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The level of anxiety, depression and quality of life among patients with heart failure in Greece
Applied Nursing Research 34 (2017) 52–56
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The level of anxiety, depression and quality of life among patients with heart failure in Greece Zoi Aggelopoulou a, Nikolaos V. Fotos a, Anastasia A Chatziefstratiou a,⁎, Konstantinos Giakoumidakis b, Ioannis Elefsiniotis b, Hero Brokalaki a a b
Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece Cardiac Surgery Intensive Care Unit, Evangelismos General Hospital of Athens, Greece
a r t i c l e
i n f o
Article history: Received 25 September 2016 Revised 14 December 2016 Accepted 31 January 2017 Available online xxxx Keywords: Heart failure Quality of life Anxiety Depression
a b s t r a c t Purpose: The assessment of the level of anxiety, depression and quality of life among patients with heart failure. Methods: It was an observational study. The populations were 231 patients with heart failure who were hospitalized in cardiology departments of 2 general hospitals in Athens, from September 1, 2010 through January 31, 2012. We used the “Minnesota Living with Heart Failure Questionnaire - MLHFQ” to evaluate patients' quality of life and the “ State-Trait Anxiety Inventory - STAI” and the “Maastricht Questionnaire - MQ” to evaluate the level of stress and depression, respectively. Results: The mean age of patients was 66.1 ± 10.1 years. The quality of life was poor, since the average score in MLHFQ was 65.4 ± 20.6. Also, patients revealed high levels of both trait and state anxiety (mean score in STAI was 54.5 ± 9.4 and 52.8 ± 8.5 respectively) and depression (mean score in MQ was 34.3 ± 8.4). Factors associated with poor quality of life and high levels of anxiety and depression were older age, low level of education, unemployment, poor economic situation, multiple hospitalizations (N 4 times) and heart failure stages III and IV in NYHA (p b 0.001 in all cases). Conclusion: Patients with heart failure present severe symptoms of anxiety and depression and poor quality of life. Assessing those patients for these symptoms and providing holistic health care by a multidisciplinary team, will lead to the prevention and early treatment not only of physical but also of the psychosocial manifestations of the disease. © 2017 Elsevier Inc. All rights reserved.
1. Introduction Heart failure (HF) is a common disease and a serious public health problem, since 26 million adults worldwide are living with HF (European Society of Cardiology, 2014). The annual incidence of HF increases steadily, however the increase depends from the aging of population in each country (European Society of Cardiology, 2014). For instance, HF is a major and growing health problem in USA since 5.7 million people have been diagnosed with HF and 1 of 9 deaths attributed to HF (Mozzafarian, 2016). In addition, 15 million people in Europe suffer from heart failure (Keel, Wait, Harding, & McLister, 2015). Regarding Greece, it is estimated that there are approximately 200.000 patients with HF and about 30.000 new cases each year (Trikas, 2005). According to literature review, the majority of patients with HF experience symptoms of anxiety and depression, while it is also observed ⁎ Corresponding author at: Boulgari 16–18, Pireaus, PC 18533, Greece. E-mail addresses: [email protected] (N.V. Fotos), [email protected] (A.A. Chatziefstratiou), [email protected] (K. Giakoumidakis), [email protected] (I. Elefsiniotis), [email protected] (H. Brokalaki).
http://dx.doi.org/10.1016/j.apnr.2017.01.003 0897-1897/© 2017 Elsevier Inc. All rights reserved.
a considerable reduction in patients' quality of life (QOL) (Kessing, Denollet, Widdershoven, & Kupper, 2016). The study of Lefteriotis et al. mentioned that the prevalence of depression among patients with HF varies between 9% to 60% depending on the method which researchers used in order to assess the level of depression (Lefteriotis, 2013). Sohani et al. found that the incidence of depression among heart failure patients estimated at 19.3% according to the method of interview and 33.6% when questionnaires are used (Sohani, 2012). Regarding anxiety, Alhurani et al. mentioned that patients with HF have higher level of anxiety by 60% in comparison with healthy elderly, whereas 40% of heart failure patients experience severe symptoms of depression (Alhurani, Dekker, FAAN, & Moser, 2015). Both depression and anxiety lead to a deterioration in patients' QOL with HF (Polikandrioti et al., 2015) (Kessing et al., 2016). In addition, many studies examined the factors which affect the development of depression and anxiety in patients with HF and the impairment of QOL. For instance, Polikandrioti et al. in a study of 190 people with HF observed that married patients have lower level of depression compared to single, divorced and widowed patients. In addition they found that patients with longer disease duration and more
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anxious and depressed (Polikandrioti et al., 2015). In another study supported that QOL among patients with HF is affected by the gender, educational level and employment status, whereas it is not affected by marital status and classification of HF by New York Heart Association (Sawafta & Chen, 2013). The aim of the present study was to estimate the level of depression, anxiety and QOL in patients with HF in Greece. In addition, we tend to examine the associated factors with the presence of anxiety, depression and poor QOL like sociodemographic characteristics and factors related to heart failure. The study will contribute to prevent all these factors that lead to depression, anxiety in order to improve QOL in patients with HF. 2. Methods 2.1. Design The sample consisted 231 patients with HF stage II to IV according to New York Heart Association (NYHA) classification. The inclusion criteria for participants were the following: (1) at least 40 years old; (2) ejection fraction (EF) ≤ 35%; (3) presence of typical symptoms of HF (breathlessness, ankle swelling, and fatigue); (4) presence of typical signs of HF (elevated jugular venous pressure, pulmonary crackles, and displaced apex beat); (5) knowledge of the Greek language; (6) ability of verbal communication; (7) written informed consent and (8) patients should not conduct any diagnostic procedure two hours before their enrolment in the study. (Grady et al., 2001) (Parajon et al., 2004) (Hunt et al., 2001) (Lloyd-Jones et al., 2002) (Bleumink et al., 2001) (Morales, Cunningham, Brown, Liu, & Hays, 1999) The exclusion criteria of the study were (Χριστοδούλου, 2004): (1) existence of depression before the diagnosis of HF; (2) existence of schizophrenia before the diagnosis of HF; (3) existence of chronic respiratory failure; (4) existence of musculoskeletal disease, which affects patients' ability to conduct any physical activity; (5) existence of chronic renal failure at end stage; (6) diagnosis of cancer during the last 5 years. 