Comparison of prevalence of symptoms of depression, anxietyand hostility in elderly heart failure, myocardial infarction andcoronary artery bypass graft patients

Debra K. Moser, DNSc, RN [Professor; Gill Chair of Nursing],University of Kentucky, College of Nursing, Lexington, KY

Kathleen Dracup, DNSc, RN [Professor; Dean],University of California, San Francisco, School of Nursing, CA

Lorraine S. Evangelista, PhD, RN [Associate Professor],University of California, Los Angeles, School of Nursing, CA

Cheryl Hoyt Zambroski, PhD, RN [Associate Professor],University of South Florida, Tampa, FL

Terry A. Lennie, PhD, RN [Associate Professor],University of Kentucky, College of Nursing, Lexington, KY

Misook L. Chung, PhD, RN [Assistant Professor],University of Kentucky, College of Nursing, Lexington, KY

Lynn V. Doering, DNSc, RN [Professor],University of California, Los Angeles, School of Nursing, CA

Cheryl Westlake, PhD, RN [Associate Professor], andCalifornia State University, Fullerton, School of Nursing, CA

Seongkum Heo, PhD, RN [Assistant Professor]Indiana University, Indianapolis, IN

AbstractThe purpose of this study was to compare prevalence of anxiety, depression and hostility amongthree clinically diverse elderly cardiac patient cohorts and a reference group of healthy elders. Thiswas a multicenter, comparative study. A total of 1167 individuals participated: 260 healthy eldersand 907 elderly cardiac patients who were at least three months from a hospitalization (478 heartfailure patients, 298 post-myocardial infarction patients and 131 post-coronary artery bypass graftpatients). Symptoms of anxiety, depression and hostility were measured using the Multiple AffectAdjective Checklist. Prevalence of anxiety, depression and hostility was higher in patients in eachof the cardiac patient groups than in the group of healthy elders. Almost three-quarters of patientswith heart failure reported experiencing symptoms of depression and the heart failure group had thegreatest percentage of patients with depressive symptoms. The high levels of emotional distress

© 2009 Mosby, Inc. All rights reserved.For correspondence: Debra K. Moser, DNSc, RN, FAAN, Professor and Linda C. Gill Chair of Nursing, University of Kentucky, Collegeof Nursing, 527 CON, Lexington, KY 40536-0232, Phone 859-323-6687, FAX 859-323-1057, dmoser@uky.edu.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customerswe are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resultingproof before it is published in its final citable form. Please note that during the production process errors may be discovered which couldaffect the content, and all legal disclaimers that apply to the journal pertain.

NIH Public AccessAuthor ManuscriptHeart Lung. Author manuscript; available in PMC 2011 September 1.

Published in final edited form as:Heart Lung. 2010 ; 39(5): 378–385. doi:10.1016/j.hrtlng.2009.10.017.

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common in cardiac patients are not a function of aging, as healthy elders have low levels of anxiety,depression and hostility.

Keywordsanxiety; depression; hostility; heart failure; myocardial infarction

Negative emotions—depression, anxiety and hostility—appear to be more common amongcardiac patients than among healthy individuals. Whether this phenomenon is related to cardiacdisease alone or to the older age of most cardiac patients is unclear. Cardiac disease incidenceincreases dramatically with age. Although some researchers have reported that aging isassociated with a reduction in anxiety and depression levels, 1 others have documented higherlevels of negative emotions in the elderly. 2, 3 Higher rates of suicide are seen in the elderlyand the distinctive stresses of aging (e.g., loss of friends and loved ones, retirement) maycontribute to substantially higher rates of emotional distress. 4

This argument is not simply academic. Negative emotional states adversely and independentlyaffect quality of life, 5-7 adherence to recommended treatment, 8-10 costs of care 11, 12 andphysical outcomes in patients with coronary heart disease and heart failure. 13-21 The risksengendered by negative emotional states may be equal to, or greater than, those seen withtraditional risk factors such as presence of diabetes, smoking, elevated low-density lipoproteinand presence of co-morbidities. 5, 19 Despite the importance of negative emotional states tothe quality of life, morbidity and mortality outcomes of cardiac patients, clinicians still do notroutinely assess for emotional distress as a significant risk factor. 22, 23 One major factorlimiting application by clinicians of the evidence regarding negative emotional states is theperception that major confounding factors like age obscure the impact of cardiac disease onemotional states. Thus, the purpose of this study was to determine the impact of cardiac diseaseon psychological adjustment by comparing the prevalence of depression, anxiety and hostilityin 3 elderly cardiac patient groups (outpatients with heart failure, post-myocardial infarctionpatients, post-coronary artery bypass graft patients) with that of a group of healthy elders.

