The effect of low social support on short-term prognosis in patients following a first myocardial infarction

Positive psychosocial factors and the development of symptoms of depression and posttraumatic stress symptoms following acute myocardial infarction

Introduction

Acute myocardial infarction (MI) is a potentially fatal condition, leading to high psychological distress and possibly resulting in the development of depressive symptoms and posttraumatic stress symptoms (PTSS). The aim of this study was to investigate the association of clusters of positive psychosocial factors (resilience, task-oriented coping, positive affect and social support) with both MI-induced depressive symptoms and PTSS, independent of demographic factors.

Methods

We investigated 154 consecutive patients with MI, 3 and 12 months after hospital discharge. All patients completed the short version of the German Resilience Scale, the Coping Inventory for Stressful Situations (CISS), the Enriched Social Support Inventory (ESSI) and the Global Mood Scale (GMS). The level of interviewer-rated MI-induced posttraumatic stress disorder (PTSD) symptoms at 3- and 12-months follow-up was evaluated through the Clinician-Administered PTSD Scale (CAPS). Depressive symptoms were assessed at 3- and 12-month follow-up with the Beck Depression Inventory (BDI-II).

Results

Three different clusters were revealed: (1) lonely cluster: lowest social support, resilience and average task-oriented coping and positive affect; (2) low risk cluster: highest resilience, task-oriented coping, positive affect and social support; (3) avoidant cluster: lowest task-oriented coping, positive affect, average resilience and social support. The clusters differed in depressive symptoms at 3 months (F = 5.10; p < 0.01) and 12 months follow-up (F = 7.56; p < 0.01). Cluster differences in PTSS were significant at 3 months (F = 4.78, p < 0.05) and 12 months (F = 5.57, p < 0.01) follow-up. Differences in PTSS subscales were found for avoidance (F = 4.8, p < 0.05) and hyperarousal (F = 5.63, p < 0.05), but not re-experiencing, at 3 months follow-up. At 12 months follow-up, cluster differences were significant for re-experiencing (F = 6.44, p < 0.01) and avoidance (F = 4.02, p < 0.05) but not hyperarousal.

Discussion

The present study contributes to a better understanding of the relationships among different positive psychosocial factors, depressive symptoms and PTSS following acute MI. Future interventions may benefit from taking into account positive psychosocial factors to potentially reduce patients' depressive symptoms and PTSS after MI.

Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

OBJECTIVE

PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations.

METHODS

A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies.

RESULTS

From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.

Course, Moderators, and Predictors of Acute Coronary Syndrome-Induced Post-traumatic Stress: A Secondary Analysis From the Myocardial Infarction-Stress Prevention Intervention Randomized Controlled Trial

Acute coronary syndromes (ACS) induce post-traumatic stress symptoms (PTSS) in one out of eight patients. Effects of preventive interventions, the course and potential moderators of ACS-induced PTSS are vastly understudied. This study explored whether a preventive behavioral intervention leads to a decrease in myocardial infarction (MI)-induced PTSS between two follow-up assessments. Sociodemographic, clinical and psychological factors were additionally tested as both moderators of change over time in PTSS and predictors of PTSS across two follow-ups. Within 48 h after reaching stable circulatory conditions, 104 patients with MI were randomized to a 45-min one-session intervention of either trauma-focused counseling or stress counseling (active control). Sociodemographic, clinical, and psychological data were collected at baseline, and PTSS were assessed with the Clinician-Administered Post-traumatic Stress Disorder Scale 3 and 12 months post-MI. PTSS severity showed no change over time from 3 to 12 months post-MI, either in all patients or through the intervention [mean group difference for total PTSS = 1.6 (95% CI -1.8, 4.9), re-experiencing symptoms = 0.8 (95% CI -0.7, 2.2), avoidance/numbing symptoms = 0.1 (95% CI -1.6, 1.7) and hyperarousal symptoms = 0.6 (95% CI -0.9, 2.1)]. Patients receiving one preventive session of trauma-focused counseling showed a decrease from 3 to 12 months post-MI in avoidance symptoms with higher age (p = 0.011) and direct associations of clinical burden indices with total PTSS across both follow-ups (p's ≤ 0.043; interaction effects). Regardless of the intervention, decreases in re-experiencing, avoidance and hyperarousal symptoms from 3 to 12 months post-MI occurred, respectively, in men (p = 0.006), participants with low education (p = 0.014) and with more acute stress symptoms (p = 0.021). Peritraumatic distress (p = 0.004) and lifetime depression (p = 0.038) predicted total PTSS across both follow-ups. We conclude that PTSS were persistent in the first year after MI and not prevented by an early one-session intervention. A preventive one-session intervention of trauma-focused counseling may be inappropriate for certain subgroups of patients, although this observation needs confirmation. As predictors of the development and persistence of PTSS, sociodemographic and psychological factors could help to identify high-risk patients yet at hospital admission.

Myocardial infarction-induced acute stress and post-traumatic stress symptoms: the moderating role of an alexithymia trait - difficulties identifying feelings

BACKGROUND

It has been acknowledged that medical life-threatening experiences such as an acute myocardial infarction (MI) often lead to acute stress disorder symptoms (ASS), which in turn can result in the development of post-traumatic stress symptoms (PTSS). Previous studies have suggested an association between various traumatic experiences and alexithymia. The association of alexithymia with ASS and PTSS in patients with MI is elusive.

OBJECTIVES

The aim of this study was to examine the association of alexithymia with MI-induced ASS and PTSS in patients at high risk of developing PTSD.

METHOD

Patients (N = 154) were examined twice, once within 48 hours, and then again three months after acute MI. All patients completed the self-rating Acute Stress Disorder Scale (ASDS) within 48 hours after the cardiac event. Three months after hospital discharge, all patients completed the Toronto Alexithymia Scale (TAS-20) and underwent the Clinician-Administered PTSD Scale (CAPS), a structured interview to assess the severity of PTSS. Descriptive statistics, correlations, multivariate linear regressions, and moderation analysis were conducted.

RESULTS

The linear regression model explained 23% of the variance in MI-induced PTSS-symptoms (F(6.109) = 5.58, p < 0.001, R ² = 0.23. ASS was significantly related to PTSS severity (r (152) = p < 0.001). The scores of the TAS-20 subscale difficulties identifying feelings (DIF) were found to significantly moderate this relationship (R²  = 0.03, p = 0.04). The scores of TAS-20 subscales DDF and EOT as well as the TAS-20 total score had no influence on the relationship between ASS and PTSS (p > 0.05).