3. Data collection 3.1. Procedure The data collection was taken place from September 2010 to January 2012 in a General Hospital of Athens in Greece. The same researcher each time distributed the tools to participants and thereafter they fulfilled the tools during a semi-structured interview. The researcher team selected this specific method in order participants to have had the ability to express their queries and the research could to simplify them. 3.2. Socio-demographic form This consisted of items regarding socio-demographic characteristics and information regarding the medical history of patients and based on the medical records. 3.3. STAI The State-Trait Anxiety Inventory (STAI) questionnaire was used to assess the level of anxiety in patients with HF. The questionnaire was developed by Spielberger in 1970 (Spielberger, Gorsuch, & Lushene, 1970). The tool consists items both for situational anxiety and constructive anxiety. The sub-scale for the situational anxiety (STAI form Y-1) includes 20 items which examine how patients feel at real time. On the other hand, the sub-scale for constructive anxiety (STAI form Y-2) consists 20 items which measure how patients feel in general. The two subscales are printed in the same page; however on reverse sides. Each
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answer encoded in a Likert-scale with four points from not at all (1) to very (4). The lower score for each subscale is 20 and the higher 80. Higher score indicates higher level of anxiety. The scale has been translated and validated in Greece (Fountoulakis, Papadopoulou, Papadopoulou, Bizeli, & Nimatoudis, 2006). The Cronbach's a value was 0.93 for the State and 0.92 for the Trait subscale (Fountoulakis et al., 2006). 3.4. MQ The Maastricht Questionnaire (MQ) was administered in patients in order to assess the level of depression. The questionnaire was developed by Appels in 1987 (Appels, Hoppener, & Mulder, 1987). It consists a 20point Likert scale and answers encoded as yes, no and not known (yes =2; not know = 1; no =0). The total score ranges from 0 (minimum) to 40 (maximum). Scores greater or equal than 15 indicates the presence of depression. The MQ has been translated and validated in Greek population, Cronbach's a values was 0.74 (Aναγνωστοπούλου & Kιοσέογλου, 1999). 3.5. MLwHFQ Patient's self-assessment of health related quality of life was measured by the Minnesota Living with Heart Failure Questionnaire (MLwHFQ). The MLwHFQ is a disease-specific measure and design by Rector for use in HF (Rector, 1992). The MLwHFQ contains 21 items with 6-point Likert response scale ranging from 0 to 5. The MLwHFQ includes subscales for physical (8 items) and emotional function (5 items) and 8 additional items that are part of the total MLwHFQ. The possible range of the total score is from 0 to 105; a higher score indicates poorer HRQL. This instrument has documented validity, reliability and sensitivity in Greece (Brokalaki et al., 2015). Brokalaki et al. found 0.97 Cronbach's alpha value among patients with heart failure in Greece (Brokalaki et al., 2015). 3.6. Ethical approval In order to use the STAI, MQ and MLwHFQ in this study, we asked the permission of the developers before the start. The study was approved by the Ethics Committee of the hospitals (34/2010). The participants in the study were informed about the purpose of the study before written consent was obtained. The researchers also guaranteed that the documents would be kept confidential. 3.7. Analysis The mean values (mean), standard deviations (Standard Deviation = SD), medians (median) and interquartile ranges used to describe the quantitative variables. Absolute (N) and relative (%) frequencies used for the description of qualitative variables. For the comparison of quantitative variables between two groups used the non-parametric test Mann-Whitney. To compare quantitative variables between more than two groups used the non-parametric test Kruskal-Wallis. For the control of Type I error due to multiple comparisons, the Bonferroni correction was used according to which the significance level is 0.05/k (k = number of comparisons). To test the relationship between two quantitative variables used the correlation coefficient of Spearman (r). The correlation is considered low when the correlation coefficient (r) ranges from 0.1 to 0.3, moderate when the correlation coefficient ranges from 0.31 to 0.5 and high when the ratio exceeds 0.5. Linear regression analysis with the procedure of sequential inclusion/removal (stepwise) was used to find independent factors associated with different scales that generated dependency rates (b) and their standard errors (standard errors = SE). The linear regression analysis was done using a logarithmic transformation. Significance levels are flanked and statistical
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significance was set at 0.05. For the analysis used the statistical program SPSS 17.0.
Table 2 Data of medical history. N Duration of HF (years) - mean ± SD Duration of treatment (years) - mean ± SD Cause of HF
4. Results 4.1. Demographic characteristics The sample consisted of 231 patients with a mean age of 66.1 years (±10.1) and 58.4% of patients were male. Demographic characteristics of patients are listed in Table 1. Also, 87.9% of participants were Greeks. The majority of patients were primary school (6 years) graduates with the rate reaching 40.7% and 71.4% of participants were married. Most of patients (60.2%) were retired and 51.1% had moderate economic situation. In the Table 2 are represented the data of the medical history of the participants and their results of diagnostic procedures. As shown in Table 2, the mean duration of disease was 6.6 years (±3.3) and 84% of patients had been hospitalized 1–4 times during the last year. Also, the severity of HF in 41.1% of patients was in level III according to NYHA classification and 60.6% of participants had not done any surgery in the past year.