METHODIn this multicenter, comparative study, data from three outpatient cohorts of communitydwelling cardiac patients and a group of community dwelling elders without known cardiacdisease were compared on anxiety, depression and hostility. A multicenter design was used toincrease clinical diversity and heterogeneity in the sample in order to enhance generalizability.

ParticipantsAfter approval of the respective Institutional Review Boards, cardiac patients were recruitedfrom outpatient clinics at academic medical centers in the Western, Mid-Western and SouthernUnited States, and a cohort of elders without cardiac disease were recruited from senior centers.All participants gave written, informed consent. Cardiac patients who met the followinginclusion criteria were enrolled: 1) at least three months from hospitalization; 2) communitydwelling; 3) age ≥ 60 years; 4) no cognitive impairment (i.e., patients unable to converseappropriately or those diagnosed with dementia or Alzheimer’s disease); and 5) confirmeddiagnosis. Elders without cardiac disease were community dwelling, had no cognitiveimpairments, were ≥ 60 years, and were free of known cardiac disease.

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MeasurementData were collected from all participants on sociodemographic characteristics by interviewand questionnaire. Clinical data were collected about patients by patient interview and medicalrecord review. Anxiety, depression and hostility were measured in participants using theMultiple Affect Adjective Checklist .

Multiple Affect Adjective Checklist—The Multiple Affect Adjective Checklist(MAACL) assesses state anxiety, depression, and hostility. 24, 25 The MAACL is a set of 132positive and negative adjectives representing each of the three emotional states arranged inalphabetical order. Subjects read through the adjectives and check all those that reflect howthey are currently feeling. The instrument is scored by calculating the number of negativeadjectives checked and the number of positive adjectives not checked. Higher scores indicatethat the respondent has higher levels of the given emotion. Respondents receive a separatescore for anxiety, depression and hostility. Standard thresholds for anxiety, depression andhostility have been established at 7, 11, and 7, respectively. This instrument measures theintensity of symptoms of anxiety, depression and hostility and is not used to make a clinicaldiagnosis. Nonetheless, this instrument was chosen for use in this project because of its clinicalutility, ease of comparison among sites, and because dysphoric symptoms, even in the absenceof a clinical diagnosis, have been shown to negatively impact outcomes. 18, 26 The MAACLhas been used extensively in research; sensitivity, reliability and validity repeatedly have beendemonstrated. 24, 25, 27 Reliability was confirmed in this study with calculation of Cronbach’salpha in each sample for each subscale of the MAACL. In each of the four groups and each ofthe three subscales, Cronbach’s alpha was > 0.85.

Data analysisNon-normally distributed data were transformed to better approximate a normal distributionusing log transformations as needed. Data were pooled for all sites, as there were no differencesin outcomes among the site. Analysis of variance (ANOVA) was used to compare meananxiety, depression and hostility scores among the cardiac patient and healthy elder groups.This provided unadjusted comparison of the means. We adjusted for baseline age, gender,ethnicity, marital status, educational level and co-morbidities using subsequent ANCOVAmodels. When a significant difference was found, post hoc testing using Bonferronicomparisons identified specific group differences. All analyses were conducted using SPSSsoftware, release 13.0. All tests for statistical significance were 2-tailed and α = 0.05.

RESULTSA total of 1167 individuals participated in this study: 907 cardiac patients and 260 healthyelders. In the cardiac patient group, there were 478 heart failure patients, 298 post-myocardialinfarction patients and 131 post-coronary artery bypass graft patients enrolled. Given our agecriterion for enrollment in the study, there were no differences in age among the four groups.As expected, however, given the typical cardiac profiles seen in the community, there were anumber of differences in baseline characteristics among the groups (Table 1).

Group differences in anxiety, depression and hostility scoresExamination of differences in anxiety, depression and hostility scores among the groupsrevealed significant group differences for each emotion (Table 2). For anxiety, the 3 cardiacpatient groups were similar, and expressed significantly higher levels of anxiety than thehealthy elders (p = 0.001), whose mean for anxiety was 40% lower than the normative thresholdfor anxiety. For depression, healthy elders expressed a mean level that was 8% below thethreshold for depression, while the heart failure group expressed a mean depression level thatwas significantly higher than either of the other two cardiac patient groups (p = 0.001). Hostility

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levels were similar and highest in post-myocardial infarction and post-coronary artery bypassgraft patients compared to the healthy elder group in whom hostility was lowest (p = 0.001)and 16% below the normative threshold.

