Secondary Logo

Journal Logo

Poor Social Support Is Associated With Increases in Depression but Not Anxiety Over 2 Years in Heart Failure Outpatients

Friedmann, Erika PhD; Son, Heesook PhD, RN, MPH; Thomas, Sue A. PhD, RN, FAAN; Chapa, Deborah W. PhD, RN, CRNP; Lee, Hyeon Joo PhD, RN, ANP; on behalf of the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigatorson behalf of the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators

The Journal of Cardiovascular Nursing: January/February 2014 - Volume 29 - Issue 1 - p 20–28
doi: 10.1097/JCN.0b013e318276fa07
ARTICLES
Free

Background: Heart failure (HF) is a major health problem in the United States, affecting 5.7 million American adults. Psychosocial distress, in particular depression, contributes to morbidity and mortality in patients with HF. Little is known about the interrelationship among disease severity, social support, and depression.

Objective: The aim of this study was to examine the contributions of social support and disease severity to longitudinal changes in depression and anxiety of outpatients with HF.

Methods: Patients (N = 108) enrolled in the Psychosocial Factors Outcome Study completed the Beck Depression Inventory-II, the State Trait Anxiety Inventory, and the Social Support Questionnaire-6 at study entry and every 6 months for up to 2 years.

Results: At baseline, 30% of the patients were depressed and 42% were anxious. Social support amount contributed to changes in depression (P = .044) but not anxiety (P = .856). Depression increased over time for patients who had lower initial social support amount. Depression did not increase for those with higher initial social support amount. Neither New York Heart Association class nor treatment group (placebo or implantable cardioverter defibrillator) interacted with time to predict depression, which indicates that changes in depression were parallel for patients with New York Heart Association class II and class III HF and for those who received implantable cardioverter defibrillators and those who did not. Assessment of patients with HF should include depression and social support. Interventions to enhance social support among patients with HF who have low social support may help alleviate the development of depression.

Conclusions: Reducing psychological distress and increasing social support may improve health outcomes among HF outpatients. It is important for studies of HF to include assessment of depression, anxiety, and social support and evaluate their contributions to health outcomes.

Erika Friedmann, PhD Professor, School of Nursing, University of Maryland, Baltimore.

Heesook Son, PhD, RN, MPH Adjunct Professor, School of Nursing, George Washington University, Washington, DC.

Sue A. Thomas, PhD, RN, FAAN Professor, School of Nursing, University of Maryland, Baltimore.

Deborah W. Chapa, PhD, RN, CRNP Assistant Professor, School of Nursing, the George Washington University, Washington, DC.

Hyeon Joo Lee, PhD, RN, ANP Nurse Practitioner, Greater Baltimore Medical Center, Maryland.

The complete list of SCD-HeFT investigators has been published previously (Eur J Heart Fail. 2002;4:541–551); the heads of the executive committee, data coordinating center, economics and quality of life (EQOL) coordinating center, and events committee are Gust H. Bardy, Kerry L. Lee, Daniel B. Marks, and Douglas L. Packer.

This research was partially supported by grant R01 NR07613 from the National Institute of Nursing Research, National Institutes of Health, and grants UO1 HL55766, UO1 HL55297, and UO1 HL55496 from the National Heart Lung and Blood Institute, National Institutes of Health, and by Medtronic, Wyeth–Ayerst Laboratories, and Knoll Pharmaceuticals.

The authors have no conflicts of interest to disclose.

Correspondence Erika Friedmann, PhD, School of Nursing, University of Maryland, 655 W Lombard St, Baltimore, MD 21201-1579 (efrie002@son.umaryland.edu).

Agrowing body of evidence supports that psychosocial distress contributes to morbidity and mortality in outpatients with heart failure (HF). Depressive symptoms are a significant predictor of worsening HF health status1–4 as well as hospitalization5–7 and mortality8–11 in patients with HF. Depression is more closely related to patients’ perceptions of their HF health status as indicated by New York Heart Association (NYHA) classification than by objective measures of HF severity.12 More severe HF was associated with more severe depressive symptoms and clinical depression in most recent studies that examined the relationship of depression to NYHA class1,2,13–22 but was not related in 2 studies.23,24 Both baseline depression and increases in depression predicted greater declines in physical functioning over 6 months.4 Worsening depressive symptoms were associated with death or cardiovascular hospitalization in HF patients.7

