The health-performance framework of presenteeism: A proof-of-concept study

There is emerging research that considers presenteeism as a neutral behavior that has both positive and negative predictors and outcomes for individuals and organizations. This neutral perspective diverges from the traditional negative view of presenteeism and is aligned with the Health-Performance Framework of Presenteeism (HFPF) in which presenteeism is considered to be an adaptive behavior that aims to balance health limitations and performance demands. This proof-of-concept study aims to investigate the existence of different profiles of presentees based on their common health problems (mental and physical) and performance, and differences in attendance and job stressors among these subgroups. Latent profile analysis with 159 clerical employees and managers from the UK private sector supported the HPFP and revealed four profiles: those reporting a good health and high performance were labeled functional presentees (who represented 19% of the sample), those with poor health and low performance were the dysfunctional presentees (14%), those with relatively high performance but poor health were labeled overachieving presentees (22%), and those with average scores on both dimensions were the average Joe/Jane presentees (45%; a new profile based on this sample). There was no profile in the present sample that corresponded to therapeutic presenteeism, characterized by low performance but relatively good health. Although average Joe/Jane presentees were comparable to functional presentees in exposure to most job stressors, they reported poorer pay and benefits, and more health problems than the latter. Average Joe/Jane presentees reported the lowest number of days of presenteeism. No difference was found in absenteeism across profiles, highlighting difficulties in measuring presenteeism using a count-measure, since three profiles presented a similar number of days of presenteeism yet contrasted health-performance configurations. Dysfunctional presentees were systematically more exposed to job stressors compared to functional presentees. The results support the HPFP proposition for different subgroups of presentees who are influenced by their work environment. The study takes a person-centered approach, disentangle presenteeism from the total count of presenteeism days, offering implications for management and intervention practice. Presenteeism can have a bright side and be functional in certain contexts when the appropriate resources are available.

Components of the Anger-Hostility Complex and Symptom Reporting in Patients with Coronary Artery Disease: A Multi-Measure Study

Multiple anger and hostility variables were investigated for associations with coronary artery disease (CAD) symptoms and to examine if those relationships were different for disease severity.Atwo year follow-up study of97 men with stenosed coronary arteries was undertaken. Questionnaires measured: nine forms of anger and hostility; Type A behaviour; anxiety; depression; social support; and ninesymptom measures. CAD severity was derived from clinicians’ ratings of coronary angiograms. Results are four fold: anger-hostility variables are relatively unimportant predictors of symptoms compared with anxiety and depression; psychosocial measures (except for expressed anger) are uncorrelated with CAD severity, though correlate numerously with CAD symptoms; symptoms are not distinguishable empirically in terms of frequency, intensity and duration with regard to type (‘angina pain’, ‘tiredness’ and ‘breathlessness and restricted mobility’); finally, CADsymptoms are unrelated to CAD severity. In conclusion, components of the angerhostility complex are of limited use for predicting CAD symptoms. However, anger expression is of utility for differentiating between CAD symptoms and disease severity.

Components of the Anger–hostility Complex as Risk Factors for Coronary Artery Disease Severity: A Multi-measure Study

Different forms of anger and hostility have been implicated in the pathogenesis of coronary artery disease (CAD), though previous research has not measured all of these in one sample. To assess their relative predictive utility, a multi-measure study was undertaken of three adult outpatient groups: 97 men identified angiographically with stenosed coronary arteries; 28 men with valvular heart disorders in the absence of CAD; and 28 men attending a fracture clinic with no CAD present. Questionnaires measured: anger expression; anger experience; cynical hostility; ‘Ho' hostility; neurotic hostility; neurotic disagreeableness; resentment; and suspiciousness. The pre-eminent anger–hostility correlate of CAD was found to be expressed anger, with years as a smoker and age also being independently related to disease severity. Thus, seven of these anger/hostility variables do not warrant similar attention as anger expression in CAD aetiology. Further research should identify coronary toxic components of anger expression and of socio-occupational environments that afford or constrain their occurrence.

Measurement of depressive symptoms among cardiac patients: Should sex differences be considered?