The percentage of cardiac patients in each group exceeding the threshold for anxiety was 37%to 44% compared to only 17% among the healthy elders (Figure 1). With regard to depression,63% of heart failure patients exceeded the threshold for depression compared to 56% of post-myocardial infarction patients, 53% of post-coronary artery bypass graft patients and only 33%of healthy elders. A total of 62% of post-coronary artery bypass graft patients compared to34% of healthy elders exceeded the hostility threshold.

In order to control for sociodemographic or clinical factors that might also affect anxiety,depression or hostility levels we used ANCOVA models with age as the covariate to adjust forgender, marital status, ethnicity, education level, presence of hypertension or diabetes, andmedications used. Within this elderly sample, age did not affect levels of anxiety, depressionor hostility, in any model.

There were no interactions between group (i.e., the 3 cardiac patient groups and the healthyelder group) and gender, although there was a main effect of gender for anxiety (p = 0.04) anddepression (p = 0.03), but not for hostility. Women expressed significantly greater levels ofanxiety and depression than men in all four groups (Table 3).

There was no education by group interaction, but there was a main effect of education level.Individuals in each group with only a high school or less education reported experiencingsignificantly higher levels of anxiety (p = 0.001), depression (p = 0.001) and hostility (p =0.006) than those who had attended at least some college (Figure 2). In this sample, there wasno interaction or main effect of marital status, ethnicity/race, hypertension or diabetes, ormedications used on anxiety, depression or hostility level.

DISCUSSIONOur findings demonstrate that the higher levels of emotional distress seen in older cardiacpatients are not a function of aging, but are directly associated with cardiac disease. Patientswith heart failure and patients who were post-myocardial infarction and post-coronary arterybypass grafting had substantially higher levels of anxiety and depression than did individualsin a group of healthy elders. Hostility levels were higher in post-myocardial infarction andpost-coronary artery bypass grafting patients than in healthy elders who were similar to heartfailure patients. In the healthy elders, mean levels of each emotion were well below thenormative threshold for distress, while they were above the threshold for patients in each ofthe three distinct cardiac groups. Thus, aging does not account for the higher levels of emotionaldistress seen in cardiac patients.

Our findings demonstrated that of the sociodemographic and clinical variables considered, onlygender and educational status affected level of anxiety, depression or hostility and they did soin a consistent fashion among the groups. Those with a high school education or less had higherlevels of psychological distress than those with at least some college. Educational attainmentoften is considered a surrogate of socioeconomic status, which is associated strongly andinversely with poor cardiac outcomes. 28, 29 This relationship is driven not only by the poorerhealth habits and higher levels of cardiac risk factors seen in individuals of lower educationalattainment, but by the chronic stresses of lower socioeconomic status 30 often manifested asdepression, anxiety or hostility.

We also noted that women reported higher levels of anxiety and depression in all groups thandid men. We and others have previously reported this phenomenon. 5, 31, 32 In each of the

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cardiac patient groups in this study, women consistently reported levels in excess of thethresholds for anxiety or depression. Given the consistency with the finding that womenexperience higher levels of psychological distress, future research should explore therelationship between poorer cardiac outcomes among women and higher levels of anxiety anddepression. Of note, even though women’s levels of depression were higher than men’s, ineach male cardiac patient group the mean level of depression also was higher than the thresholdfor depression.

Our data indicate that the majority of patients post-myocardial infarction, post-coronary arterybypass, and with heart failure have depressive symptoms, that about 40% of these cardiacpatients experience anxiety, and that hostility is apparent in about half. These levels fordepression are consistent with those reported in the literature when considering the combinedprevalence of clinical diagnoses and symptoms of psychological distress. 33 Neither anxietynor hostility have been studied in sufficient depth to provide reliable prevalence estimates. Thehigh levels of depression, anxiety and hostility seen in these older cardiac patient samples areof concern for a number of reasons. First, both older age and negative emotions predict short-and long-term morbidity and mortality among heart failure, coronary artery bypass graft, andmyocardial infarction patients. 5, 6, 13, 16-18, 21, 34-42 The combined impact of increasing ageand negative emotions work together to substantially increase the risk faced by elder cardiacpatients for poor quality of life, recurrent cardiac events and increased mortality. Under thesecircumstances it is imperative that clinicians recognize and appropriately manage negativeemotions in their cardiac patients.