In the few studies that examined the relationship of anxiety to HF outcomes, greater anxiety was associated with increased HF severity.14,17 Both baseline anxiety symptoms and increases in anxiety symptoms predicted greater declines in physical functioning over 6 months.4 Anxiety also was associated with hospital readmission but not mortality after controlling for the effect of disease severity on these outcomes.25

Little is known about the interrelationship among disease severity, social support, and depression or anxiety. Patients with HF who had a significantly higher level of social support had better outcomes including self-care behavior; more frequent consultation with a health professional for weight gain; and adherences to medication, diet, and exercise, as compared with those with lower or medium levels of social support.26 Social factors such as living alone, alcohol abuse, perception of medical care as a substantial economic burden, and poor disease-related quality of life were predictors of the development of depression.27 A lack of social support was correlated with higher depression in both outpatients20 and hospitalized patients with HF28 and a lack of remission of depression.28 Tsuchihashi-Makaya and colleagues5 related alcohol use and low social support to anxiety among outpatients with HF.

The Psychosocial Factors Outcome Study (PFOS) in Sudden Cardiac Death was the first study to simultaneously evaluate depression, anxiety, and social support over 2 years in outpatients with HF. The PFOS was an independently funded ancillary study to the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT), a National Heart Lung and Blood Institute–funded international clinical trial. Psychosocial data were collected in PFOS and health status data were collected in SCD-HeFT.

The purpose of this study was to examine the contributions of social support and disease severity to changes over 2 years in depression and anxiety of HF outpatients.

Back to Top | Article Outline

Methods

The PFOS longitudinal observational study was designed to examine changes in psychosocial status over time of patients with HF who did and did not receive implantable cardioverter defibrillators (ICDs). The current question addresses the contribution of social support and disease severity to longitudinal changes in anxiety and depression of HF outpatients using data from PFOS.

Back to Top | Article Outline

Recruitment

Participation in PFOS was limited to HF patients enrolled in SCD-HeFT, which was the first trial to compare use of medication and ICDs as primary prevention in patients with HF. Inclusion criteria for SCD-HeFT included NYHA class II or III HF and left ventricular ejection fraction of 35% or less and exclusion criteria eliminated patients with a history of ventricular arrhythmias or cardiac arrest. In SCD-HeFT, participants were randomized to an ICD or placebo. Complete inclusion and exclusion criteria and recruitment methods have been published elsewhere.29

Patients who had been enrolled in the SCD-HeFT clinical trial at 21 sites were invited to participate in PFOS. Because the PFOS study began after SCD-HeFT recruitment began, both patients newly enrolling in SCD-HeFT after PFOS began and patients who returned for SCD-HeFT follow-ups were eligible for recruitment into PFOS if they could read and write English. Each PFOS participant signed a separate informed consent at enrollment.

Back to Top | Article Outline

Data Collection

Demographic, medical history, medication, and cardiac data were obtained from SCD-HeFT (Table 1). Participants in PFOS completed questionnaires to assess psychosocial status, including depression, anxiety, and social support, at PFOS entry, after 1 month, and at 6-month intervals for a maximum of 3years or until death, whichever occurred first. The staggered enrollment caused variation in length of follow-up. Some participants were enrolled in the study for less than 2 years when it ended because of their time of enrollment, deaths, or failure to complete follow-up. Data obtained during the first 2 years of participation in PFOS were included in this analysis: Completed depression/anxiety scales were obtained from 99 of 105 participants at intake, 44 of 46 participants at 6 months, 74 of 78 participants at 12 months, 60 of 61 participants at 18 months, and 54 of 53 participants at 2 years, a total of 331 depression and 343 anxiety assessments.

TABLE 1

TABLE 1

Back to Top | Article Outline

Instruments

The Beck Depression Inventory-2 (BDI-II) was used to assess depressive symptoms. The BDI is the most widely used tool for self-assessment of depression in clinical research. The BDI-II consists of 21 items rated on a Likert (0–3) scale. Total BDI-II scores range from 0 to 63, with higher scores indicating increased depressive symptoms. The reliability and validity of the BDI are well established.30 The internal consistency of the scale is high, 0.86 to 0.88 among psychiatric patients and 0.81 among nonpsychiatric patients.31 There is ample evidence of construct-, concurrent-, and criterion-related validity; the BDI is an acceptable tool for screening for significant depressive symptoms in cardiac patients.32 The BDI is recommended by the National Heart Lung and Blood Institute Working Group on Assessment and Treatment of Depression in Patients With Cardiovascular Disease for screening depression in cardiac patients.33 Depression severity was categorized according to the BDI-II manual31 as absent (0–12), mild (13–19), moderate (20–28), or severe (≥29). When depression was dichotomized, it was categorized as absent (0–12) or present (≥13).

