Psychiatric outcome in men and women after coronary bypass surgery

A systematic review of health-related quality of life and psychological outcomes after lung transplantation

BACKGROUND

Lung transplantation (LTx) aims to reduce physical disability and mental distress, extend survival, and improve health-related quality of life (HRQoL). In this systematic review we aimed to: (1) augment evidence regarding measures to assess HRQoL and psychological outcomes after LTx; and (2) summarize HRQoL and psychological outcomes after LTx.

METHODS

Validated and standardized instruments with well-known psychometric properties used for assessing HRQoL and psychological outcomes after LTx were identified by means of comprehensive literature searches of PsychINFO and Medline/PubMed, up through March 2014, using the following search terms in various combinations: lung transplantation; physical functioning; symptom experience; mental health; anxiety; depression; distress; social functioning; life satisfaction; and health-related quality of life.

RESULTS

The search strategy identified 371 titles and abstracts. Of these, 279 were retrieved for further assessment and 63 articles selected for final review. Thirty-nine studies were found for HRQoL, 15 for physical functioning, 5 for mental health and 4 for social functioning. A total of 50 psychometric instruments were encountered.

CONCLUSIONS

Considerable heterogeneity exists in methodology, operational concepts and applied outcome measures in the existing literature on HRQoL and psychological outcomes after LTx. Nevertheless, the studies generally point to significant improvements in both mental health and HRQoL post-transplant. Further research is warranted utilizing consistent outcome measures, including LTx-specific measures and longitudinal study designs.

A systematic review of pre-operative predictors of post-operative depression and anxiety in individuals who have undergone coronary artery bypass graft surgery

In addition to the physical benefits, another important objective of coronary artery bypass graft (CABG) surgery is improvement of health-related quality of life. The aim of this systematic review is to provide an overview of the literature relating to the pre-operative prediction of post-operative depression and anxiety in individuals who have undergone CABG surgery. Forty-six studies were identified through a literature search of electronic databases conducted using explicit inclusion and exclusion criteria. The study characteristics, methodological features, and psychometric and clinical outcomes were summarised in a systematic manner. Collective appraisal of the studies indicated that symptoms of depression and anxiety exhibited after CABG surgery are best predicted by pre-operative measures of functioning in that area. Papers were inconclusive with respect to the predictive qualities of gender and age. Further research is required to clarify the predictive values of these and other factors, including pre-morbid ill health and socio-economic status. The findings of this review indicate a range of pre-operative predictors of post-operative depression and anxiety in patients with CABG. Chief among these are pre-operative depression and anxiety. These findings have clinical implications concerning the importance of pre and post-operative psychological assessment and intervention for individuals at risk of poor psychological recovery.

The coronary artery bypass experience: gender differences

OBJECTIVE

The primary purpose of this study was to examine differences between women and men on physical, social and psychological domains of health quality of life before, 1 month after, and 3 months after coronary artery bypass surgery.

DESIGN

A prospective, longitudinal design was used.

SETTING

The study was conducted at a Midwestern, 500-bed community hospital with an ongoing cardiothoracic surgical program.

PARTICIPANTS

Forty pairs of women and men matched on age within 5 years and body surface area within 0.1m 2.

INSTRUMENTS

The physical, social and psychological domains of health quality of life were assessed using the following instruments: Ferrans and Powers Quality of Life Index, Specific Activity Scale, Symptom Scale, Profile of Mood States, Overall Health Rating Index, and Personal Resource Questionnaire.

RESULTS

Both women and men improved on physical and psychological measures following coronary artery bypass surgery. Compared with men, women reported more shortness of breath and depression and lower ratings of activity, vigor, and overall health. Measures of social support yielded little information.

CONCLUSIONS

Despite matching for age and body surface area, women did not have as favorable an outcome after surgery as men. Continued research needs to further examine the interaction of physical outcomes and depression in women after coronary artery bypass surgery.

Emotional and functional outcomes in women with coronary heart disease

Instruments used to measure emotional and functional outcomes of coronary heart disease show a fairly high level of consistency. Scores on depression scales are typically higher in women than men, yet this finding must be balanced with data showing that mean scores for depression are low. Both sexes report moderate levels of anxiety after a cardiac event; however, global mental health is rated as relatively high. Women report lower levels of physical activity and higher levels of disruption in functional activities than men. Women also report resuming household activities early in their recovery, a finding most likely reflective of traditional role responsibilities. Last, for both sexes, emotional distress and functional disability decrease over time and appear to be stable by 6 months after the event.

