist 90-Revised (SCL90R) at the diagnostic interview session, at 3 and at 12 months. Statistically significant drops were observed on multiple scales of the SCL90R at both 3 and 12 months. An item from the SCL90R was used as a proxy for angina. Multiple measures of emotional distress at baseline were found to correlate with chest pain at baseline, but not a number of traditional cardiovascular risk factors. The chest pain item displayed improvement at both 3 and 12 months. Improvement on all scales of the SCL90R correlated with improvement in chest pain. It may be possible to control chest pain in some CAD patients with psychosocial interventions.