The Spielberger State Trait Anxiety Inventory (STAI) was used to assess state anxiety,34 how a person feels at the time, at study entry and each follow-up. The state anxiety scale contains 20 items that ask for a description of how one feels at a specific point in time. Internal consistency ranges from 0.88 to 0.94 in older adults.35 The STAI had high concordance in older adults with and without anxiety disorders.36 State anxiety scores range from 20 (none) to 80 (extreme). Cardiac patients with state anxiety scores of 40 or above are considered to be anxious.36 When state anxiety was dichotomized, it was categorized as absent (0–40) or present (>40).

The Social Support Questionnaire-6 (SSQ-6) was used to quantify both the amount of and satisfaction with social support. The SSQ-6 provided 6 circumstances potentially requiring social support and asked respondents who they could rely on for help in each situation (amount) and how satisfied they would be with the help they received in each situation (satisfaction), resulting in a 12-item instrument. The number of people providing each type of support is summed to obtain the social support amount; scores range from 0 (no support) to 54. In a study designed to identify the extent to which social support is related to resting cardiovascular function in physically healthy women,38 both the short form of the social support amount and the social support satisfaction showed very good internal reliability consistency (Cronbach α = .90 for social support amount and α = .87 for social support satisfaction). The SSQ-6 was validated by negative correlations with scales of lack of social support, including the Multiple Affect Adjective Checklist loneliness scale and the Lack of Protection Scale.39 A high amount of social support obtained with the SSQ-6 predicted survival in post–myocardial infarction (MI) patients40 and outpatients with HF.41

Back to Top | Article Outline

Analysis

Descriptive statistics including z tests for skew and kurtosis and residual analysis were used to examine the normality of the continuous outcomes before multivariate analyses. The skewed distribution of depression necessitated square root transformations and of social support necessitated log transformations, which generated normal distributions. The transformed variables were used for parametric statistical analysis. SPSS for Windows 19 (SPSS Inc, Chicago, Illinois) was used for all analyses.

The randomness of missing data for each dependent variable was examined to confirm that data were missing at random or completely at random. Both logistic regression and pattern-mixture models39 provided no evidence that depression or anxiety data were missing systematically.

Chi-square tests were used to examine differences in frequency of depression and anxiety between the treatments at each time period. Separate sets of linear mixed models were used to examine changes in depression and state anxiety over 2 years. Linear mixed models have the advantage of allowing cases with variable numbers of assessments to be included in the analysis and thus do not require replacement of missing data.42 Thus, data from participants who died over the course of the study or who provided data at some but not all points were included in the analysis. The models examined changes in these dependent variables among participants to explore the potential effects of severity (NYHA class), age, social support amount, and gender on changes in depression and anxiety after controlling for treatment type (ICD or placebo medication). Unstructured error covariance structure was chosen on the basis of model fit.

Each series of models began with only unconditional means and unconditional growth models. Both random intercept and random slope/random intercept models with several correlation structures were examined.42 Random intercept models were superior and were thus used for all analyses. All models except unconditional means and unconditional growth models included treatment group to control for its effects. A series of models were conducted that added NYHA class, age, gender, amount of social support, and time and then added the interaction of each predictor with time and the 3-way interactions with time. Predictor interaction terms and predictors were then removed to obtain the best predictive model for each outcome based on Akaike Information Criterion and Schwarz Bayesian Information Criterion.42 For analyses of depression, age was dichotomized as 60 years or younger and older than 60 years to achieve convergence.

Back to Top | Article Outline

Results

Patient Characteristics

A total of 108 patients with HF participated in the current study, 57 who received ICDs and 51 who received placebo medication. The SCD-HeFT sites that participated in PFOS randomized 387 participants in SCD-HeFT: 140 to ICDs and 147 to standard care plus placebo medication. The PFOS included 41% of the ICD recipients and 35% of the placebo recipients at these sites (Figure 1). Patients were largely men and white; ages ranged from 35.5 to 85.1 years. Twelve patients, 6 ICD recipients and 6 placebo recipients, died during follow-up, which lasted up to 35.9 months after PFOS enrollment. All-cause mortality in PFOS was 11.1%. Demographic, medical history, and follow-up information for participants according to treatment group is included in Table 1. The demographics and clinical characteristics of the PFOS participants were comparable with those of the SCD-HeFT participants, except that there were more minorities in SCD-HeFT. Most of the PFOS participants (73%) had NYHA class II HF; comorbidities included diabetes (32%) and atrial fibrillation or flutter (20%). Depression, state anxiety, and social support scores at initial assessment according to treatment group are included in Table 2. Chi-square analyses indicated that there were no significant differences in frequencies of comorbidities or medications between the patients who received ICDs and those who received placebo. There also were no significant differences in average age, left ventricular ejection fraction, length of follow-up, time from SCD-HeFT enrollment to initial psychosocial assessment, baseline state anxiety scores, or baseline social support amount between the 2 groups. Baseline depression scores were slightly higher in ICD patients than in the placebo group (t89.3 = 2.02, P = .047).