Second, emotional distress is modifiable, but only if it is recognized and treated. Although insome cases, anxiety or depression will diminish without treatment, investigators havedocumented poor resolution of either condition over the long-term. 10, 43 In current clinicalpractice, recognition and treatment of psychological distress is extremely poor even whenlevels are high as they are in the current patient sample. 22, 23, 43 There are a number of possiblereasons for under-recognition and under-treatment of dysphoric states. 19, 33 Many cliniciansbelieve that emotional distress after a cardiac event is a normal response to illness that willresolve with time. Others fail to appreciate the extent of the problem or believe that they willeasily recognize serious emotional distress in their patients when it is present, despite evidenceto the contrary. 22, 23 Finally, there is a general lack of knowledge among healthcare providersregarding appropriate assessment and treatment of emotional distress with many cliniciansbelieving that assessment is too difficult and that treatment options are few.

Third, emotional distress, particularly anxiety and depression, are easily assessed in the clinicalsetting by non-psychiatrists and there are effective nonpharmacologic and pharmacologictreatments. 19, 33, 44 Despite the notable failure of some large-scale intervention trials todemonstrate a significant impact on outcomes, 45 others have demonstrated that reducingemotional distress with nonpharmacologic interventions can reduce mortality, 46 particularlyin the subset of patients with high distress. 47 Pharmacologic management of depression andanxiety is effective and safe in the elderly 48 when medications appropriate for cardiac patients(e.g. selective serotonin reuptake inhibitors) are used judiciously.

LimitationsThis study had some potential limitations. We assessed for severity of symptoms of threedysphoric states, anxiety, depression and hostility, but did not make clinical diagnoses.However, existing evidence indicates that even symptoms of anxiety and depression are ofmajor importance in predicting poor outcomes in cardiac patients. 5, 18, 49

There were some sociodemographic differences between the healthy elder group and thecardiac patient groups that were unavoidable given the demographics typical of healthy elders.

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These differences had the potential to affect our findings. There were significantly more womenin the healthy elder group than in any of the cardiac patient groups, but given the higher levelsof anxiety seen in all groups among women this probably resulted in over-estimation of levelsof psychological distress in the healthy elder group. The end result of this bias would be todecrease the differences between the healthy elders and the cardiac patient groups, thus it likelythat differences in psychological distress between healthy elders and cardiac patients are evenmore dramatic than we have shown here.

ConclusionThe emotional distress seen in elderly cardiac patients is not a function of aging, as healthyelders, even those with hypertension and diabetes, have low levels of anxiety, depression andhostility. Women and those of lower educational attainment are particularly at risk forpsychological distress. Patients with heart failure exhibit the highest levels of depression, whileheart failure and post-myocardial infarction patients experience the highest levels of anxiety,and post-coronary artery bypass patients the highest levels of hostility. The findings add to theburgeoning literature demonstrating the increased prevalence of negative emotions in cardiacpatients, dispel the notion that negative emotions in elderly cardiac patients are a function ofaging, and call for more aggressive assessment and management of psychological distress.

AcknowledgmentsThe project described was supported in part by (1) a Center grant, 1P20NR010679 from NIH, National Institute ofNursing Research. The content is solely the responsibility of the authors and does not necessarily represent the officialviews of the National Institute of Nursing Research or the National Institutes of Health, (2) Funding from a NationalAmerican Heart Association Established Investigator Award, and (3) a Western Division American Heart Associationgrant (NCR,133-09).

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Figure 1.Percent of patients in each group exceeding the published threshold for anxiety, depressionand hostility

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Figure 2.Anxiety (panel A), depression (panel B) and hostility (panel C) levels in each group comparedby education level. Individuals in each group with only a high school or less education reportedexperiencing significantly higher levels of anxiety (p = 0.001), depression (p = 0.001) andhostility (p = 0.006) than those who had attended at least some college.

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0.0

3.7

7.5

O

ther

6.2

5.3

7.7

8.8

Hyp

erte

nsio

n, %

55.8

29.6

35.7

51.5

0.00

1

Dia

bete

s, %

16.1

14.9

12.2

38.1

0.00

1

Left

vent

ricul

arej

ectio

n fr

actio

n, m

ean

± SD

, %

Not

asse

ssed

58.6

± 1

0.9

50.5

± 1

6.9

29.5

± 1

2.2

0.00

1

Heart Lung. Author manuscript; available in PMC 2011 September 1.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

Moser et al. Page 12

Tabl

e 2

Com

pari

son

of a

nxie

ty, d

epre

ssio

n an

d ho

stili

ty sc

ores

am

ong

the

3 ca

rdia

c pa

tient

gro

ups a

nd th

e he

alth

y el

der

grou

p

Hea

lthy

elde

rs(n

= 2

60)

Cor

onar

yar

tery

bypa

ssgr

aft

(n =

131

)

Post

-m

yoca

rdia

lin

farc

tion

(n =

298)

Hea

rtfa

ilure

(n =

478

)

p

Anx

iety

scor

e, m

ean

± SD

(95%

CI)

4.2

± 3.