CONCLUSION

In MI patients with high levels of DIF, ASS predicted the development of PTSS. If replicated, the finding may inform emotion-oriented interventions to investigate whether increasing the capacity to identify feelings following acute MI could be beneficial in preventing the development of PTSS.

Psychosocial Factors Associated with Subclinical Atherosclerosis in South Asians: The MASALA Study

South Asians have the highest rates of premature atherosclerotic cardiovascular disease amongst all ethnic groups in the world; however this risk cannot be fully explained by traditional risk factors. Participants from the Mediators of Atherosclerosis in South Asians Living in America Study were included in this cross-sectional analysis. The purpose of this study was to investigate the association of psychosocial factors (including anger, anxiety, depressive symptoms, current and chronic stress, and everyday hassles) with carotid intima-media thickness (CIMT). Three multivariate models were examined to evaluate the association between the psychosocial factors and CIMT. Findings suggest that the impact of psychosocial factors on subclinical atherosclerosis is differential for South Asian men and women. For men, anxiety and depression were associated; while for women, stress was associated with common carotid intima media thickness, independent of traditional CVD risk factors, diet and physical activity.

Measures of Patient Activation and Social Support in a Peer-Led Support Network for Women With Cardiovascular Disease

PURPOSE

Social support has been associated with beneficial effects on many disease states and overall health and well-being. However, there is limited research exploring the impact of peer-led support models among women living with coronary heart disease. This study describes the structure of peer-led support groups offered by WomenHeart (WH): The National Coalition for Women Living with Heart Disease, and assesses WH participants' quality of life and social, emotional, and physical health.

METHODS

Participants were recruited from 50 WH groups. A 70-item online survey was administered, and the main analytic sample included 157 women. Multivariate logistic regression was used to examine the association between patient activation levels (lower activation levels: 1, 2 vs higher activation levels: 3, 4) and social support scores (range: lowest 8 to highest 34), adjusting for age.

RESULTS

High levels of social support, patient activation, physical activity, and low levels of stress, anxiety, and depression were reported. Those who were at or above the median for the social support measures (indicating high levels of social support) had greater odds of high levels of patient activation (level 3 or 4) than individuals reporting low levels of social support (OR = 2.23; 95% CI, 1.04-4.76; P = .012).

CONCLUSIONS

Women who regularly attended a support group by a trained peer leader were highly engaged in their health care and had low levels of stress, anxiety, and depression. These findings lend credibility to the value of the peer support model and could potentially be replicated in other disease states to enhance patient care.

Social and health-related factors associated with refraining from seeking dental care: A cross-sectional population study

BACKGROUND

Social inequities are considered to affect healthcare utilization, whereas less is known about the factors associated with refraining from seeking dental care. This study aimed to investigate whether people with no social support, long-term illness, caregiver burden and low socioeconomic status (SES) refrained from seeking dental care in higher proportion than the general Swedish population.

METHODS

This study used cross-sectional questionnaire data from repeated nationwide health surveys during 2004-2013 of a total of 90 845 people. The questionnaire included questions on demographic characteristics, social support, long-term illness, caregiving burden, SES and dental care-seeking behaviour. Descriptive statistics, chi-square tests, correlation analyses and logistic regressions were used to investigate associations between independent variables and dental care-seeking behaviour.

RESULTS

In the total sample, 15.1% of respondents reported refraining from seeking dental care. Having no emotional social support or having no instrumental social support was separately associated with reporting refraining from seeking dental care in adjusted multivariate models (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.18-1.34 and OR: 1.89, 95% CI: 1.67-2.13, respectively). Having a long-term illness was associated with refraining from seeking dental care in adjusted models (adjusted OR: 1.43, 95% CI: 1.35-1.51). Furthermore, being an informal caregiver was associated with refraining from seeking dental care (adjusted OR: 1.15, 95% CI: 1.07-1.23). Low SES was associated with higher refraining from seeking dental care; the strongest association was with having financial problems (adjusted OR: 3.57, 95% CI: 3.19-4.00). Interaction effects were found between education level and SES, and between social support and long-term illness, and the outcome.

CONCLUSIONS

The findings in this study imply that having no social support, having long-term illness, being informal caregiver or having financial problems are factors associated with reporting refraining from seeking dental care, on a population basis.

Posttraumatic stress disorder after myocardial infarction and coronary artery bypass grafting

Post traumatic stress disorder is a psychiatric disease that is usually precipitated by life threatening stressors. Myocardial infarction, especially in the young can count as one such event. The development of post traumatic stress after a coronary event not only adversely effects psychiatric health, but leads to increased cardiovascular morbidity and mortality. There is increasing evidence that like major depression, post traumatic stress disorder is also a strong coronary risk factor. Early diagnosis and treatment of this disease in patients with acute manifestations of coronary artery disease can improve patient outcomes.

The Role of Sexual Satisfaction, Age, and Cardiac Risk Factors in the Reduction of Post-MI Anxiety

BACKGROUND

Anxiety is common after myocardial infarction (MI); however, little is known about the role of sexual satisfaction and return to sexual activity on anxiety post-MI.

AIM

To examine the role of sexual satisfaction in reducing anxiety post-MI.

METHODS

Patients with acute myocardial infarction (MI) recruited from one U.S. medical center completed questionnaires at baseline while hospitalized and at 1, 3, and 5 months post-MI. This analysis includes 64 patients compared on low or high anxiety at 5 months post-MI using sexual satisfaction and selected demographic and clinical variables in the analysis.

RESULTS

Patients with high anxiety scores reported lower sexual satisfaction (p < .001) and a higher percentage of coronary risk factors (p < .01). The OLS regression model provided similar results with an adjusted R-square of .422, accounting for approximately 42% of anxiety (p < .001). Sexual satisfaction accounted for the most variance in the model, showing an inverse relationship between sexual satisfaction and anxiety. An inverse relationship also existed between age and anxiety.

CONCLUSIONS

Anxiety is common after MI, and decreased sexual satisfaction appears to contribute to heightened anxiety. Attention to sexual concerns of MI patients before and after hospital discharge may improve psychosocial outcomes.

Effect of low perceived social support on health outcomes in young patients with acute myocardial infarction: results from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study

Background

Social support is an important predictor of health outcomes after acute myocardial infarction (AMI), but social support varies by sex and age. Differences in social support could account for sex differences in outcomes of young patients with AMI.