TABLE 2

TABLE 2

FIGURE 1

FIGURE 1

At initial assessment, 30% of the patients were depressed: 35.8% among those who received ICDs and 23.9% among those who received placebo. At initial assessment, 41.9% of the patients were anxious: 45% among those who received ICDs and 38% among those who received placebo. Initial state anxiety scores were highly correlated with initial depression scores (r = 0.445, P < .001). At initial assessment, social support amount ranged from 0 to 54, with a mean (SD) of 15.6 (12.6) and a median of 12. There are no cutoff points for identifying high or low social support. There were no significant differences in the average amount of social support in patients with NYHA class II and III HF (t101 = 0.115, P = .909) or in the SCD-HeFT treatment groups (t101 = 0.762, P = .448). At initial assessment, social support amount was not correlated significantly with depression (r = −0.144, P = .158), state anxiety (r = −0.059, P = .558), or age (r = −0.144, P = .146).

Back to Top | Article Outline

Changes in Depression

The best model for predicting depression explained 18.5% of the variance in depression. Initial social support amount significantly predicted changes in depression over time, as indicated by a significant interaction between social support and time (Table 3). Depression increased over time for patients who had lower baseline social support amount after controlling for age, treatment group, and disease severity. The lower the social support amount at the initial assessment is, the greater the increase in depression over time. Estimated depression scores according to initial social support amount are included in Figure 2. Depression did not increase for those with higher initial social support amount. Neither NYHA class nor treatment group interacted with time to predict depression, which indicates that changes in depression were parallel for patients with NYHA class II and those with class III HF and for those who received ICDs and those who did not.

TABLE 3

TABLE 3

FIGURE 2

FIGURE 2

Back to Top | Article Outline

Changes in Anxiety

The best model for predicting state anxiety explained 7.4% of the variance in anxiety. It included the impact of social support amount, NYHA, and age and interactions among the 3 variables. Social support did not make a significant independent contribution to changes in state anxiety. Changes in state anxiety did not depend on NYHA class, initial amount of social support, ICD intervention, or age, as indicated by a lack of significant interactions of these variables with time (see Table 4).

TABLE 4

TABLE 4

Back to Top | Article Outline

Discussion

This study examines the contributions of social support and disease severity (NYHA class) to long-term changes in depression and state anxiety in outpatients with HF. It was conducted within the PFOS43 and SCD-HeFT29 trials.

There are no other available data on social support scores with the SSQ in patients with HF. The social support scores of patients with HF in the current study are comparable with those of patients with MI enrolled in similar clinical trial substudies. In the psychosocial substudy of the Cardiac Arrhythmia Suppression Trial,40 the mean (SD) social support amount of 424 post-MI patients with ventricular arrhythmias was 17.1 (14.0), and in the psychosocial response substudy of the Home Automatic External Defibrillator Trial clinical trial,44 the mean (SD) social support amount of 460 post-MI patients who lived with a spouse or companion was 18.69 (13.3). The average social support amount of the patients with HF in the current study was significantly lower (mean [SD], 13.49 [10.8]) than in the 2 groups of post-MI patients (P < .02, corrected for multiple comparisons).

Social support significantly predicted changes in depression over time. Depression increased over time for patients who had lower initial social support amount. The finding that social support contributed to longitudinal changes in depression over 2 years in outpatients with HF extends findings relating living alone and other social factors to development of depression.27 Other social factors and the individual’s perception of quality of life not examined in the current study may also influence changes in depression in patients with HF. This finding complements the finding that illness intrusiveness, which includes disruption in social/family/work activities, mediated the relationship between illness severity and depression in a cross-sectional study of older veterans with HF. Both studies indicate that modification of social support may be useful in reducing the influence of HF on the development of depression.45

In the current study, HF severity, as indicated by NYHA classification, was not related to changes in depression or anxiety. This finding goes beyond most of the studies of patients with HF that found a relationship between depression1,2,12–18,45 or anxiety14,17 and HF severity. The current study addresses change in depression and anxiety, whereas the previous studies examined a cross-sectional relationship.