Depressive symptomatology in coronary artery bypass graft surgery patients

Depression is commonly reported in coronary artery bypass graft (CABG) surgery patients. This study assesses the relationship of preoperative characteristics, life stressors, social support, major cardiac and neurologic outcomes and other complications to depressive symptomatology. Demographic and clinical data, CES-D score and information on life stressors and social support were collected from 237 patients; 92% completed 6-month follow-up. CES-D score > or = 16 was defined as significant depressive symptomatology. Significant depressive symptomatology was found in 43% of patients preoperatively and 23% postoperatively. In multivariate models, low social support (p = 0.008), presence of at least one life stressor within a year of surgery (p = 0.006), moderate to severe dyspnea (p = 0.003), little to no available help (p = 0.05) and less education (p = 0.05) were associated with higher preoperative CES-D score, while longer intensive care unit (ICU) stay (p = 0.0001) and little or no available help (p = 0.0008) predicted higher postoperative CES-D scores when controlling for preoperative CES-D scores. Neither pre- nor postoperative depressive symptomatology was related to major outcomes or other complications. A high rate of significant depressive symptomatology exists in CABG patients preoperatively, and it decreases significantly postoperatively. Patients with the above preoperative characteristics as well as those who stay in the ICU postoperatively for more than 2 days might benefit from psychosocial interventions.

The psychology of men and women recovering from coronary artery bypass surgery

BACKGROUND

Little is known about the differences between men's and women's cardiac rehabilitation processes. What helps men during recovery may not necessarily aid women's recovery. Psychosocial variables are known to impact recovery in positive and negative ways. Unfortunately, it is not clear what variables are the most effective predictors of recovery outcomes for men and women.

METHODS

Ninety coronary artery bypass graft patients (60 men, 30 women) completed a battery of psychological questionnaires on or after the third day after surgery.

RESULTS

Results showed that women reported significantly more depressive symptoms than men. For women, pain was correlated positively with depressive symptomatology and functional impairment. For men, pain and functional impairment were correlated negatively with social support. In addition, the results of a multiple regression of pain on age, severity of disease, and two psychosocial variables (depressive symptomatology and social support) for the women showed that after controlling for age and severity of disease, depressive symptomatology and social support accounted for a significant 43% increment in the variance in pain. The psychosocial variables accounted for much less variance in pain in men. However, in a multiple regression of functional impairment on the same variables, depressive symptomatology and social support accounted for a significant 14% increment in the variance in pain in men but a nonsignificant increment for the women.

CONCLUSIONS

The results support the notion that psychosocial variables play different roles in the recovery paths of men and women. In consequence, cardiac rehabilitation programs would be more effective with gender-specific tailoring.

A structural modeling analysis of anxiety and depression in patients undergoing coronary artery bypass graft surgery: a model generating approach

The present study is a longitudinal study designed to explore structural relationships between anxiety, depression, personality, and background factors (e.g., gender, age, and complicated medical characteristics) in patients undergoing coronary artery bypass graft (CABG) surgery. At two timepoints before and two after CABG, 217 patients completed self-report questionnaires. To explore structural relationships, the structural equation modeling (SEM) method was applied. Using the model-generating approach, a model was developed, providing a good fit. The structural relationships revealed, in particular, the key position of neuroticism, which was related to both pre- and postoperative anxiety and depression. Relationships between anxiety and depression over time, both intra- and interrelationships, were relatively weak. Relationships between anxiety and depression at the same points in time were relatively strong, with preoperative depression leading to preoperative anxiety, and postoperative anxiety leading to postoperative depression. To provide a useful framework for development of intervention strategies, further research is needed to evaluate the plausibility of the final structural model.

Gender differences in fears related to coronary arteriography

OBJECTIVE

To compare levels of fear and the intensity of specific fears in women and men related to coronary arteriography (CA).

DESIGN

Prospective survey.

SETTING

A 1360-bed university hospital. Data were collected before, during, and after CA, and again 6 months later.

SUBJECTS

The sample consisted of 54 women and 166 men undergoing scheduled CA.

METHODS

To compare fear levels at different points of evaluation; two analyses of covariance for repeated measures were performed.

RESULTS

On average, women had significantly higher mean scores of fear across the points of evaluation on the Visual Analogue Scale than men (P <.001). During the hospital stay, the most intense fear for both women and men was the fear of coronary artery bypass grafting and the uncertainty about the illness, whereas at home it was the fear of myocardial infarction. On average, women reported significantly intense fears more frequently than men across time. On average, men experienced more intensive fear of problems in their sex life than women (P =. 032). The changes in intensity of fears over time were not significantly different by gender, except in fear of pain (P =.013), health care staff not having enough time to care for the patient (P =.039), and health care staff discussing the patient's condition without the patient being present (P =.048). Age and prior CA were found to be significantly related to most of the fears at different points of evaluation, and to the changes of fears over time.