Number of hospitalization during the last year Severity of HF (NYHA)
Ejection fraction (mean ± SD) Medication regimen for anxiety or/and depression Number of pills (mean ± SD) Average number of doses (mean ± SD) Cardiac surgeries during the last year
Ischemic heart disease Valvular disease Dilated cardiomyopathy 1–4 N4 NYHA II NYHA III NYHA IV Anti-anxiety Anti-depression Both
CABG PTCA Valve replacement None
%
6.6 ± 3.3 3.7 ± 2.8 141 61.0 58 32
25.1 13.9
194 84.0 37 16.0 90 38.9 95 41.1 46 19.9 43.7 ± 7.9 139 60.2 17 7.4 75 32.5 4.0 ± 1.6 3.3 ± 1.0 14 6.1 54 23.4 23 10.0 140 60.6
4.2. QOL 4.5. Correlations In Table 3 are given the dimensions of quality of life as derived from the MLwHFQ. The mean score of patients in dimension of physical health was 25.9 (± 8.4), while in the dimension of emotional health was 15.2 (± 6.4). The average score in the overall QOL was 65.4 (±20.6) with higher values indicate poorer QOL. 4.3. STAI In Table 4 are given the scores of participants in temporary and permanent anxiety using the STAI questionnaire. As shown in Table 4, the mean score of patients in temporary anxiety scale was 54.4 (± 9.4) and the mean score of in permanent anxiety scale was 52.8 (±8.5). 4.4. MQ In Table 5 lists the participants' score in MQ. The average score in MQ was 4.3 (±8.4). According to the score the 96.1% of patients suffers from depression. Table 1 Demographic characteristics of the sample. N Age (mean ± SD) Sex Nationality Level of education
Marital status Living condition Job
Economic status
Men Women Greek Other Primary (6 years) Secondary (3 years) High school (3 years) University (4–5 years) Married Unmarried/Divorced/Widower Live alone Live with other Occupied Unemployed Retired Householders Low Medium High
%
66.1 ± 10.1 135 58.4 96 41.6 203 87.9 28 12.1 94 40.7 38 16.5 70 30.3 29 12.6 165 71.4 66 28.6 65 28.1 166 71.9 67 29.0 1 0.4 139 60.2 24 10.4 72 31.2 118 51.1 41 17.7
It was observed a significant positive correlation between all variables of patients. More specific, higher level of anxiety and depression was associated with worse quality of life. Also, patients with anxiety experienced more symptoms of depression and worse emotional health which is associated with worse general QOL. In Table 6 are represented the results of the correlation analysis. According the correlation between QOL and demographic characteristics, the results are shown in Table 6. As shown in the table, there was a statistically significant difference in the scores of participants in physical health dimension, emotional sub-dimension and total score in MLwHFQ according to their educational level. Specifically, participants who were university graduates had significantly lower scores, which means better physical and emotional health, in comparison with participants with other levels of education (p b 0.005). In addition, employed participants had significantly lower scores in both dimensions compare to unemployed participants, householders and retired people. Finally, participants with good financial situation had significantly lower scores compared with participants who had poor economic status (p = 0.006). In addition, participants who were hospitalized N 4 times during the last year had significantly higher score in dimension of physical health, emotional health and total score in MLwHFQ in contrast to participants who were hospitalized at most 4 times. Also, there was a significant difference in scores concerning the severity of HF. Finally, it was observed a strong correlation between patients' QOL, age, duration of the HF, duration of medication regiment, the number of medications and daily doses. 4.6. Discussion The results of the present study indicated that the mean score in total quality of life in patients with HF in Greece was 65.4, 25.9 in
Table 3 QOL of patients.
Physical health Emotional health Total QOL
Minimum score
Maximum Score
Mean ± SD
Median (range)
3.0 0.0 9.0
40.0 25.0 102.0
25.9 ± 8.4 15.2 ± 6.4 65.4 ± 20.6
26 (20−33) 15 (11−20) 64 (52–82)
Z. Aggelopoulou et al. / Applied Nursing Research 34 (2017) 52–56 Table 4 Level of state and trait anxiety.
Minimum Maximum Mean ± SD Median (range)
Table 6 Correlation among QOL depression and anxiety. State anxiety
Trait anxiety
23.0 76.0 54.5 ± 9.4 53 (49–59)
30.0 71.0 52.8 ± 8.5 50 (48–58)
physical health and 15.2 in emotional health. In addition, it was proved that the mean score in STAI was 54.4 and 52.8 for the temporary and permanent anxiety, respectively, whereas 96.1% of the sample had depression. Noteworthy were the results regarding factors affecting patients' quality of life. More specific, higher score in anxiety and depression was associated with worse quality of life both in total scale and two subscales. Also, the level of education, the occupational status, the rate of hospitalization and the cause of HF were strongly associated with the level of quality of life. The assessment of anxiety, depression and QOL in patients with HF is one of the most important issues because of the nature of the disease. The HF as a chronic disease is characterized by long-term treatment regimens, emotional instability, low self-esteem, dependence and major changes in lifestyle (Μπροκαλάκη μπροκαλάκη-Πανανουδάκη, 2014). Moreover, patients with HF experience a steadily disease progression and a deterioration in their physical capacity as a result of dyspnea, fatigue, loss of muscle strength, dietary restrictions and difficulty in walking (Μπροκαλάκη μπροκαλάκη-Πανανουδάκη, 2014). In recent years, more and more researchers examine the level of anxiety, depression and QOL among patients with HF. In this study, we aimed to estimate these parameters in patients with HF and attempted to correlate them both with demographic and clinical characteristics of the sample. The mean age of study participants was 66.1 (±10.1) years. These finding are in agreement with current literature, which argues that the prevalence of the HF increases with age (Keel et al., 2015). More specific, it is recorded that the majority of patients are older than 65 years old. Simultaneously, it is believed that the progressive aging of the population, which is already recorded in developed countries, will increase the incidence of HF at ages over 65 years (Roger et al., 2011). Patients' QOL in the study was poor both in physical and emotional dimension and many factors were identified which affect it. Specifically, it was found that participants who were university graduates had significantly better physical and emotional QOL in comparison with those who were primary school graduates as well as those who were high school graduates. Moreover, participants who were high school graduates had significantly better physical and emotional health, compared with those who were primary school graduates. Similar results were reported by Philbin et al. who studied the relationship between income, level of education and occupation of patients with HF with the rate of reintroduction to hospital, QOL, anxiety and depression (Hunt et al., 2005). Among other findings, researchers proved that patients with low incomes and unemployed had higher levels of anxiety and depression compared with employees and those who reported a good financial situation. In the same result end the studies of Farcaş and Laura in 2011 (Farcaş & Laura, 2011). Also Chu et al. supported that HF patients with