Overall state anxiety did not change over 2 years in the current study. None of the potential moderator variables, social support, age, and NYHA class, predicted changes in anxiety. Almost one-third (32%) of the HF patients remained anxious over the 2-year period of study. It is important to identify other patient characteristics such as poor coping and increased stress that might be related to anxiety and evaluate their potential for targeting to reduce anxiety in this vulnerable population.

The current study provided evidence that social support amount predicts changes in depression symptoms in patients with HF. Lower social support at baseline was associated with increases in depression symptoms in patients with HF, although the change was small. High levels of social support may protect patients from the negative prognostic consequences of depression. The continued high levels of depression symptoms even after 2 years may continue to have a negative impact on health outcomes. In a recent study, worsening depressive symptoms were associated with death or cardiovascular hospitalization in patients with HF.21

Medication may not be the best approach to reduce the contribution of depression symptoms to mortality in patients with HF. Recent clinical trial data46 and clinical data from hospitalized patients with HF47 indicate that antidepressant use does not improve outcomes in patients with HF.

The relationship of social support to changes in depression suggests that social support enhancement has the potential to moderate changes in depression. It is important to consider whether intervention to improve psychosocial status in this group of HF patients will have a positive impact on depression and, thus, on health outcomes. A variety of modalities may be useful for decreasing depression and anxiety and increasing social support for HF patients. Support groups, exercise, and self-management interventions can enhance social support, improve psychological status, and change health behaviors.48,49

Successful management of HF requires the active involvement of the patient in his/her own care. In HF, self-management or self-care includes adherence with medication, regular exercise, and dietary restrictions on salt as instructed by the healthcare provider as well as monitoring and interpreting signs and symptoms to assess disease status and seeking care when indicated. Poor self-management is associated with psychosocial distress.49,50 On the basis of a randomized intervention study in HF patients, Jaarsma et al51 concluded that general disease management programs are not effective for HF patients who are depressed and recommended identification of depressive symptoms before initiation of a disease management program. Poor social support inhibits the development and use of HF self-management skills.26,49

No large clinical trials of education or self-management interventions demonstrate the effectiveness of these interventions to improve social support or reduce depression or anxiety in HF patients.52,53 In a small treatment group–only pilot study in HF patients (N = 26), depression and social support were significantly improved 1 year after baseline.54 A larger study with a comparison group found lower depression and a tendency for better social functioning in the self-management intervention than in the control group at 3 months but not at 1 year.55 Education and self-management interventions may increase perceptions of control and decrease depression and anxiety. Future studies are needed to assess the effectiveness of self-management interventions with depressed and anxious HF patients.

Back to Top | Article Outline

Limitations

The findings are based on use of self-report symptom questionnaires to assess depression and anxiety. Although both the BDI and the STAI are widely used in studies of cardiac patients and are preferable to single-item reports of mood, they do not provide clinical diagnoses of anxiety or depression.32,56 The current study was limited to symptoms of depression and anxiety expressed by the patients at specific times and did not include evaluation of the effect of treatment for these or other psychiatric disorders. The generalizability of the current study is limited by the lack of diversity in race and gender among the cohort studied. The participants in this study were a subgroup of the SCD-HeFT sample, and their experience of psychological changes may not represent those of the entire cohort. In the current study, the range of HF severity is limited to patients with NYHA class II or III HF. Patients with NYHA class IV HF have significantly more depressive symptoms than do those with classes I to III HF,57 and the findings cannot be generalized to them. This longitudinal study could not identify individuals who were depressed or anxious before study entry. Another major limitation was that use of antidepressant and antianxiety medication was not available from the parent trial (SCD-HeFT), and thus, the influence of medication on levels of or changes in anxiety and depression could not be ascertained.

The amount of missing data is of potential concern. It is possible that more depressed or anxious participants refused to participate in the study, withdrew from the study, or died. Our analyses indicated that data were missing at random, which means that initial status (depression scores, anxiety scores, social support, NYHA class, age, gender) does not predict missing data at subsequent data collection points or patterns of missing data. The linear mixed-models statistical technique used in the current study uses all data points and allows different numbers of measurements for each case. Data that are missing at random are expected and do not compromise the analysis.39,42 Only a small proportion of variability in outcomes was explained by the variables assessed in the current study. Additional variables may help to explain changes in depression and anxiety in this population.