CONCLUSION

There existed differences in the tendency to report intensity of fears by gender; however, the intensity of fears changed in a similar way over time. The results suggest that the few gender differences in fears that existed may be explained by the treatment chosen for the patients and the patients' acceptance of it. Therefore, it is important to adapt information and support according to the treatment chosen for the patient.

The course of anxiety and depression in patients undergoing coronary artery bypass graft surgery

A semilongitudinal study was designed to follow-up the course of anxiety and depression in patients undergoing coronary artery bypass graft (CABG) surgery. The focus was on possible effects of gender and age on variations in both mean level and interindividual differences over time. At two timepoints before and two after surgery, 217 patients completed self-report questionnaires. Multivariate testing revealed an overall decrease in mean levels of anxiety and depression in the postoperative period but different trends for men and women. Compared with men, women reported more anxiety and depression, both pre- and postoperatively, but showed a relatively stronger decrease in the early postoperative period. Regarding variations in interindividual differences over time, multivariate testing revealed different trends of depression for men and women. Women appeared to be most homogeneous in the early days after surgery, whereas interindividual differences for men showed a stable trend.

How gender affects psychological adjustment one year after coronary artery bypass graft surgery

This research investigated gender differences in psychological adjustment among patients (112 males, 39 females) one year after coronary artery bypass graft surgery (CABG). Information regarding post-CABG depression, non-cardiac chronic conditions, and socioeconomic variables were obtained from a survey. Additional cardiac, surgical, and demographic data were retrieved from a hospital computer database. Women were more likely than men to experience postoperative depression, attributable to their poor health. Depression one year post-CABG was predicted by non-cardiac chronic illnesses, postoperative fatigue and shortness of breath and socioeconomic status.

Psychological recovery from coronary artery bypass graft surgery: the use of complementary therapies

This study explored the use of complementary therapies that patients pursued after coronary artery bypass graft (CABG) surgery and its relation to psychological recovery, particularly postoperative distress. Information about post-CABG Surgery depression and general distress, health-care practice thereafter, perceived social support, and chronic conditions other than cardiac disease was gathered from a sample of 151 patients through two questionnaires. Additional cardiac, surgical, and demographic data were obtained from medical records. Structural equation modeling (LISREL 8) was used to test the hypothesis that patients' health-care practices improved psychological adjustment after CABG. Of the sample, 85% practiced complementary approaches, especially prayer, exercise, and lifestyle-diet modification. The number of the other chronic illnesses strongly predicted post-CABG depression and general distress. CABG patients who pursued complementary approaches, particularly exercise and prayer, had better psychological recovery.

Prediction of quality of life after coronary artery bypass graft surgery: a review and evaluation of multiple, recent studies

OBJECTIVE

To review studies predicting psychosocial outcome after coronary artery bypass graft surgery (CABG).

METHODS

Seventeen prospective studies, appearing in the MEDLINE and PsycLIT data bases between 1986 and 1996, were reviewed regarding objectives, methodological issues, results, and clinical relevance.

RESULTS

All studies reported that psychological factors bad predictive value. In particular, preoperative anxiety and depression predicted postoperative psychological maladjustment; social support, preoperative feelings of control, denial, and optimism contributed to psychological adjustment.

CONCLUSIONS

Many specific psychological outcomes seem to be best predicted by preoperative assessment of functions in that specific area, especially in the case of anxiety and depression. Furthermore, personality factors including denial, optimism, control, and the need for support appear to be predictors of psychological outcome. Appropriate identification of predictive factors might improve the development of individually tailored interventions for patients at risk of postoperative psychological problems.

Psychosocial factors of coronary heart disease in women: a review

Although coronary heart disease is the leading cause of death in women in most industrialized countries, much less research has been carried out on this topic to date than in men. This article gives an overview of psychosocial factors of coronary heart disease in women, focussing on psychosocial risk factors for coronary heart disease in women such as socioeconomic status, employment status, chronic troubling emotions, social support and bereavement/widowhood. A second focus lies on psychosocial adjustment in women once coronary heart disease has become manifest, i.e. well-being, return to work, sexual activity and rehabilitation outcome after a myocardial infarction or coronary artery bypass grafting. Via a computerized literature research in Medline, Psychlit and Sociofile over the period 1980-1994 all studies on these topics were collected and reviewed. Comparatively more research has been undertaken on psychosocial risk factors for than on psychosocial adjustment to coronary heart disease in women. Low social class, low educational attainment, the double loads of work and family, chronic troubling emotions and lack of social support emerge as documented risk factors in women. Regarding psychosocial adjustment to coronary heart disease in women, there is a paucity of data, and studies including large samples of women and adjusting for gender are warranted. Psychosocial adjustment in women after a myocardial infarction seems to be worse than in men, whereas results on adjustment after coronary artery bypass grafting are inconclusive. Return to work rates after myocardial infarction or coronary artery bypass grafting are significantly lower in women than in men. Data on sexual activity of women after myocardial infarction or coronary artery bypass grafting are scarce, and there seems to be a complete lack of physician counseling on this topic. Studies on rehabilitation outcome report poorer programme uptake, poorer adherence and significantly higher drop-out rates for women than for men, yet those women who complete cardiac rehabilitation show the same or even greater functional improvements than men.