Table 5 Level of depression (MQ). Depression Minimum Maximum Mean ± SD Median (Range)
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5.0 42.0 34.3 ± 8.4 38 (31–41)
Trait anxiety State anxiety Trait anxiety Physical health Emotional health Total QOL
r 0.47 P b0.001 r 1.00 P r P r P r P
Physical health
Emotional health
Total QOL
0.46 b0.001 0.32 b0.001 1.00
0.46 b0.001 0.39 b0.001 0.82 b0.001 1.00
0.52 b0.001 0.40 b0.001 0.96 b0.001 0.91 b0.001 1.00
Depression 0.42 b0.001 0.34 b0.001 0.66 b0.001 0.77 b0.001 0.72 b0.001
high annually salary are characterized by less level of depression and anxiety (Chu et al., 2012). The fact that may be explained since good economic situation associated with the sense of security. The marital status of patients in this study had a significant effect on symptoms of anxiety and depression, and affected the emotional part of their QOL. Those patients who were living with family members showed less temporary anxiety than those who lived alone. Also, married faced more symptoms of depression compared to unmarried, divorced and/or widowers, but had better QOL regarding the emotional sub-dimension. Obviously married and those living with a third person had psychological and emotional support. Another statistically significant factor in the prevalence of anxiety, depression and poor of QOL was the severity of the disease. In particular, it was found that patients with HF stage II (sorted by NYHA) had fewer symptoms of anxiety and depression and better QOL compared with those who were stage III or IV. Also, patients with HF stage III had significantly less anxiety and experienced less deterioration in QOL compared with those who were stage IV. These findings are in concordance with other studies (Ramos, Prata, Gonclaves, & Coelho, 2014) (Chu et al., 2012). This fact is more than expected since patients with higher stage of HF experience more symptoms and the severity of these is more significant thus patients face greater deterioration in their QOL and feel more uncomfortable and less independent (Cardiology, 2010) (Μπροκαλάκη μπροκαλάκη-Πανανουδάκη, 2014). In addition, we proved that emotional health of patients is affected by the cause of the disease. Specifically, it was found that participants who were suffering from valvular disease had poorer emotional health than those who suffered from ischemic heart disease or dilated cardiomyopathy. This finding is in contrast with the results of the study of Parajon et al. which mentioned that patients with ischemic heart disease were characterized by poorer emotional health (Parajon et al., 2004). However, it is observed a lack of studies examining the association between QOL and the cause of HF. Another finding in the present study is the correlation among rate of hospitalization, QOL and anxiety. More specific, total, physical and emotional QOL and anxiety were influenced by the number of re-hospitalization. Participants who had been hospitalized N 4 times in the last year had poorer QOL in all dimensions and were more anxious than those who were hospitalized b4 times. This fact is explained since patients who hospitalized many times feel that they disease threat their health and their lives, therefore they are anxious about the outcome of HF and the extensive deterioration in their QOL. However, the rate of readmissions in hospital was not associated with the prevalence of depression. Finally, in the present study was not found statistically significant difference between men and women in terms of QOL and the prevalence of anxiety and depression. This finding contrasts with the results of other studies, however a possible explanation is the small sample of the study and the absence of significant difference in the number of men and women in the present study. Specifically, the study of Chu et al. found that women had impaired emotional situation than men
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(Chu et al., 2012). In the study of Ramos et al. women had higher level of depression compared to men (Ramos et al., 2014). It is obviously that patients with heart failure are characterized by poor quality of life due to symptoms of depression and anxiety. However, there is a plenty of factors which affect the level of depression and anxiety like age, sex, educational and marital status. On the other hand, it is needed more research regarding the impact of heart failure's severity and the presence of other diseases' in patients' QOL. 4.7. Limitations The study conducted only in one center and patients did not retrieve from the community, so it is restricted the generalization of the results in HF patients in the community. Also, the small sample size may affect the analysis of the data. 5. Conclusion In this study for the first time in Greece are used all together the scales MQ, STAI and MLwHFQ. The results indicated that patients' quality of life is very poor and they experienced high level of anxiety and depression which deteriorate more QOL. In addition, patients' QOL is affected by irreversible factors like age, sex and socioeconomic status, however patients' education and especially their knowledge about HF leads to an improvement to QOL and symptoms of depression. Implications to clinical practice The psychosocial assessment and support of patients with HF is important in order to improve patients' quality of life and to eliminate the level of anxiety and depression as a result a reduction of health care cost and rate of re-hospitalization. Therefore, the implementation of new diagnostic and therapeutic approach to these patients is necessary. Specifically, nurses can incorporate into daily clinical practice the use of valid tools of anxiety, depression and QOL so as to assess the psychosocial impact of HF and therapeutic interventions on QOL. In addition, nurses are able to plan and provide holistic care in order to meet effectively the needs of patients and improve patients' QOL. Therefore, it is imperative nurses to provide educational intervention in patients and their caregivers regarding the nature of HF, symptoms, prognosis and treatment. Particular emphasis should be given to strengthen selfcare and psychological support. This paper is in memory of Mrs. Zoi Aggelopoulou who did not achieve to complete the paper because of her sudden death. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References Alhurani, S., Dekker, L., FAAN, & Moser, K. (2015). The association of co-morbid symptoms of depression and anxiety with all-cause mortality and cardiac rehospitalization in patients with heart failure. Psychosomatics, 58(4), 371–380. Appels, A., Hoppener, P., & Mulder, P. (1987). A questionnaire to assess premonitory symptoms of myocardial infarction. International Journal of Cardiology, 17, 15–24. Aναγνωστοπούλου, T., & Kιοσέογλου, K. (1999). Παρουσίαση της ελληνικής προσαρμογής του ερωτηματολογίου Maastricth για τη μέτρηση της ενεργειακής εξάντλησης. (Vol. III). Θεσσαλονίκη: Επιστημονική Επετηρίδα της Φιλοσοφικής Σχολής, Τμήμα Ψυχολογίας.