Back to Top | Article Outline

Conclusions

Low social support at baseline was associated with worsening depression, and even patients with higher social support did not experience great reductions in depression over 2 years. Anxiety in outpatients with HF remains high over 2 years. Reducing psychological distress and increasing social support may improve health outcomes among HF outpatients. Longitudinal studies of more diverse population are necessary to extend the generalizability of the findings. It is important for studies of HF to include assessment of depression, anxiety, and social support and evaluate their contributions to health outcomes.

Back to Top | Article Outline

Clinical Pearls

  • In outpatients with HF (n = 108), 30% were depressed and 42% were anxious.
  • Higher social support contributed to decreases in depression but not anxiety over 2 years.
  • Neither severity of illness (NYHA class) nor having an ICD was associated with changes in depression.
  • Assessment of depression and anxiety should be conducted in outpatients with HF.
  • Interventions to improve social support may reduce depression in patients with HF.
Back to Top | Article Outline

What’s New and Important

  • Little is known about the interrelationship among disease severity, social support, and depression or anxiety. This study showed that low social support at baseline was associated with worsening depression, and even patients with higher social support did not experience great reductions in depression over 2 years.
  • Implanted cardioverter defibrillators in patients with heart failure were not related to increased depression or anxiety, which is unlike what occurs in patients who receive implantable cardioverter defibrillators for ventricular arrhythmias.
Back to Top | Article Outline

Acknowledgments

The authors gratefully acknowledge the support of the principal investigators of SCD-HeFT, Gust Bardy, MD, FACC, and Kerry Lee, PhD, and the Seattle Institute for Cardiovascular Research Clinical Research Coordinator, Jill Anderson, RN.