Confounding of depressive and cardiac symptoms may hold implications for assessment. This study investigated psychometric properties and sex differences in two depression scales among cardiac patients. Cardiac inpatients from 11 hospitals were recruited and completed a mailed survey including the Beck Depression Inventory-II and Gotland Scale of Male Depression 1 year later. The scales were significantly correlated and both were associated with social desirability. Females scored higher than males on the fatigue factor only ( p < .001). Psychometric properties of the Beck Depression Inventory-II were more favorable in this population. Practitioners must not overlook reports of fatigue in female cardiac patients.

Mood symptoms and personality dimensions as determinants of health-related quality of life in patients with coronary artery disease

This study examined the effects of personality dimensions in relation to the symptoms of depression and anxiety on health-related quality of life in coronary artery disease patients (N = 514). A linear regression analysis showed that symptoms of depression and anxiety as well as personality trait of emotional stability have independent significant effect on the health-related quality of life in patients with coronary artery disease. Psychological interventions in coronary artery disease patients should not only be limited to the treatment of symptoms of depression and anxiety but should also be extended to the management of personality traits.

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.

Empirically Derived Psychometric Screening for Emotional Distress in Coronary Artery Disease Patients

BACKGROUND AND RESEARCH OBJECTIVES

Multiple types of evidence implicate emotional distress as a cause of adverse outcomes in individuals with coronary artery disease. The present study was intended to determine the most accurate and user-friendly means of screening patients with coronary artery disease for emotional distress using age at initial diagnosis as the criterion.

SUBJECTS AND METHODS

Two clinical databases consisting of patients with documented coronary artery disease, each contained multiple measures of emotional distress, were used. These databases were investigated by tests of covariation of the emotional distress measures with age at initial diagnosis. If these were statistically significant, sequential testing of cutpoints yielded the minimum score for positivity. Sensitivity, specificity, and positive predictive value calculations were made for the significant measures. Single-sex tests of covariation were also examined.

RESULTS AND CONCLUSIONS

The Patient Health Questionnaire was the only significant bedside measure of emotional distress (Pearson r = -0.149, P = .058), with a cutpoint of 10 or greater. The Beck Depression Inventory, Hospital Anxiety and Depression Scale, and Crown-Crisp Phobic Anxiety Scale failed to reach significance as covariates of age at initial diagnosis. Substantially greater sensitivity occurs with larger and more cumbersome measures of emotional distress. For example, the Ketterer Stress Symptom Frequency Checklist yielded consistent results with greater variance explained, particularly in men (Pearson r for self-ratings of anger = -0.339, P = .001; depression = -0.363, P = .005; anxiety = -0.273, P = .028). Brief bedside/clinic screening of emotional in populations with coronary artery disease is possible and necessary to improve quality of life, compliance (eg, smoking cessation), and possibly morbidity/mortality. Initial screening can and should occur at the bedside/clinic by cardiology or primary care personnel using the Patient Health Questionnaire.

“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.

Do others really know us better? Predicting migraine activity from self- and other-ratings of negative emotion

OBJECTIVE

The validity of self-reported negative emotion to predict health status is limited by response biases, introspection limitations, and methodological confounds. The reports of significant others about the patients' negative emotion may circumvent these limitations. This study sought to compare the validity of self- versus other-reported negative emotion as a correlate of migraine headache activity.

METHODS

On 89 patients with migraine headache (74 women and 15 men), we correlated self-ratings and significant-other-ratings of patients' negative emotion with patients' report of migraine frequency and severity, which were assessed both cross-sectionally and prospectively, 3 months later.

RESULTS

Other-reported negative emotion correlated with migraine activity better than did self-reported negative emotion, both cross-sectionally and prospectively. Patterns were different for women and men, however. Among women, other-reported negative emotion was positively associated with migraine activity. Among men, other-reported negative emotion was inversely associated with migraine frequency and severity.

CONCLUSION

The results suggest that it may be valuable to obtain significant-other-ratings when assessing negative emotion in patients and that the genders may differ in how others' ratings are related to the patients' health.

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.

Five-year risk of cardiac mortality in relation to initial severity and one-year changes in depression symptoms after myocardial infarction

BACKGROUND

Although previous research demonstrated an independent link between depression symptoms and cardiac mortality after myocardial infarction (MI), depression was assessed only once, and a dose-response relationship was not evaluated.