Sex differences in patient recovery patterns after coronary artery bypass surgery

OBJECTIVE

To describe sex differences in physical, psychologic, and social recovery patterns after coronary artery bypass surgery (CABS).

DESIGN

Repeated measures between groups (men versus women) design. Data were collected before discharge from the hospital and at 1, 3, and 6 weeks after discharge.

SETTING

Five teaching hospitals: one urban, three suburban, and one midstate hospital that serves rural and urban clients

SAMPLE

The initial sample consisted of 187 men and 70 women; 132 men and 47 women completed the study.

OUTCOME MEASURES

Physical recovery was assessed by three subscales of the Sickness Impact Profile--ambulation, sleep-rest, body care and movement; a Symptom Inventory, and a Cantril Ladder Scale. Psychologic recovery was measured by the Beck Depression Inventory, the Rosenberg Self-Esteem Scale, and a Cantril Ladder Scale. Social recovery was measured by three subscales of the Sickness Impact Profile--home management, social interaction, and recreation and pastimes.

RESULTS

All measures indicated significant improvement over time with the exception of self-esteem and perception of mental health, which remained stable. There were significant differences between men and women on five recovery variables: ambulation dysfunction, physical symptoms, perceptions of physical health, symptoms of depression, and home management dysfunction.

CONCLUSIONS

Though it is encouraging that both sex groups experienced significant improvement in recovery over time, men and women show some differences in recovery experiences that need to be considered when planning their care.

Psychosocial adjustment before and after coronary artery bypass surgery

Twenty-eight consecutive male patients were examined a few days before, and again twelve months after, coronary artery bypass surgery. The evaluation included the patients' psychological distress, psychosocial adjustment, cardiac state, personality and family relations. Before surgery the patients were relatively well adjusted, despite being severely disabled physically. On the follow-up evaluation the cardiac state improved significantly on every index examined. On the other hand no change occurred in the psychological distress, personality and family relations. Significant post-operative improvement was found in some of the domains of the psychosocial adjustment, but not in others.

Beneficial effects of psychiatric intervention on recovery after coronary artery bypass graft surgery

The effects of perioperative psychiatric intervention were studied in 33 patients undergoing coronary artery bypass graft (CABG) surgery. All patients were evaluated preoperatively using the Mini-Mental State Exam and the Psychological Adjustment to Illness Scale-Self-Report. Participants in the study group (N = 16) had a structured psychiatric interview prior to surgery and were followed daily with supportive psychotherapy throughout their hospitalization. The number of medical complications was higher in the control group. No significant differences were found in neurologic or psychologic complications. The study group used significantly more oxycodone-acetaminophen (Percocet), but less morphine-sulfate or benzodiazepine on postoperative days 3, 4, and 6. The mean length of stay was 3 days shorter for patients in the study group. In the current era of escalating health care costs and high technology, clinical protocols and research studies that evaluate the cost effectiveness and efficacy of psychiatric intervention in medically ill patients should be pursued.

Denial: predictor of outcome following coronary bypass surgery

Using a modified version of the Hackett-Cassem denial scale we measured preoperative denial in 121 patients scheduled for CABG surgery. A significant inverse relationship was found between the denial scale and Hamilton Anxiety measures four days postoperatively (p less than .02). Longitudinal assessments were carried out using the Spielberger State Anxiety Inventory (SSAI), the Zung Self-Rating Depression Scale (Zung SDS) and the Psychosocial Adjustment to Illness Scale (PAIS). Six months following the surgery, significant negative relationships between denial and these self-report outcome measures were observed as follows: denial and SSAI (p less than .001), denial and Zung SDS (p less than .01), and denial and PAIS (p less than .01). However, the same analysis at twelve months showed no statistically significant correlations between denial and these psychologic outcome measures. Our findings suggest that denial serves as an adaptive mechanism, especially in the immediate postoperative period. Furthermore, higher levels of denial may be predictive of improved psychologic outcome for up to six months following surgery. Subsequently, however, other events, unrelated to the surgery, may be of greater importance than preoperative denial in determining psychological outcome from CABG surgery.