Back to Top | Article Outline

REFERENCES

1. Faris R, Purcell H, Henein MY, Coats AJS. Clinical depression is common and significantly associated with reduced survival in patients with non-ischaemic heart failure. Eur J Heart Fail. 2002; 4: 541–551.
2. Rumsfeld JS, Havranek E, Masoudi FA, et al. Depressive symptoms are the strongest predictors of short-term declines in health status in patients with heart failure. J Am Coll Cardiol. 2003; 42 (10): 1811–1817.
3. Rutledge T, Reis VA, Linke SE, Greenberg BH, Mills PJ. Depression in heart failure a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. J Am Coll Cardiol. 2006; 48 (8): 1527–1537.
4. Shen BJ, Eisenberg SA, Maeda U, et al. Depression and anxiety predict decline in physical health functioning in patients with heart failure. Ann Behav Med. 2011; 41 (3): 373–382.
5. Tsuchihashi-Makaya M, Kato N, Chishaki A, Takeshita A, Tsutsui H. Anxiety and poor social support are independently associated with adverse outcomes in patients with mild heart failure. Circ J. 2009; 73 (2): 280–287.
6. Jiang W, Krishnan R, Kuchibhatla M, et al. Characteristics of depression remission and its relation with cardiovascular outcome among patients with chronic heart failure (from the SADHART-CHF Study). Am J Cardiol. 2011; 107 (4): 545–551.
7. Johnson TJ, Basu S, Pisani BA, et al. Depression predicts repeated heart failure hospitalizations. J Card Fail. 2012; 18 (3): 246–252.
8. Kato N, Kinugawa K, Yao A, Hatano M, Shiga T, Kazuma K Relationship of depressive symptoms with hospitalization and death in Japanese patients with heart failure. J Card Fail. 2009; 15 (10): 912–919.
9. Adams J, Kuchibhatla M, Christopher EJ, et al. Association of depression and survival in patients with chronic heart failure over 12 Years. Psychosomatics. 2012; 53 (4): 339–346.
10. Frasure-Smith N, Lesperance F, Habra M, et al. Elevated depression symptoms predict long-term cardiovascular mortality in patients with atrial fibrillation and heart failure. Circulation. 2009; 120 (2): 134–140.
11. Lupon J, Gonzalez B, Santaeugenia S, et al. Prognostic implication of frailty and depressive symptoms in an outpatient population with heart failure. Rev Esp Cardiol. 2008; 61 (8): 835–842.
12. Gottlieb SS, Kop WJ, Ellis SJ, et al. Relation of depression to severity of illness in heart failure (from Heart Failure and a Controlled Trial Investigating Outcomes of Exercise Training [HF-ACTION]). Am J Cardiol. 2009; 103 (9): 1285–1289.
13. Gottlieb SS, Khatta M, Friedmann E, et al. The influence of age, gender, and race on the prevalence of depression in heart failure patients. J Am Coll Cardiol. 2004; 43 (9): 1542–1549.
14. Haworth JE, Moniz-Cook E, Clark AL, Wang M, Waddington R, Cleland JG. Prevalence and predictors of anxiety and depression in a sample of chronic heart failure patients with left ventricular systolic dysfunction. Eur J Heart Fail. 2005; 7 (5): 803–808.
15. Holzapfel N, Zugck C, Muller-Tasch T, et al. Routine screening for depression and quality of life in outpatients with congestive heart failure. Psychosomatics. 2007; 48 (2): 112–116.
16. Jiang W, Kuchibhatla M, Clary GL, et al. Relationship between depressive symptoms and long-term mortality in patients with heart failure. Am Heart J. 2007; 154 (1): 102–108.
17. Junger J, Schellberg D, Muller-Tasch T, et al. Depression increasingly predicts mortality in the course of congestive heart failure. Eur J Heart Fail. 2005; 7 (2): 261–267.
18. Moorman AJ, Mozaffarian D, Wilkinson CW, et al. In patients with heart failure elevated soluble TNF-receptor 1 is associated with higher risk of depression. J Card Fail. 2007; 13 (9): 738–743.
19. Muller-Tasch T, Peters-Klimm F, Schellberg D, et al. Depression is a major determinant of quality of life in patients with chronic systolic heart failure in general practice. J Card Fail. 2007; 13 (10): 818–824.
20. Murberg TA, Bru E. Social relationships and mortality in patients with congestive heart failure. J Psychosom Res. 2001; 51 (3): 521–527.
21. Sherwood A, Blumenthal JA, Trivedi R, et al. Relationship of depression to death or hospitalization in patients with heart failure. Arch Intern Med. 2007; 167 (4): 367–373.
22. Westlake C, Dracup K, Fonarow G, Hamilton M. Depression in patients with heart failure. J Card Fail. 2005; 11 (1): 30–35.
23. Schiffer AA, Pedersen SS, Broers H, Widdershoven JW, Denollet J. Type-D personality but not depression predicts severity of anxiety in heart failure patients at 1-year follow-up. J Affect Disord. 2008; 106 (1–2): 73–81.
24. Cully JA, Phillips LL, Kunik ME, Stanley MA, Deswal A. Predicting quality of life in veterans with heart failure: the role of disease severity, depression, and comorbid anxiety. Behav Med. 2010; 36 (2): 70–76.
25. Volz A, Schmid JP, Zwahlen M, Kohls S, Saner H, Barth J. Predictors of readmission and health related quality of life in patients with chronic heart failure: a comparison of different psychosocial aspects. J Behav Med. 2011; 34 (1): 13–22.
26. Gallagher R, Luttik ML, Jaarsma T. Social support and self-care in heart failure. J Cardiovasc Nurs. 2011; 26 (6): 439–445.
27. Havranek EP, Spertus JA, Masoudi FA, Jones PG, Rumsfeld JS. Predictors of the onset of depressive symptoms in patients with heart failure. J Am Coll Cardiol. 2004; 44 (12): 2333–2338.
28. Koenig HG. Depression in hospitalized older patients with congestive heart failure. Gen Hosp Psychiatry. 1998; 20 (1): 29–43.
29. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005; 352 (3): 225–237.
30. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory—25 years of evaluation. Clin Psychol Rev. 1988; 8 (1): 77–100.
31. Beck AT, Stear RA, Brown GK. The Beck Depression Inventory Second Edition. Boston, MA: Houghton Mifflin; 1996.
32. Strik JJ, Honig A, Lousberg R, Denollet J. Sensitivity and specificity of observer and self-report questionnaires in major and minor depression following myocardial infarction. Psychosomatics. 2001; 42 (5): 423–428.
33. Davidson KW, Kupfer DJ, Bigger JT, et al. Assessment and treatment of depression in patients with cardiovascular disease: National Heart, Lung, and Blood Institute Working Group Report. Psychosom Med. 2006; 68 (5): 645–650.
34. Spielberger CD, Lushene RE, Gorsuch RL. STAI Manual. Palo Alto, CA: Consulting Psychology Press; 1972.
35. Stanley MA, Novy DM, Bourland SL, Beck JG, Averill PM. Assessing older adults with generalized anxiety: a replication and extension. Behav Res Ther. 2001; 39 (2): 221–235.
36. Stanley MA, Beck JG, Zebb BJ. Psychometric properties of four anxiety measures in older adults. Behav Res Ther. 1996; 34 (10): 827–838.
37. Frasure-Smith N, Lesperance F, Talajic M. The impact of negative emotions on prognosis following myocardial infarction: is it more than depression? Health Psychol. 1995; 14 (5): 388–398.
    38. Hughes BM, Howard S. Social support reduces resting cardiovascular function in women. Anxiety Stress Coping. 2009; 22 (5): 537–548.
    39. Son H, Friedmann E, Thomas SA. Application of pattern mixture models to address missing data in longitudinal data analysis using SPSS. Nurs Res. 2012; 61 (3): 195–203.
    40. Thomas SA, Friedmann E, Wimbush F, Schron E. Psychological factors and survival in the Cardiac Arrhythmia Suppression Trial (CAST): a reexamination. Am J Crit Care. 1997; 6 (2): 116–126.
    41. Friedmann E, Thomas SA, Liu F, Morton PG, Chapa D, Gottlieb SS. Relationship of depression, anxiety, and social isolation to chronic heart failure outpatient mortality. Am Heart J. 2006; 152 (5): 940–948.
    42. Singer JD, Willett JB. Applied Longitudinal Data Analysis:. Modeling Change and Event Occurrence. New York, NY: Oxford University Press; 2003.
    43. Thomas SA, Friedmann E, Gottlieb SS, et al. Changes in psychosocial distress in outpatients with heart failure with implantable cardioverter defibrillators. Heart Lung. 2009; 38 (2): 109–120.
    44. Friedmann E, Thomas SA, Son H. Pets, depression and long term survival in community living patients following myocardial infarction. Anthrozoos. 2011; 24 (3): 273–285.
    45. LeMaire AW, Shahane A, Dao TK, Kibler JL, Cully JA. Illness intrusiveness mediates the relationship between heart failure severity and depression in older adults. J Appl Gerontol. 2011; 31 (5): 608–621.
    46. O’Connor CM, Jiang W, Kuchibhatla M, et al. Safety and efficacy of sertraline for depression in patients with heart failure: results of the SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial. J Am Coll Cardiol. 2010; 56 (9): 692–699.
    47. O’Connor CM, Jiang W, Kuchibhatla M, et al. Antidepressant use, depression, and survival in patients with heart failure. Arch Intern Med. 2008; 168 (20): 2232–2237.
    48. Myers GM, James GD. Social support, anxiety, and support group participation in patients with an implantable cardioverter defibrillator. Prog Cardiovasc Nurs. 2008; 23 (4): 160–167.
    49. Riegel B, Moser DK, Anker SD, et al. State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association. Circulation. 2009; 120 (12): 1141–1163.
    50. Moser DK, Doering LV, Chung ML. Vulnerabilities of patients recovering from an exacerbation of chronic heart failure. Am Heart J. 2005; 150 (5): 984.
    51. Jaarsma T, Lesman-Leegte I, Hillege HL, Veeger NJ, Sanderman R, van Veldhuisen DJ. Depression and the usefulness of a disease management program in heart failure: insights from the COACH (Coordinating study evaluating Outcomes of Advising and Counseling in Heart failure) study. J Am Coll Cardiol. 2010; 55 (17): 1837–1843.
    52. Smeulders ES, van Haastregt JC, Janssen-Boyne JJ, Stoffers HE, van Eijk JT, Kempen GI. Feasibility of a group-based self-management program among congestive heart failure patients. Heart Lung. 2009; 38 (6): 499–512.
    53. Smeulders ES, van Haastregt JC, Ambergen T, et al. Nurse-led self-management group programme for patients with congestive heart failure: randomized controlled trial. J Adv Nurs. 2010; 66 (7): 1487–1499.
    54. Flynn KJ, Powell LH, Mendes de Leon CF, et al. Increasing self-management skills in heart failure patients: a pilot study. Congest Heart Fail. 2005; 11 (6): 297–302.
    55. Martensson J, Stromberg A, Dahlstrom U, Karlsson JE, Fridlund B. Patients with heart failure in primary health care: effects of a nurse-led intervention on health-related quality of life and depression. Eur J Heart Fail. 2005; 7 (3): 393–403.
    56. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.
    57. Pena FM, da Silva SJ, Paiva BT, et al. Sociodemographic factors and depressive symptoms in hospitalized patients with heart failure. Exp Clin Cardiol. 2010; 15 (2): e29–e32.
    Keywords:

    anxiety; depression; heart failure; longitudinal; social support

    © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins