Psychological Distress and Mortality in Systolic Heart Failure

Abstract

Background-Depression, anxiety, and type D ("distressed") personality (tendency to experience negative emotions paired with social inhibition) have been associated with poor prognosis in coronary heart disease, but little is known about their role in chronic heart failure. Therefore, we investigated whether these indicators of psychological distress are associated with mortality in chronic heart failure. Method and Results-Consecutive outpatients with chronic heart failure (nϭ641; 74.3% men; mean age, 66.6Ϯ10.0 years) filled out a 4-item questionnaire to assess mixed symptoms of anxiety and depression and the 14-item type D scale. End points were defined as all-cause and cardiac mortality.

Pathophysiological Relationships Between Heart Failure and Depression and Anxiety

“…Interaction between the biological and psychological realms is illustrated by increased mortality in patients with depression and heart failure. 13,22,25,31,[36][37][38][39][40] An example of the interaction between the psychological and the social realms is the independent association between increased anxiety and low social support that is predictive of readmission of heart failure patients. 23 Another example of the interaction of all 3 realms is the relationship of dog ownership and cardiovascular health.…”

“…In 2 studies 31,37 no relationship was detected between depressive symptoms and mortality. In one of these studies, 37 a questionnaire with only 4 items was used to assess both anxiety and depression, a method that decreases sensitivity and specificity of the assessment. In the other study, 31 the sample size was small (n=111), mortality was low, and none of the patients had indications of severe depression.…”

“…13,22,25,31,[36][37][38][39][40] In most studies (7 of 9), 13,22,25,36,[38][39][40] increases in depression symptoms were significantly predictive of higher mortality rates. In 2 studies 31,37 no relationship was detected between depressive symptoms and mortality. In one of these studies, 37 a questionnaire with only 4 items was used to assess both anxiety and depression, a method that decreases sensitivity and specificity of the assessment.…”

Are we witnessing the decline effect in the Type D personality literature? What can be learned?

“…The first of the investigator groups' larger studies attempted to predict 47 deaths, but the prognostic value of Type D personality did not hold, once appropriate controls were introduced [13]. The second study attempted to predict 123 deaths among 641 heart failure patients, but Type D personality failed to be a significant prognostic indicator in either bivariate or multivariate analyses with statistical controls [14]. The third study attempted to predict 187 deaths among 1234 consecutive CVD patients receiving a percutaneous coronary intervention and found no association between Type D personality and mortality [15].…”

“…The Tilburg group identified patients as having a Type D personality if they were above the median [8,10] or, in later studies [9,13,14], if they scored above 10 on continuous measures of both negative affectivity (NA) and social inhibition (SI), and then compared the outcomes of these patients in the high/high quadrant to the other three quadrants. Such an analytic strategy for combining continuous predictor variables has been widely rejected for decades in the personality, education, and basic statistics literatures [21][22][23][24][25][26][27] because it likely leads to spurious results.…”