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The level of anxiety, depression and quality of life among patients with heart failure in Greece Zoi Aggelopoulou a, Nikolaos V. Fotos a, Anastasia A Chatziefstratiou a,⁎, Konstantinos Giakoumidakis b, Ioannis Elefsiniotis b, Hero Brokalaki a a b
Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece Cardiac Surgery Intensive Care Unit, Evangelismos General Hospital of Athens, Greece
a r t i c l e
i n f o
Article history: Received 25 September 2016 Revised 14 December 2016 Accepted 31 January 2017 Available online xxxx Keywords: Heart failure Quality of life Anxiety Depression
a b s t r a c t Purpose: The assessment of the level of anxiety, depression and quality of life among patients with heart failure. Methods: It was an observational study. The populations were 231 patients with heart failure who were hospitalized in cardiology departments of 2 general hospitals in Athens, from September 1, 2010 through January 31, 2012. We used the “Minnesota Living with Heart Failure Questionnaire - MLHFQ” to evaluate patients' quality of life and the “ State-Trait Anxiety Inventory - STAI” and the “Maastricht Questionnaire - MQ” to evaluate the level of stress and depression, respectively. Results: The mean age of patients was 66.1 ± 10.1 years. The quality of life was poor, since the average score in MLHFQ was 65.4 ± 20.6. Also, patients revealed high levels of both trait and state anxiety (mean score in STAI was 54.5 ± 9.4 and 52.8 ± 8.5 respectively) and depression (mean score in MQ was 34.3 ± 8.4). Factors associated with poor quality of life and high levels of anxiety and depression were older age, low level of education, unemployment, poor economic situation, multiple hospitalizations (N 4 times) and heart failure stages III and IV in NYHA (p b 0.001 in all cases). Conclusion: Patients with heart failure present severe symptoms of anxiety and depression and poor quality of life. Assessing those patients for these symptoms and providing holistic health care by a multidisciplinary team, will lead to the prevention and early treatment not only of physical but also of the psychosocial manifestations of the disease. © 2017 Elsevier Inc. All rights reserved.
1. Introduction Heart failure (HF) is a common disease and a serious public health problem, since 26 million adults worldwide are living with HF (European Society of Cardiology, 2014). The annual incidence of HF increases steadily, however the increase depends from the aging of population in each country (European Society of Cardiology, 2014). For instance, HF is a major and growing health problem in USA since 5.7 million people have been diagnosed with HF and 1 of 9 deaths attributed to HF (Mozzafarian, 2016). In addition, 15 million people in Europe suffer from heart failure (Keel, Wait, Harding, & McLister, 2015). Regarding Greece, it is estimated that there are approximately 200.000 patients with HF and about 30.000 new cases each year (Trikas, 2005). According to literature review, the majority of patients with HF experience symptoms of anxiety and depression, while it is also observed ⁎ Corresponding author at: Boulgari 16–18, Pireaus, PC 18533, Greece. E-mail addresses: [email protected] (N.V. Fotos), [email protected] (A.A. Chatziefstratiou), [email protected] (K. Giakoumidakis), [email protected] (I. Elefsiniotis), [email protected] (H. Brokalaki).
http://dx.doi.org/10.1016/j.apnr.2017.01.003 0897-1897/© 2017 Elsevier Inc. All rights reserved.
a considerable reduction in patients' quality of life (QOL) (Kessing, Denollet, Widdershoven, & Kupper, 2016). The study of Lefteriotis et al. mentioned that the prevalence of depression among patients with HF varies between 9% to 60% depending on the method which researchers used in order to assess the level of depression (Lefteriotis, 2013). Sohani et al. found that the incidence of depression among heart failure patients estimated at 19.3% according to the method of interview and 33.6% when questionnaires are used (Sohani, 2012). Regarding anxiety, Alhurani et al. mentioned that patients with HF have higher level of anxiety by 60% in comparison with healthy elderly, whereas 40% of heart failure patients experience severe symptoms of depression (Alhurani, Dekker, FAAN, & Moser, 2015). Both depression and anxiety lead to a deterioration in patients' QOL with HF (Polikandrioti et al., 2015) (Kessing et al., 2016). In addition, many studies examined the factors which affect the development of depression and anxiety in patients with HF and the impairment of QOL. For instance, Polikandrioti et al. in a study of 190 people with HF observed that married patients have lower level of depression compared to single, divorced and widowed patients. In addition they found that patients with longer disease duration and more
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anxious and depressed (Polikandrioti et al., 2015). In another study supported that QOL among patients with HF is affected by the gender, educational level and employment status, whereas it is not affected by marital status and classification of HF by New York Heart Association (Sawafta & Chen, 2013). The aim of the present study was to estimate the level of depression, anxiety and QOL in patients with HF in Greece. In addition, we tend to examine the associated factors with the presence of anxiety, depression and poor QOL like sociodemographic characteristics and factors related to heart failure. The study will contribute to prevent all these factors that lead to depression, anxiety in order to improve QOL in patients with HF. 2. Methods 2.1. Design The sample consisted 231 patients with HF stage II to IV according to New York Heart Association (NYHA) classification. The inclusion criteria for participants were the following: (1) at least 40 years old; (2) ejection fraction (EF) ≤ 35%; (3) presence of typical symptoms of HF (breathlessness, ankle swelling, and fatigue); (4) presence of typical signs of HF (elevated jugular venous pressure, pulmonary crackles, and displaced apex beat); (5) knowledge of the Greek language; (6) ability of verbal communication; (7) written informed consent and (8) patients should not conduct any diagnostic procedure two hours before their enrolment in the study. (Grady et al., 2001) (Parajon et al., 2004) (Hunt et al., 2001) (Lloyd-Jones et al., 2002) (Bleumink et al., 2001) (Morales, Cunningham, Brown, Liu, & Hays, 1999) The exclusion criteria of the study were (Χριστοδούλου, 2004): (1) existence of depression before the diagnosis of HF; (2) existence of schizophrenia before the diagnosis of HF; (3) existence of chronic respiratory failure; (4) existence of musculoskeletal disease, which affects patients' ability to conduct any physical activity; (5) existence of chronic renal failure at end stage; (6) diagnosis of cancer during the last 5 years. 