3(3

.8-4

.6)

6.8

± 4.

0(6

.1-7

.5)

6.9

± 4.

6(6

.4-7

.4)

6.9

± 4.

7(6

.3-7

.4)

0.00

1*

Dep

ress

ion

scor

e, m

ean

± SD

(95%

CI)

10.2

± 6

.3(9

.4-1

1.0)

13.0

± 5

.5(1

2.0-

13.9

)12

.6 ±

6.5

(11.

8-13

.3)

14.2

± 7

.6(1

3.4-

15.1

)0.

001†

Hos

tility

scor

e, m

ean

± SD

(95%

CI)

6.3

± 3.

5(5

.9-6

.8)

8.5

± 4.

1(7

.8-9

.2)

8.2

± 4.

3(7

.7-8

.7)

6.9

± 4.

3(6

.4-7

.4)

0.00

1‡

Hig

her s

core

s ind

icat

e hi

gher

leve

ls o

f anx

iety

, dep

ress

ion

or h

ostil

ity.

* post

hoc

Bon

ferr

oni r

evea

led

diff

eren

ces b

etw

een

heal

thy

elde

r gro

up v

ersu

s all

othe

rs

† post

hoc

Bon

ferr

oni r

evea

led

diff

eren

ces b

etw

een

hear

t fai

lure

and

myo

card

ial i

nfar

ctio

n; a

nd b

etw

een

heal

thy

elde

rs v

ersu

s all

othe

rs

‡ post

hoc

Bon

ferr

oni r

evea

led

diff

eren

ces b

etw

een

heal

thy

elde

rs v

ersu

s myo

card

ial i

nfar

ctio

n an

d co

rona

ry a

rtery

byp

ass;

and

bet

wee

n he

art f

ailu

re v

ersu

s myo

card

ial i

nfar

ctio

n an

d co

rona

ry a

rtery

byp

ass

Heart Lung. Author manuscript; available in PMC 2011 September 1.

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

NIH

-PA Author Manuscript

Moser et al. Page 13

Tabl

e 3

Com

pari

son

of a

nxie

ty, d

epre

ssio

n an

d ho

stili

ty sc

ores

by

gend

er a

mon

g th

e 3

card

iac

patie

nt g

roup

s and

the

heal

thy

elde

r gr

oup

Hea

lthy

elde

rs(n

= 2

60)

Cor

onar

yar

tery

bypa

ss g

raft

(n =

131

)

Post

-m

yoca

rdia

lin

farc

tion

(n =

298)

Hea

rt fa

ilure

(n =

478

)p

Anx

iety

scor

e, m

ean

± SD

Wom

en4.

4 ±

3.4

7.6

± 4.

18.

5 ±

4.6

7.2

± 4.

80.

028*

Men

3.6

± 3.

06.

8 ±

4.0

6.6

± 4.

56.

7 ±

4.5

Dep

ress

ion

scor

e, m

ean

± SD

Wom

en10

.4 ±

6.6

15.0

± 4

.514

.1 ±

6.4

15.0

± 7

.50.

037*

Men

9.1

± 5.

312

.8 ±

5.6

12.4

± 6

.513

.9 ±

7.7

Hos

tility

scor

e, m

ean

± SD

Wom

en6.

4 ±

3.5

9.0

± 3.

18.

8 ±

3.9

6.2

± 4.

00.

616†

Men

5.8

± 3.

78.

5 ±

4.2

8.1

± 4.

47.

2 ±

4.4

Hig

her s

core

s ind

icat

e hi

gher

leve

ls o

f anx

iety

, dep

ress

ion

or h

ostil

ity.

* mai

n ef

fect

of g

ende

r; no

gro

up b

y ge

nder

inte

ract

ion

† no in

tera

ctio

n of

gro

up b

y ge

nder

, no

gend

er m

ain

effe

ct

Heart Lung. Author manuscript; available in PMC 2011 September 1.