Methods and Results

Data from the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, an observational study of AMI patients aged ≤55 years in the United States and Spain, were used for this study. Patients were categorized as having low versus moderate/high perceived social support using the ENRICHD Social Support Inventory. Outcomes included health status (Short Form‐12 physical and mental component scores), depressive symptoms (Patient Health Questionnaire), and angina‐related quality of life (Seattle Angina Questionnaire) evaluated at baseline and 12 months. Among 3432 patients, 21.2% were classified as having low social support. Men and women had comparable levels of social support at baseline. On average, patients with low social support reported lower functional status and quality of life and more depressive symptoms at baseline and 12 months post‐AMI. After multivariable adjustment, including baseline health status, low social support was associated with lower mental functioning, lower quality of life, and more depressive symptoms at 12 months (all P<0.001). The relationship between low social support and worse physical functioning was nonsignificant after adjustment (P=0.6). No interactions were observed between social support, sex, or country.

Conclusion

Lower social support is associated with worse health status and more depressive symptoms 12 months after AMI in both young men and women. Sex did not modify the effect of social support.

An Enduring Somatic Threat Model of Posttraumatic Stress Disorder Due to Acute Life-Threatening Medical Events

Posttraumatic stress disorder (PTSD) occurs in 12-25% of survivors of acute life-threatening medical events such as heart attack, stroke, and cancer, and is associated with recurrence of cardiac events and mortality in heart attack survivors. This article reviews the current state of knowledge about PTSD after such events, and proposes an Enduring Somatic Threat (EST) model of PTSD due to acute life-threatening medical events to address underappreciated differences between PTSD due to past, discrete/external traumatic events (such as combat) and PTSD due to acute manifestations of chronic disease that are enduring/internal in nature (such as heart attack and stroke). The differences include the external versus internal/somatic source of the threat, the past versus present/future temporal focus of threatening cognitions, the different types and consequences of avoidance behavior, and the different character and consequences of hyperarousal. Although important differences between the two types of PTSD exist, the EST model proposes that the underlying fear of mortality maintains PTSD symptoms due to both discrete/external and ongoing/somatic events. Finally, this article offers a research agenda for testing the EST model, with a particular focus on areas that may improve cardiovascular prognosis and health behaviors in survivors of heart attack and stroke.

Posttraumatic stress disorder following myocardial infarction: personality, coping, and trauma exposure characteristics

OBJECTIVE

This study aimed to investigate the interrelationship between trauma exposure characteristics of myocardial infarction (MI), MI patients' personality traits, coping strategies, post-MI PTSD, and general psychological distress.

METHOD

One hundred and twenty MI patients were recruited from two general practices. The MI patients were interviewed using a MI experience questionnaire and completed the Posttraumatic Stress Diagnostic Scale (PDS), the General Health Questionnaire-28 (GHQ-28), the NEO-Five Factor Inventory (NEO-FFI), and the COPE Scale.

RESULTS

Neuroticism was directly associated with post-MI PTSD and general psychological distress, while agreeableness did not link to the outcomes directly. Neuroticism influenced MI exposure characteristics which in turn influenced PTSD. Agreeableness affected PTSD and general psychological distress through MI exposure characteristics. Neuroticism influenced problem-focused coping which in turn affected general psychological distress. Agreeableness influenced problem-focused coping which in turn affected PTSD and general psychological distress.

CONCLUSIONS

Patients developed PTSD and general psychological distress following MI. Neurotic and antagonistic personality traits combined with patients' subjective experiences of MI and usage of problem-focused coping influenced the severity of outcomes.

Effects of depression and social support on comprehension and recall of informed consent information among Parkinson disease patients and their caregivers

OBJECTIVE

Relatively little attention has focused on the impact of psychiatric conditions on human subjects' comprehension of consent information. The purpose of this randomized study was to determine whether depression affects comprehension and recall of informed consent information among persons with Parkinson's disease and their caregivers and to evaluate the effects of support on comprehension and recall during the consent process.

METHOD

Comprehension and recall of information were assessed using a modified version of the Modified Quality of Informed Consent Questionnaire, taken 1 week and 1 month later, and scored using a consensus-based algorithm. Participants also completed the Center for Epidemiologic Studies Depression Scale. Data analyses were conducted on 129 patients and caregivers (t-tests, Fisher's exact tests, and ANCOVAs).

RESULTS

T-tests showed no significant differences in comprehension and recall between depressed and nondepressed participants at 1 week and 1 month. However, ANCOVA showed patients with a support person present had significantly higher comprehension and recall at 1 week but not at 1 month compared with controls. Caregivers present with a patient had lower comprehension/recall than those without a patient present (p = 0.02).

CONCLUSIONS

Having a support person present during the informed consent process helps depressed PD patients better retain information in the short-term, but effects diminish over the long-term. Implications for interventions will be discussed.

Chronic posttraumatic stress and its predictors in patients living with an implantable cardioverter defibrillator

INTRODUCTION

Patients with an implantable cardioverter defibrillator (ICD) show clinically relevant depression and anxiety, but little is known about their levels of posttraumatic stress. We assessed chronic posttraumatic stress attributable to a traumatic cardiac event and its predictors in patients at two time points after ICD placement.

METHODS

We investigated 107 consecutively enrolled patients (57 ± 14 years, 62% men) on average 24 ± 21 months after ICD placement (baseline) and again 41 ± 18 months later (follow-up). All patients completed the Impact of Event Scale-Revised (IES-R) to self-rate the severity of posttraumatic stress (range 0-110). The 30% of patients with the highest IES-R scores (≥ 25) at baseline were defined as PTSD cases; the same threshold was applied to define PTSD caseness at follow-up.

RESULTS

Posttraumatic stress increased from baseline to follow-up (19 ± 22 vs. 25 ± 19, p < 0.001); 19% of patients had PTSD at both assessments, 12% at baseline only, and 18% at follow-up only. Female gender as well as greater peritraumatic dissociation and depression predicted greater posttraumatic stress at baseline (p-values ≤ 0.041). Greater baseline posttraumatic stress, helplessness, alexithymia, and ≥ 5 shocks during follow-up all predicted greater posttraumatic stress at follow-up (p-values ≤ 0.029). Female gender, helplessness, and depression predicted PTSD at baseline (p-values ≤ 0.022); low education and posttraumatic stress at baseline predicted PTSD at follow-up (p-values ≤ 0.003).