3. Data collection 3.1. Procedure The data collection was taken place from September 2010 to January 2012 in a General Hospital of Athens in Greece. The same researcher each time distributed the tools to participants and thereafter they fulfilled the tools during a semi-structured interview. The researcher team selected this specific method in order participants to have had the ability to express their queries and the research could to simplify them. 3.2. Socio-demographic form This consisted of items regarding socio-demographic characteristics and information regarding the medical history of patients and based on the medical records. 3.3. STAI The State-Trait Anxiety Inventory (STAI) questionnaire was used to assess the level of anxiety in patients with HF. The questionnaire was developed by Spielberger in 1970 (Spielberger, Gorsuch, & Lushene, 1970). The tool consists items both for situational anxiety and constructive anxiety. The sub-scale for the situational anxiety (STAI form Y-1) includes 20 items which examine how patients feel at real time. On the other hand, the sub-scale for constructive anxiety (STAI form Y-2) consists 20 items which measure how patients feel in general. The two subscales are printed in the same page; however on reverse sides. Each
53
answer encoded in a Likert-scale with four points from not at all (1) to very (4). The lower score for each subscale is 20 and the higher 80. Higher score indicates higher level of anxiety. The scale has been translated and validated in Greece (Fountoulakis, Papadopoulou, Papadopoulou, Bizeli, & Nimatoudis, 2006). The Cronbach's a value was 0.93 for the State and 0.92 for the Trait subscale (Fountoulakis et al., 2006). 3.4. MQ The Maastricht Questionnaire (MQ) was administered in patients in order to assess the level of depression. The questionnaire was developed by Appels in 1987 (Appels, Hoppener, & Mulder, 1987). It consists a 20point Likert scale and answers encoded as yes, no and not known (yes =2; not know = 1; no =0). The total score ranges from 0 (minimum) to 40 (maximum). Scores greater or equal than 15 indicates the presence of depression. The MQ has been translated and validated in Greek population, Cronbach's a values was 0.74 (Aναγνωστοπούλου & Kιοσέογλου, 1999). 3.5. MLwHFQ Patient's self-assessment of health related quality of life was measured by the Minnesota Living with Heart Failure Questionnaire (MLwHFQ). The MLwHFQ is a disease-specific measure and design by Rector for use in HF (Rector, 1992). The MLwHFQ contains 21 items with 6-point Likert response scale ranging from 0 to 5. The MLwHFQ includes subscales for physical (8 items) and emotional function (5 items) and 8 additional items that are part of the total MLwHFQ. The possible range of the total score is from 0 to 105; a higher score indicates poorer HRQL. This instrument has documented validity, reliability and sensitivity in Greece (Brokalaki et al., 2015). Brokalaki et al. found 0.97 Cronbach's alpha value among patients with heart failure in Greece (Brokalaki et al., 2015). 3.6. Ethical approval In order to use the STAI, MQ and MLwHFQ in this study, we asked the permission of the developers before the start. The study was approved by the Ethics Committee of the hospitals (34/2010). The participants in the study were informed about the purpose of the study before written consent was obtained. The researchers also guaranteed that the documents would be kept confidential. 3.7. Analysis The mean values (mean), standard deviations (Standard Deviation = SD), medians (median) and interquartile ranges used to describe the quantitative variables. Absolute (N) and relative (%) frequencies used for the description of qualitative variables. For the comparison of quantitative variables between two groups used the non-parametric test Mann-Whitney. To compare quantitative variables between more than two groups used the non-parametric test Kruskal-Wallis. For the control of Type I error due to multiple comparisons, the Bonferroni correction was used according to which the significance level is 0.05/k (k = number of comparisons). To test the relationship between two quantitative variables used the correlation coefficient of Spearman (r). The correlation is considered low when the correlation coefficient (r) ranges from 0.1 to 0.3, moderate when the correlation coefficient ranges from 0.31 to 0.5 and high when the ratio exceeds 0.5. Linear regression analysis with the procedure of sequential inclusion/removal (stepwise) was used to find independent factors associated with different scales that generated dependency rates (b) and their standard errors (standard errors = SE). The linear regression analysis was done using a logarithmic transformation. Significance levels are flanked and statistical
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significance was set at 0.05. For the analysis used the statistical program SPSS 17.0.
Table 2 Data of medical history. N Duration of HF (years) - mean ± SD Duration of treatment (years) - mean ± SD Cause of HF
4. Results 4.1. Demographic characteristics The sample consisted of 231 patients with a mean age of 66.1 years (±10.1) and 58.4% of patients were male. Demographic characteristics of patients are listed in Table 1. Also, 87.9% of participants were Greeks. The majority of patients were primary school (6 years) graduates with the rate reaching 40.7% and 71.4% of participants were married. Most of patients (60.2%) were retired and 51.1% had moderate economic situation. In the Table 2 are represented the data of the medical history of the participants and their results of diagnostic procedures. As shown in Table 2, the mean duration of disease was 6.6 years (±3.3) and 84% of patients had been hospitalized 1–4 times during the last year. Also, the severity of HF in 41.1% of patients was in level III according to NYHA classification and 60.6% of participants had not done any surgery in the past year.
Number of hospitalization during the last year Severity of HF (NYHA)
Ejection fraction (mean ± SD) Medication regimen for anxiety or/and depression Number of pills (mean ± SD) Average number of doses (mean ± SD) Cardiac surgeries during the last year
Ischemic heart disease Valvular disease Dilated cardiomyopathy 1–4 N4 NYHA II NYHA III NYHA IV Anti-anxiety Anti-depression Both
CABG PTCA Valve replacement None
%
6.6 ± 3.3 3.7 ± 2.8 141 61.0 58 32
25.1 13.9
194 84.0 37 16.0 90 38.9 95 41.1 46 19.9 43.7 ± 7.9 139 60.2 17 7.4 75 32.5 4.0 ± 1.6 3.3 ± 1.0 14 6.1 54 23.4 23 10.0 140 60.6
4.2. QOL 4.5. Correlations In Table 3 are given the dimensions of quality of life as derived from the MLwHFQ. The mean score of patients in dimension of physical health was 25.9 (± 8.4), while in the dimension of emotional health was 15.2 (± 6.4). The average score in the overall QOL was 65.4 (±20.6) with higher values indicate poorer QOL. 4.3. STAI In Table 4 are given the scores of participants in temporary and permanent anxiety using the STAI questionnaire. As shown in Table 4, the mean score of patients in temporary anxiety scale was 54.4 (± 9.4) and the mean score of in permanent anxiety scale was 52.8 (±8.5). 4.4. MQ In Table 5 lists the participants' score in MQ. The average score in MQ was 4.3 (±8.4). According to the score the 96.1% of patients suffers from depression. Table 1 Demographic characteristics of the sample. N Age (mean ± SD) Sex Nationality Level of education
Marital status Living condition Job
Economic status
Men Women Greek Other Primary (6 years) Secondary (3 years) High school (3 years) University (4–5 years) Married Unmarried/Divorced/Widower Live alone Live with other Occupied Unemployed Retired Householders Low Medium High
%
66.1 ± 10.1 135 58.4 96 41.6 203 87.9 28 12.1 94 40.7 38 16.5 70 30.3 29 12.6 165 71.4 66 28.6 65 28.1 166 71.9 67 29.0 1 0.4 139 60.2 24 10.4 72 31.2 118 51.1 41 17.7
It was observed a significant positive correlation between all variables of patients. More specific, higher level of anxiety and depression was associated with worse quality of life. Also, patients with anxiety experienced more symptoms of depression and worse emotional health which is associated with worse general QOL. In Table 6 are represented the results of the correlation analysis. According the correlation between QOL and demographic characteristics, the results are shown in Table 6. As shown in the table, there was a statistically significant difference in the scores of participants in physical health dimension, emotional sub-dimension and total score in MLwHFQ according to their educational level. Specifically, participants who were university graduates had significantly lower scores, which means better physical and emotional health, in comparison with participants with other levels of education (p b 0.005). In addition, employed participants had significantly lower scores in both dimensions compare to unemployed participants, householders and retired people. Finally, participants with good financial situation had significantly lower scores compared with participants who had poor economic status (p = 0.006). In addition, participants who were hospitalized N 4 times during the last year had significantly higher score in dimension of physical health, emotional health and total score in MLwHFQ in contrast to participants who were hospitalized at most 4 times. Also, there was a significant difference in scores concerning the severity of HF. Finally, it was observed a strong correlation between patients' QOL, age, duration of the HF, duration of medication regiment, the number of medications and daily doses. 4.6. Discussion The results of the present study indicated that the mean score in total quality of life in patients with HF in Greece was 65.4, 25.9 in
Table 3 QOL of patients.
Physical health Emotional health Total QOL
Minimum score
Maximum Score
Mean ± SD
Median (range)
3.0 0.0 9.0
40.0 25.0 102.0
25.9 ± 8.4 15.2 ± 6.4 65.4 ± 20.6
26 (20−33) 15 (11−20) 64 (52–82)
Z. Aggelopoulou et al. / Applied Nursing Research 34 (2017) 52–56 Table 4 Level of state and trait anxiety.
Minimum Maximum Mean ± SD Median (range)
Table 6 Correlation among QOL depression and anxiety. State anxiety
Trait anxiety
23.0 76.0 54.5 ± 9.4 53 (49–59)
30.0 71.0 52.8 ± 8.5 50 (48–58)
physical health and 15.2 in emotional health. In addition, it was proved that the mean score in STAI was 54.4 and 52.8 for the temporary and permanent anxiety, respectively, whereas 96.1% of the sample had depression. Noteworthy were the results regarding factors affecting patients' quality of life. More specific, higher score in anxiety and depression was associated with worse quality of life both in total scale and two subscales. Also, the level of education, the occupational status, the rate of hospitalization and the cause of HF were strongly associated with the level of quality of life. The assessment of anxiety, depression and QOL in patients with HF is one of the most important issues because of the nature of the disease. The HF as a chronic disease is characterized by long-term treatment regimens, emotional instability, low self-esteem, dependence and major changes in lifestyle (Μπροκαλάκη μπροκαλάκη-Πανανουδάκη, 2014). Moreover, patients with HF experience a steadily disease progression and a deterioration in their physical capacity as a result of dyspnea, fatigue, loss of muscle strength, dietary restrictions and difficulty in walking (Μπροκαλάκη μπροκαλάκη-Πανανουδάκη, 2014). In recent years, more and more researchers examine the level of anxiety, depression and QOL among patients with HF. In this study, we aimed to estimate these parameters in patients with HF and attempted to correlate them both with demographic and clinical characteristics of the sample. The mean age of study participants was 66.1 (±10.1) years. These finding are in agreement with current literature, which argues that the prevalence of the HF increases with age (Keel et al., 2015). More specific, it is recorded that the majority of patients are older than 65 years old. Simultaneously, it is believed that the progressive aging of the population, which is already recorded in developed countries, will increase the incidence of HF at ages over 65 years (Roger et al., 2011). Patients' QOL in the study was poor both in physical and emotional dimension and many factors were identified which affect it. Specifically, it was found that participants who were university graduates had significantly better physical and emotional QOL in comparison with those who were primary school graduates as well as those who were high school graduates. Moreover, participants who were high school graduates had significantly better physical and emotional health, compared with those who were primary school graduates. Similar results were reported by Philbin et al. who studied the relationship between income, level of education and occupation of patients with HF with the rate of reintroduction to hospital, QOL, anxiety and depression (Hunt et al., 2005). Among other findings, researchers proved that patients with low incomes and unemployed had higher levels of anxiety and depression compared with employees and those who reported a good financial situation. In the same result end the studies of Farcaş and Laura in 2011 (Farcaş & Laura, 2011). Also Chu et al. supported that HF patients with
Table 5 Level of depression (MQ). Depression Minimum Maximum Mean ± SD Median (Range)
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5.0 42.0 34.3 ± 8.4 38 (31–41)
Trait anxiety State anxiety Trait anxiety Physical health Emotional health Total QOL
r 0.47 P b0.001 r 1.00 P r P r P r P
Physical health
Emotional health
Total QOL
0.46 b0.001 0.32 b0.001 1.00
0.46 b0.001 0.39 b0.001 0.82 b0.001 1.00
0.52 b0.001 0.40 b0.001 0.96 b0.001 0.91 b0.001 1.00
Depression 0.42 b0.001 0.34 b0.001 0.66 b0.001 0.77 b0.001 0.72 b0.001
high annually salary are characterized by less level of depression and anxiety (Chu et al., 2012). The fact that may be explained since good economic situation associated with the sense of security. The marital status of patients in this study had a significant effect on symptoms of anxiety and depression, and affected the emotional part of their QOL. Those patients who were living with family members showed less temporary anxiety than those who lived alone. Also, married faced more symptoms of depression compared to unmarried, divorced and/or widowers, but had better QOL regarding the emotional sub-dimension. Obviously married and those living with a third person had psychological and emotional support. Another statistically significant factor in the prevalence of anxiety, depression and poor of QOL was the severity of the disease. In particular, it was found that patients with HF stage II (sorted by NYHA) had fewer symptoms of anxiety and depression and better QOL compared with those who were stage III or IV. Also, patients with HF stage III had significantly less anxiety and experienced less deterioration in QOL compared with those who were stage IV. These findings are in concordance with other studies (Ramos, Prata, Gonclaves, & Coelho, 2014) (Chu et al., 2012). This fact is more than expected since patients with higher stage of HF experience more symptoms and the severity of these is more significant thus patients face greater deterioration in their QOL and feel more uncomfortable and less independent (Cardiology, 2010) (Μπροκαλάκη μπροκαλάκη-Πανανουδάκη, 2014). In addition, we proved that emotional health of patients is affected by the cause of the disease. Specifically, it was found that participants who were suffering from valvular disease had poorer emotional health than those who suffered from ischemic heart disease or dilated cardiomyopathy. This finding is in contrast with the results of the study of Parajon et al. which mentioned that patients with ischemic heart disease were characterized by poorer emotional health (Parajon et al., 2004). However, it is observed a lack of studies examining the association between QOL and the cause of HF. Another finding in the present study is the correlation among rate of hospitalization, QOL and anxiety. More specific, total, physical and emotional QOL and anxiety were influenced by the number of re-hospitalization. Participants who had been hospitalized N 4 times in the last year had poorer QOL in all dimensions and were more anxious than those who were hospitalized b4 times. This fact is explained since patients who hospitalized many times feel that they disease threat their health and their lives, therefore they are anxious about the outcome of HF and the extensive deterioration in their QOL. However, the rate of readmissions in hospital was not associated with the prevalence of depression. Finally, in the present study was not found statistically significant difference between men and women in terms of QOL and the prevalence of anxiety and depression. This finding contrasts with the results of other studies, however a possible explanation is the small sample of the study and the absence of significant difference in the number of men and women in the present study. Specifically, the study of Chu et al. found that women had impaired emotional situation than men
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(Chu et al., 2012). In the study of Ramos et al. women had higher level of depression compared to men (Ramos et al., 2014). It is obviously that patients with heart failure are characterized by poor quality of life due to symptoms of depression and anxiety. However, there is a plenty of factors which affect the level of depression and anxiety like age, sex, educational and marital status. On the other hand, it is needed more research regarding the impact of heart failure's severity and the presence of other diseases' in patients' QOL. 4.7. Limitations The study conducted only in one center and patients did not retrieve from the community, so it is restricted the generalization of the results in HF patients in the community. Also, the small sample size may affect the analysis of the data. 5. Conclusion In this study for the first time in Greece are used all together the scales MQ, STAI and MLwHFQ. The results indicated that patients' quality of life is very poor and they experienced high level of anxiety and depression which deteriorate more QOL. In addition, patients' QOL is affected by irreversible factors like age, sex and socioeconomic status, however patients' education and especially their knowledge about HF leads to an improvement to QOL and symptoms of depression. Implications to clinical practice The psychosocial assessment and support of patients with HF is important in order to improve patients' quality of life and to eliminate the level of anxiety and depression as a result a reduction of health care cost and rate of re-hospitalization. Therefore, the implementation of new diagnostic and therapeutic approach to these patients is necessary. Specifically, nurses can incorporate into daily clinical practice the use of valid tools of anxiety, depression and QOL so as to assess the psychosocial impact of HF and therapeutic interventions on QOL. In addition, nurses are able to plan and provide holistic care in order to meet effectively the needs of patients and improve patients' QOL. Therefore, it is imperative nurses to provide educational intervention in patients and their caregivers regarding the nature of HF, symptoms, prognosis and treatment. Particular emphasis should be given to strengthen selfcare and psychological support. This paper is in memory of Mrs. Zoi Aggelopoulou who did not achieve to complete the paper because of her sudden death. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References Alhurani, S., Dekker, L., FAAN, & Moser, K. (2015). The association of co-morbid symptoms of depression and anxiety with all-cause mortality and cardiac rehospitalization in patients with heart failure. Psychosomatics, 58(4), 371–380. Appels, A., Hoppener, P., & Mulder, P. (1987). A questionnaire to assess premonitory symptoms of myocardial infarction. International Journal of Cardiology, 17, 15–24. Aναγνωστοπούλου, T., & Kιοσέογλου, K. (1999). Παρουσίαση της ελληνικής προσαρμογής του ερωτηματολογίου Maastricth για τη μέτρηση της ενεργειακής εξάντλησης. (Vol. III). Θεσσαλονίκη: Επιστημονική Επετηρίδα της Φιλοσοφικής Σχολής, Τμήμα Ψυχολογίας.
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