METHODS AND RESULTS

We administered the Beck Depression Inventory to 896 post-MI patients during admission and at 1 year. Five-year survival was ascertained using Medicare data. We observed a significant long-term dose-response relationship between depression symptoms during hospitalization and cardiac mortality. Results remained significant after control for multiple measures of cardiac disease severity. Although 1-year scores were also linked to cardiac mortality, most of that impact was explained by baseline scores. Improvement in depression symptoms was associated with less cardiac mortality only for patients with mild depression. Patients with higher initial scores had worse long-term prognosis regardless of symptom changes.

CONCLUSIONS

The level of depression symptoms during admission for MI is more closely linked to long-term survival than the level at 1 year, particularly in patients with moderate to severe levels of depression, suggesting that the presumed cardiovascular mechanisms linking depression to cardiac mortality may be more or less permanent for them.

Psychological factors affecting a medical condition: ischemic coronary heart disease

The criteria for scientific validation of the entities currently subsumed under the DSM-IV category of "Psychological Factors Affecting a Medical Condition" have never been clearly enumerated. Historically, its precursor category ("Psychophysiological Disorder") was rarely used, and predicated upon clinical observation of personality styles among patients with specific physical illnesses, or clinical observations relating psychosocial events and symptom exacerbation. Because of logical flaws with either of these methods, clarification of the most rigorous criteria for demonstrating a cause-effect relationship is necessary. With the increase in well-designed and carefully executed epidemiological and treatment studies, this diagnostic category has evolved into an arena where cutting-edge insights and therapies are becoming available for a growing variety of medical conditions, especially ischemic coronary heart disease. The present article reviews the nature of the scientific evidence necessary to accept an etiological or aggravating role for psychological events.

Five-year follow-up for adverse outcomes in males with at least minimally positive angiograms: importance of "denial" in assessing psychosocial risk factors

The purpose of this study was to test the role of "denial" (spouse/friend minus self-ratings on parallel versions of the same questionnaire) in diluting the predictive value of emotional distress for cardiac events (deaths, new MIs, and/or revascularizations). One hundred forty-four men with no history of prior revascularization who had at least minimally positive diagnostic coronary angiograms, and someone they selected as "someone who knows you well," completed parallel versions of the Ketterer Stress Symptom Frequency Checklist (KSSFC). They were followed up by phone an average of 59.7 months after recruitment. Length of follow-up, baseline cardiac risk factors, and a number of baseline-obtained psychosocial risk factors were tested as prospective predictors of combined events (death by any cause, new MIs, and/or revascularizations) and current anginal frequency. Only spouse/friend observed anxiety on the KSSFC predicted current anginal frequency (p = 0.001). On the self-report version of the KSSFC, patients with one or more events reported less anger (p = 0.031), depression (p = 0.008), and anxiety (p = 0.003). These results may be attributable to "denial" because there were no differences in spouse/friend ratings, and difference scores (spouse/friend minus patient) on the KSSFC scales, particularly anger, were also related to events: AIAI (p = 0.002); depression (p = 0.063); and anxiety (p = 0.010). Denial may be a major limiting factor in accurately assessing emotional distress in cardiac populations, and may help account for a number of the previous findings.

Emotional distress among males with "syndrome X"

The present study examined traditional risk factors and various indices of emotional distress in males with positive angiograms (N = 122), "syndrome X" males with negative or nominal results on angiogram (N = 53), and age- and socioeconomic status-matched males with no manifest history of otherosclerotic disease (N = 56). Syndrome X patients reported more depression on the Ketterer Stress Symptom Frequency Checklist (KSSFC) than positive angiographic patients. And compared with healthy controls, they were more likely to be perceived by a spouse/friend as depressed and anxious on the KSSFC, scored higher on the Framingham Type A Scale, and reported more unprovoked nocturnal awakening. Syndrome X patients generally appear to be similar to patients with positive angiograms with regard to traditional risk factor history but are more distressed than healthy controls. This becomes most evident when denial is circumvented by discussion with significant others or inquiries are "framed" appropriately.