CONCLUSIONS

Between 2 and 5.5 years post-ICD placement chronic posttraumatic stress slightly increased and nearly one-fifth of patients had newly developed PTSD. The identified psychological predictors of long-term chronicity of posttraumatic stress might particularly inform behavioral interventions for ICD recipients.

Depressive symptoms and poor social support have a synergistic effect on event-free survival in patients with heart failure

BACKGROUND

Depressive symptoms and poor social support are predictors of increased morbidity and mortality in patients with heart failure (HF). However, the combined contribution of depressive symptoms and social support event-free survival of patients with HF has not been examined.

OBJECTIVE

To compare event-free survival in 4 groups of patients with HF stratified by depressive symptoms and perceived social support (PSS).

METHOD

A total of 220 patients completed the Beck Depression Inventory-II and the Multidimensional Perceived Social Support Scale and were followed for up to 4 years to collect data on death and hospitalizations.

RESULTS

Depressive symptoms (hazard ratio = 1.73, P = .008) and PSS (hazard ratio = 1.51, P = .048) were independent predictors of event-free survival. Depressed patients with low PSS had 2.1 times higher risk of events than non-depressed patients with high PSS (P = .003).

CONCLUSION

Depressive symptoms and poor social support had a negative additive effect on event-free survival in patients with HF.

Stress-related symptoms and positive emotions after a myocardial infarction: a longitudinal analysis

BACKGROUND

There is a controversy as to whether the diagnostic umbrella of post-traumatic stress reactions is directly applicable to serious health conditions like myocardial infarction (MI).

OBJECTIVE

The principal objective of this study was to examine longitudinally the prevalence of posttraumatic stress-related symptoms, throughout three measurement periods, for patients who had suffered a first MI. In addition to the analysis of symptoms related to stress and general distress, the presence of and temporary evolution of positive emotions and optimism in these patients was also evaluated.

DESIGN

A longitudinal study with three periods of evaluation after the MI (Time 1 (T1): 48-72 hours, Time 2 (T2): 5 months, and Time 3 (T3): 13 months).

RESULTS

In T1 few symptoms related to the stressful event were found. The probable prevalence of PTSD was 8-11% at 5 months after the MI and 0-3% 13 months after the event. With regard to subjective severity of the infarction, although in the first instance patients did not regard the event as excessively traumatic, in the periods T2 and T3 this perception increased significantly [F (2, 32)=20.00; p=0.0001]. At all times during the measurement period the mean positive affect was significantly greater than the negative affect.

CONCLUSIONS

As the results show, the probable prevalence of PTSD, as well as the severity of different symptom clusters, is low at all times of the evaluation. The diagnostic implications of these findings are discussed as well as the uses and abuses of diagnostic labels to characterize the psychological experiences lived through after a potentially life-threatening health problem.

Single-living is associated with increased risk of long-term mortality among employed patients with acute myocardial infarction

OBJECTIVE

There is conflicting evidence about the impact of social support on adverse outcome after acute myocardial infarction (MI). We examined the relation between single-living and long-term all-cause mortality after MI.

DESIGN

A prospective cohort study of 242 employed patients with MI followed up to 16 years after MI.

RESULTS

A total of 106 (43.8%) patients died during the follow-up. Single-living nearly doubled the risk of death; after adjusting for potential confounding factors, single-living was an independent predictor of death, with a hazard ratio of 2.55 (95% confidence interval: 1.52-4.30). Other predictors of death were diabetes mellitus, atrial fibrillation, age, and ejection fraction less than 35%.

CONCLUSION

Single-living is a prognostic determinant of long-term all-cause mortality after MI.

Change over time in posttraumatic stress caused by myocardial infarction and predicting variables

OBJECTIVE

The traumatic experience of a heart attack may evolve into symptoms of posttraumatic stress disorder, which can be diagnosed at the earliest 1 month after myocardial infarction (MI). While several predictors of posttraumatic stress in the first year after MI have been described, we particularly sought to identify longer-term predictors and predictors of change in posttraumatic stress over time.

METHODS

We studied 274 post-MI patients with complete data (mean 61+/-10 years, 84% men). After a median of 60 days (range 30-365) following the index MI (study entry), they were asked to rate MI-related posttraumatic stress as well as psychological distress perceived during MI. After a median of 32 months (range 19-45) later, all patients were asked to rate posttraumatic stress again (follow-up).

RESULTS

Female gender (P=.038) as well as greater helplessness (P<.001) and pain (P=.049) during MI predicted greater posttraumatic stress at study entry. Greater posttraumatic stress at follow-up was predicted by greater posttraumatic stress at study entry (P<.001), shorter duration of follow-up (P=.046), and greater pain during MI (P=.030). The decrease in posttraumatic stress over time (P<.001) was greater in patients with greater posttraumatic stress at study entry (P<.001) and in those with less pain during MI (P=.032).

CONCLUSIONS

Demographic characteristics and perceived distress during MI were predictors of shorter-term posttraumatic stress. Although posttraumatic stress decreased over time and strongest in patients showing the greatest levels initially, greater short-term posttraumatic stress predicted maintenance of posttraumatic stress. Intense pain during MI adversely impacted both longer-term posttraumatic stress and its recovery.

Testing a Model of Physical and Psychological Recovery After a Cardiac Event

Little is known about the specific sources and types of support that assist patients in alleviating stress and achieving positive recovery outcomes after a cardiac event. The purpose of this study is to examine the effects of illness-related stress, emotional and tangible support from a significant other, and informational support from a health care provider on physical and psychological recovery outcomes in cardiac patients 8 weeks after their cardiac event. The sample consists of 220 cardiac patients. Data analysis uses structural equation modeling. Final fit indices were as follows: χ2 ( df = 110) = 156.169, comparative fit index = .963, Tucker—Lewis index = .949, and root mean square error of approximation = .044 suggesting an acceptable model. Illness-related stress has direct effects on depression, physical recovery, and activity levels. Partner emotional support has a direct effect on depression. The findings provide direction for developing social support interventions aimed at improving recovery outcomes.

Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis

OBJECTIVE

To assess the association of anxiety after myocardial infarction (MI) with cardiac prognosis.

METHODS

A meta-analysis of references derived from MEDLINE, EMBASE, and PSYCINFO (1975-March 2009) was performed without language restrictions. End point was cardiac outcome defined as all-cause mortality, cardiac mortality, and cardiac events. The authors selected prospective studies with at least 6 months follow-up, and anxiety had to be assessed within 3 months after MI with reliable and valid instruments.

RESULTS

Twelve papers met selection criteria. These studies described follow-up (on average, 2.6 years) of 5750 patients with MI. Anxious patients were at risk of adverse events (odds ratio (OR) fixed, 1.36; 95% confidence interval (CI), 1.18-1.56; p < .001). Anxiety was also specifically associated with all-cause mortality (OR fixed, 1.47; 95% CI, 1.02-2.13; p = .04), cardiac mortality (OR fixed, 1.23; 95% CI, 1.03-1.47; p = .02), and new cardiac events (OR fixed, 1.71; 95% CI, 1.31-2.23; p < .001).

CONCLUSIONS

Post-MI anxiety is associated with a 36% increased risk of adverse cardiac outcomes in bivariate analyses. Because the existing literature is small and contains several limitations, more research is needed to evaluate the association of anxiety and prognosis in patients with MI and to assess the extent to which this association is independent of clinical variables, such as disease severity, and other psychological variables, especially depression.

Post-traumatic stress disorder following myocardial infarction: prevalence and risk factors

BACKGROUND

Post-traumatic stress disorder (PTSD) is associated with negative impacts on physical health. Victims of a myocardial infarction (MI) who develop PTSD may be particularly affected by these impacts due to their cardiovascular vulnerability. Post-traumatic reactions in this population are not well known.

OBJECTIVES

To examine the prevalence of PTSD after MI and its risk factors, and to validate a prediction model for PTSD symptoms.

METHODS

Patients hospitalized for MI (n=477) were recruited in three hospitals. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and questionnaires concerning PTSD symptoms and general measures were administered to patients during hospitalization and at one-month follow-up.

RESULTS

Four per cent of the patients had PTSD and 12% had partial PTSD. The perception of a threat to life, the intensity of acute stress disorder and depression symptoms several days after the MI, a history of referral to a psychologist or psychiatrist, and female sex were risk factors for the intensity of PTSD symptoms in a sequential multiple regression analysis (R=0.634). The prediction model was validated by applying the regression equation to 48 participants who were not included in the initial regression (R=0.633).

CONCLUSIONS

The risk factors for development of PTSD symptoms identified in the present study could be used to facilitate the detection of patients at risk for developing PTSD symptoms so they can later be offered psychological interventions as needed.

Trajectory of posttraumatic stress disorder caused by myocardial infarction: a two-year follow-up study

OBJECTIVE

A substantial proportion of patients develop posttraumatic stress disorder (PTSD) following myocardial infarction (MI). Previous research on the trajectory over time of PTSD in post-MI patients is scant and refers to self-rated posttraumatic symptoms. The aim of this study was to investigate the longitudinal course of an interviewer-rated diagnosis of PTSD and PTSD symptom severity following MI.

METHODS

Study participants were 40 patients (78% men, mean age 54 +/- 8 years) who were diagnosed with PTSD using the Clinician-administered PTSD Scale (CAPS) after an average of 5 +/- 4 months (range 2-16 months) following an index MI. After a mean follow-up of 26 +/- 6 months (range 12-36 months), 24 patients underwent a second diagnostic interview.

RESULTS

Two-thirds of patients (n = 16) still qualified for a diagnosis of PTSD at follow-up. In all 24 patients, total PTSD symptoms (p = 0.001), re-experiencing symptoms (p < 0.001), avoidance symptoms (p = 0.015), and, with borderline significance, hyperarousal symptoms (p < 0.06) had all decreased over time. However, in the subgroup of the 16 patients who had retained PTSD diagnostic status at follow-up, symptoms of avoidance (p = 0.23) and of hyperarousal (p = 0.48) showed no longitudinal decline. Longer duration of follow-up was associated with a greater decrease in avoidance symptoms (p = 0.029) and, with borderline significance, in re-experiencing symptoms (p < 0.07) across all patients.

CONCLUSION

Although PTSD symptomatology waned over time and in relation to longer follow-up, two-thirds of patients still qualified for a diagnosis of PTSD 2 years after the initial diagnosis. In post-MI patients, clinical PTSD is a considerably persistent condition.

Incidence of posttraumatic stress disorder (PTSD) after myocardial infarction (MI) and predictors of ptsd symptoms post-MI--a brief report

OBJECTIVES

The objectives of this pilot study were to determine the incidence of Posttraumatic Stress Disorder (PTSD) one to two months after Myocardial Infarction (MI), and to evaluate potential predictors of PTSD symptoms post-MI.

METHODS

A convenience sample of 31 patients hospitalized for treatment of acute MI was interviewed during hospitalization and one to two months later. The assessments included socio-demographic questions, questions related to clinical history and hospitalization, assessment of depressive symptoms using the Center for Epidemiologic Studies-Depression (CES-D) scale, medical comorbidity using the Charlson Comorbidity Index (CCI), and perceived social support using the Medical Outcomes Study (MOS) scale. Medical records were reviewed for collection of clinical data. Symptoms of PTSD were evaluated using the Structured Clinical Interview for DSM-IV (SCID) and the Impact of Events Scale-Revised (IES-R).

RESULTS

While one patient (4.0%) met DSM IV criteria for PTSD; additional 16% of the patients had significant symptoms of PTSD as measured by the IES-R (scoring above 24). Higher scores of PTSD symptoms were significantly associated (p < 0.05) with younger age, black race, depressive symptoms in baseline, and self-reported anxiety during the MI.

CONCLUSIONS

The incidence of PTSD following MI was low, but 16% of MI patients developed subsyndromal PTSD. The emotional status of the patients at the time of the MI and their subjective reaction to the event were important factors in the development of PTSD symptoms. Black and younger patients were in increased risk of developing PTSD symptoms post-MI.

Acute stress disorder after myocardial infarction: prevalence and associated factors

OBJECTIVE

To examine the prevalence of acute stress disorder (ASD) after a myocardial infarction (MI) and the factors associated with its development.

METHODS

Of 1344 MI patients admitted to three Canadian hospitals, 474 patients did not meet the inclusion criteria and 393 declined participation in the study; 477 patients consented to participate in the study. A structured interview and questionnaires were administered to patients 48 hours to 14 days post MI (mean +/- standard deviation = 4 +/- 2.73 days).

RESULTS

Four percent were classified as having ASD using the Structured Clinical Interview for DSM-IV, ASD module. The presence of symptoms of depression (Beck Depression Inventory; odds ratio (OR) = 29.92) and the presence of perceived distress during the MI (measured using the question "How difficult/upsetting was the experience of your MI?"; OR = 3.42, R(2) = .35) were associated with the presence of symptoms of ASD on the Modified PTSD Symptom Scale. The intensity of the symptoms of depression was associated with the intensity of ASD symptoms (R = .65). The models for the detection and estimation of ASD symptoms were validated by applying the regression equations to 72 participants not included in the initial regressions. The results obtained in the validation sample did not differ from those obtained in the initial sample.

CONCLUSIONS

The symptoms of depression and the subjective distress during the MI could be used to improve the detection of ASD.

Health service interventions targeting relatives of heart patients: A review of the literature

Aims: Relatives of heart patients experience anxiety, uncertainty, and low quality of life, and the hospitalization of a heart patient is associated with increased risk of death for the partner. Relatives' physical and mental problems may be rectified by activities established by the health services to support relatives and to enable them to handle the situation. This study systematically reviewed the literature on the latest health service interventions targeting relatives of heart patients. Methods: The literature about interventions targeting relatives of heart patients has been systematically reviewed to clarify what the health services do for relatives of heart patients and to assess the effects of interventions. We searched Medline, EMBASE, PsycINFO, CINAHL database, CSA and the Cochrane Library from January 2000 to March 2006. Results: Only six scientific articles reported on interventions testing health service activities for relatives of heart patients, and one literature review scrutinized earlier studies within the field. All the interventions indicate positive effects on patients' and/or relatives' health and well-being, in accordance with nurses' assessments. Nevertheless, the few studies and their questionable quality means that full evidence on the effects of the interventions is lacking. Conclusions: Future research should clarify the evidence for health service interventions and draw up guidelines for activities for the relatives of heart patients.

Persistence of posttraumatic stress symptoms 12 and 36 months after acute coronary syndrome

OBJECTIVES

To assess the prevalence and predictors of posttraumatic stress symptoms in patients at 12 and 36 months post hospital admission for an acute coronary syndrome (ACS). There is increasing recognition that posttraumatic stress may develop in the aftermath of an acute cardiac event. However, there has been little research on the longer-term prevalence of posttraumatic stress disorder (PTSD).

METHODS

Posttraumatic stress symptoms were assessed at 12 months in 213 patients with ACS and in 179 patients at 36 months. Predictor variables included clinical, demographic, and emotional factors measured during hospital admission.

RESULTS

At 12 months post ACS, 26 (12.2%) patients qualified for a diagnosis of PTSD; 23 (12.8%) patients were identified with PTSD at 36 months. Posttraumatic symptoms at 12 months were associated with younger age, ethnic minority status, social deprivation, cardiac symptom recurrence, history of depression, depressed mood during admission, hostility, and Type D personality. In multiple regression, depressed mood during admission and recurrent cardiac symptoms were independent predictors of posttraumatic symptoms (R(2) = 0.507, p < .001). At 36 months, posttraumatic stress symptoms were independently predicted by posttraumatic symptom levels at 12 months and depressed mood during admission (R(2) = 0.635, p < .001).

CONCLUSION

Posttraumatic stress symptoms persist for at least 3 years after an acute cardiac event. Early emotional responses are important in predicting longer-term posttraumatic stress. It is important to identify patients at risk for posttraumatic stress as they are more likely to experience reduced quality of life.

Cardiac rehabilitation: health characteristics and socio-economic status among those who do not attend

BACKGROUND

Cardiac rehabilitation (CR) is well documented, in randomised trials, to reduce mortality risk after myocardial infarction (MI). Selection of healthy patients for CR is a relatively unexplored problem. Our aims were to identify predictors of CR-attendance and to describe the prognosis as concerns mortality, re-admission and invasive treatment among CR-attendees as compared to CR-non-attendees.

METHODS

From a cohort of 138 290 persons aged 30-69 years, we identified consecutive MI patients, between 1 April 2000 and 31 March 2002. There were 206 MI patients, who survived until admission, and among the 200 who survived 30 days, 145 (72.5%) attended a comprehensive CR programme. Data were obtained from patient charts and from Danish population registers, and as a result we had no non-participation for the study.

RESULTS

The 2-year mortality proportions for patients surviving the first 30 days of admission were 2.8 and 21.8% among CR-attendees and CR-non-attendees, respectively (P < 0.0001). Among CR-non-attendees, there was a smaller fraction having an invasive treatment performed as compared with CR-attendees. By multiple logistic regression controlling for age and sex, CR-attendance was associated with chest pain, whereas CR-non-attendance was associated with low gross income, single living and inverted T-wave in the electrocardiogram.

CONCLUSION

CR attendance rate was 72.5%. Non-attendees have a higher mortality risk, which in part may be attributed to selection of healthy patients. Non-attendees are older and more likely to have atypical symptoms at admission, a low socioeconomic status and to live alone. Special attention is needed to improve CR attendance among such patients.

Coping with posttraumatic stress disorder and comorbidity after myocardial infarction

OBJECTIVE

Literature on the relationship between coping strategies, posttraumatic stress after myocardial infarction (post-MI PTSD), and comorbidity is limited. This study aimed to fill this gap in literature by investigating this relationship.

METHOD

One hundred twenty patients with MI were recruited from 2 general practices and interviewed using the Posttraumatic Stress Diagnostic Scale, the General Health Questionnaire, and the COPE Scale.

RESULTS

Thirty-one percent had PTSD. Patients used acceptance-focused coping in that most of them accepted that the MI had happened and that it could not be changed. At the same time, some patients used avoidance-focused coping in that they disengaged themselves mentally and behaviorally from the traumatic effects of MI. When the variables of age, bypass surgery, mental health problems before MI, and angioplasty were held constant, the results showed that patients who used maladaptive coping strategies of emotion-focused and avoidance-focused copings tended to report more comorbid symptoms. Patients who underwent medical procedures or interventions such as bypass surgery and angioplasty tended to report more PTSD symptoms.

CONCLUSIONS

The way in which MI patients' coping strategies relate to health outcomes has been shown to be symptom-specific. Using maladaptive coping strategies does not necessarily have a significant impact on PTSD symptoms. On the other hand, medical procedures or interventions for treating MI can play a major role in maintaining PTSD symptoms for patients with MI.

Type-D personality mechanisms of effect: the role of health-related behavior and social support

OBJECTIVE

To (a) investigate the prevalence of type-D personality (the conjoint effects of negative affectivity and social inhibition) in a healthy British and Irish population; (b) to test the influence of type-D on health-related behavior, and (c) to determine if these relationships are explained by neuroticism.

METHODS

A cross-sectional design was employed; 1012 healthy young adults (225 males, 787 females, mean age 20.5 years) from the United Kingdom and Ireland completed measures of type-D personality, health behaviors, social support, and neuroticism.

RESULTS

The prevalence of type-D was found to be 38.5%, significantly higher than that reported in other European countries. In addition, type-D individuals reported performing significantly fewer health-related behaviors and lower levels of social support than non-type-D individuals. These relationships remained significant after controlling for neuroticism.

CONCLUSION

These findings provide new evidence on type-D and suggest a role for health-related behavior in explaining the link between type-D and poor clinical prognosis in cardiac patients.

Posttraumatic stress and co-morbidity following myocardial infarction among older patients: the role of coping

This study aimed to investigate co-morbidity and coping strategies among older patients who suffer from different levels of posttraumatic stress disorder (PTSD) following myocardial infarction. Ninety-six older myocardial infarction (MI) patients were recruited from two general practices and completed the Posttraumatic Stress Diagnostic Scale (PDS), the General Health Questionnaire-28 (GHQ-28) and the COPE Scale. Ninety-two older patients with no previous MI experience constituted the control. Using the PDS, 30, 42 and 28% had full, partial and no-PTSD respectively. There were significant differences between the patient groups and the control on all GHQ-28 sub-scales. Significant differences were also identified between the patient groups in the following coping strategies: seeking emotional social support, suppression of competing activities, restraint coping, focusing on and venting of emotion, mental and behavioural disengagement. Controlling for bypass surgery, previous mental health difficulties, angioplasty, heart failure and angina, MANCOVA results did not change the overall results of the GHQ-28 but changed the results of coping in that seeking emotional social support and behavioural disengagement stopped being significant. Coping was a partial mediator between different levels of post-MI PTSD and co-morbidity. Depending on the severity of PTSD symptoms, co-morbidity and coping strategies can vary among older patients. Older patients with full-PTSD tend to use both maladaptive coping strategies as well as problem-focused coping.

A cognitive intervention to enhance institutionalized older adults' social support networks and decrease loneliness

Nearly all older adults experience social losses, which can disrupt their social support networks and impair their quality of life. Events such as retirement, an inability to drive, death of a spouse and/or close life-long friends, or moving to an elder care facility may negatively affect the quality of older adults' social support networks. Low levels of perceived social support are associated with increased depression, impaired immune functioning and reduced life expectancy. Moreover, social interactions can be cognitively stimulating and may help older adults preserve their cognitive abilities. In the present study, institutionalized older adults were exposed to either a cognitive enhancement programme designed to enhance social networks or a control group. Measures of perceived social support and loneliness were administered before and after a 3-month, group-based intervention. There was a significant interaction between group and time. Those who did not participate in the intervention experienced a decrease in perceived social support and an increase in perceived loneliness. Participants in the intervention group stayed the same on the above measures. Helping older adults increase or maintain the quality of their social networks may lead to enhanced cognitive functioning, decreased depression and improved quality of life. Recommendations to help assisted living facilities, nursing homes, retirement communities and senior centres develop social and cognitive interventions are provided.

Psychological correlates of PTSD symptoms following stroke

This study assessed associations between a number of demographic, medical and psychological risk factors and post-traumatic stress disorder (PTSD) symptoms following stroke. Individuals (N = 102) who had experienced a stroke within the previous year participated in the study. Participants completed questionnaires containing measures of PTSD symptoms and a range of psychological risk factors (i.e., anxiety, depression, negative affect, dissociation, cognitive appraisals). Regression analyses revealed the variables under consideration were able to explain large proportions of the variance in the number (R(2) = .54, p < 0.001) and severity (R(2) = .58, p < 0.001) of PTSD symptoms. Number of strokes, negative affect and cognitive appraisals emerged as significant predictors of both the number and severity of PTSD symptoms. The present findings suggest that a significant proportion of stroke patients may benefit from the detection and treatment of PTSD symptoms.

Comorbidity and personality traits in patients with different levels of posttraumatic stress disorder following myocardial infarction

More research is needed to further our understanding of posttraumatic stress responses and comorbidity following myocardial infarction (MI), and to help us identify more clearly the personality traits which indicate that a person is more prone to developing post-MI posttraumatic stress disorder (PTSD). This study aimed to 1) investigate the comorbidity of patients who suffered from different levels of posttraumatic stress disorder following myocardial infarction (i.e. post-MI PTSD), and 2) investigate to what extent patients with different levels of post-MI PTSD differed in their personality traits. One hundred and twenty MI patients from two general practices were recruited for the study. They were asked to complete the Posttraumatic Stress Diagnostic Scale (PDS), the General Health Questionnaire-28 (GHQ-28) and the NEO-Five Factor Inventory (NEO-FFI). They were divided into a no-PTSD group, a partial-PTSD group and a full-PTSD group, according to the scores of the PDS. One hundred and sixteen members of the general public were also recruited for comparison purposes. They were asked to complete the GHQ-28. The results showed that patients with full-PTSD reported significantly more somatic problems, anxiety, social dysfunction and depression than the other two patient groups and the control group. When age, bypass surgery, mental health problems before MI and angioplasty were controlled for, patients with full-PTSD also reported greater symptom severity of the four GHQ subscales than the other two patient groups. Patients with full-PTSD were significantly more neurotic than those with no-PTSD and partial-PTSD. Patients with full-PTSD were less agreeable than patients with no-PTSD. Regression analyses showed that personality did not moderate the relationship between PTSD and comorbidity. To conclude, following MI, those with full-PTSD tend to report more severe comorbidity than those who have not developed PTSD fully. The former can also be distinguished from the latter by virtue of their specific personality traits.

Normal personality characteristics in schizophrenia: a review of the literature involving the FFM

Schizophrenia is generally viewed as a disruption of normal functioning because of an underlying core illness. A number of theorists have speculated that this core illness may unilaterally disrupt normal personality functioning. However, recent data suggests that the relationship may be more complex and reciprocal than previously conceptualized. Furthermore, basic personality characteristics appear to be associated with numerous clinical phenomena. This article reviews the empirical literature pertaining to normal personality characteristics [structured around the five-factor model (FFM) of personality] in individuals with schizophrenia. Evidence suggests that certain personality characteristics may be uniquely related to the etiology of psychosis, as well as symptom severity, occupational functioning, cigarette smoking, substance use and violent behavior, social isolation, and suicidality in patients with schizophrenia. The implications of these findings and suggestions for future research are discussed.

Posttraumatic stress disorder and general health problems following myocardial infarction (Post-MI PTSD) among older patients: the role of personality

OBJECTIVES

This study aimed to: (1) investigate the degree to which older MI patients experienced post-MI PTSD and general health problems, and to (2) identify the association between five personality traits, post-MI PTSD and general health problems among these older people.

METHODS

The sample comprised 96 older MI patients and were recruited from two general practices. They were interviewed using the Posttraumatic Stress Diagnostic Scale (PDS), the General Health Questionnaire-28 (GHQ-28) and the NEO-Five Factor Inventory (NEO-FFI). The control group comprised 92 older people who experienced no MI. They were assessed using the GHQ-28.

RESULTS

The older MI patients experienced hyperarousal the most, followed by avoidance and re-experiencing symptoms. PDS revealed that 30% had full PTSD. The older patients were conscientious and agreeable individuals. They were also somewhat extraverted and open to experience. They also showed traits of neuroticism. Controlling for bypass surgery, heart failure, previous mental health difficulties, angina and angioplasty, regression analyses showed that neuroticism predicted re-experiencing and avoidance symptoms and general health total. Neuroticism and less agreeableness predicted hyperarousal symptoms.

CONCLUSIONS

MI older patients could manifest PTSD symptoms and general health problems following their MI. Personality traits, particularly neuroticism and antagonism, played a role in the manifestation of these symptoms.

Myocardial infarction and post-traumatic stress disorder: frequency, outcome, and atherosclerotic mechanisms

BACKGROUND

Post-traumatic stress disorder (PTSD) may develop in the aftermath of an acute myocardial infarction (MI). Whether PTSD is a risk factor for cardiovascular disease (CVD) is elusive. The biological mechanisms linking PTSD with atherosclerosis are unclear.

DESIGN

A critical review of 31 studies in the English language pursuing three aims: (i) to estimate the prevalence of PTSD in post-MI patients; (ii) to investigate the association of PTSD with cardiovascular endpoints; and (iii) to search for low-grade systemic inflammatory changes in PTSD pertinent to atherosclerosis.

METHODS

We located studies by PubMed electronic library search and through checking the bibliographies of these sources.

RESULTS

The weighted prevalence of PTSD after MI was 14.7% (range 0-25%; a total of 13 studies and 827 post-MI patients). Two studies reported a prospective association between PTSD and an increased risk of cardiovascular readmission in post-MI patients and of cardiovascular mortality in combat veterans, respectively. In a total of 11 studies, patients with PTSD had increased rates of physician-rated and self-reported cardiovascular diseases. Various cytokines and C-reactive protein were investigated in a total of seven studies suggesting that PTSD confers a pro-inflammatory state.

CONCLUSIONS

Increasing evidence suggests that PTSD specifically related to MI develops considerably frequently in post-MI patients. More research is needed in larger cohorts applying a population design to substantiate findings suggesting PTSD is an atherogenic risk factor and to understand better the suspected behavioural and biological mechanisms involved.

Recent evidence linking coronary heart disease and depression

OBJECTIVES

To review the recent literature on the relation between depression and coronary heart disease (CHD), including both etiologic studies (that is, depression preceding development of CHD) and prognostic studies (that is, depression predicting prognosis in established CHD), and to assess the degree to which the literature supports a causal interpretation of the link between depression and CHD.

METHOD

We searched the MEDLINE, Current Contents, and PsycINFO databases for articles published between December 15, 2003, and December 15, 2005, containing combinations of several key words related to CHD, prognosis, and depression. We reviewed papers for evidence of 6 rule-of-thumb criteria for making causal inferences: objective CHD outcome measures, prospective designs, results showing consistent and strong dose-response relations, adequate covariate adjustment, biological plausibility, and evidence from clinical trials that changing depression alters CHD risk.

RESULTS

We found 8 recent etiologic studies, 16 prognostic studies, 2 publications with both types of data, and 23 review papers. Although there was much methodological variability concerning measurement of depression and assessment of cardiac outcomes, the recent etiologic studies increase the evidence of a role for depression. Recent prognostic data are less consistent. Small studies showing no link between depression and CHD prognosis continue to appear, despite lack of adequate statistical power.

CONCLUSIONS

The recent literature continues to support both an etiologic and a prognostic role for depression in CHD. Despite this evidence, there have been few clinical trials of depression treatment in CHD patients and no clinical trials of depression prevention. Additional trials are needed.

Posttraumatic stress disorder in medically ill patients: what is known, what needs to be determined, and why is it important?

Can a medical illness or its treatment qualify as an emotionally traumatic event and can it cause posttraumatic stress disorder symptoms? If so, can the view of a medical illness as a traumatic experience enhance our ability to understand patients' adjustment to illness and their emotional reactions to it? Is it important to identify posttraumatic symptoms and try to address them in medically ill patients? These questions form the backbone for this review. Because many questions remain unanswered (or the answers are not definitive yet), we concisely summarize the issues and present our own view of the most pressing questions for further research.

Posttraumatic stress disorder in the wake of heart disease: prevalence, risk factors, and future research directions

BACKGROUND

There is increasing recognition that patients after a cardiac event may be at risk of posttraumatic stress disorder (PTSD). The present article reviews studies looking at PTSD as a sequel of heart disease with a focus on prevalence, risk factors, and future research directions.

METHODS

We conducted a search on PsychInfo and MEDLINE from 1980 to the present. Studies were included in the review if they looked at PTSD after a cardiac event, reported on the number of cases with PTSD, and had been published in English.

RESULTS

We identified 25 studies that fulfilled the inclusion criteria, of which 7 reported on the follow-up of previously published studies. The prevalence of PTSD after heart disease varied from 0% to 38% across studies. PTSD has been most rigorously researched after myocardial infarction with the best-powered studies finding a prevalence rate of 15%. Studies including control groups showed that cardiac patients were at risk of developing PTSD. Risk factors included sociodemographic and psychological characteristics and aspects related to the cardiac event.

CONCLUSION

Despite substantial heterogeneity in the methodology of studies and differences in prevalence across studies, this review indicates that subgroups of patients are at risk of PTSD after a cardiac event. Future studies investigating PTSD as a sequel of heart disease should be more systematic, use a prospective study design with multiple assessments, and include sufficiently large samples. PTSD should not be ignored as a sequel of heart disease, given preliminary evidence that PTSD may be associated with nonadherence with medication and an increased risk of clinical adverse events.