- Email: [email protected]
Depression and Quality of Life in Terms of Personal Resources in Heart Transplant Recipients
Depression and Quality of Life in Terms of Personal Resources in Heart Transplant Recipients E.W. Ruzyczka, I. Milaniak, P. Przybyłowski, K. Wierzbicki, J. Siwin´ska, F.K. Hubner, and J. Sadowski ABSTRACT Background. Heart transplantation is the first option for treatment of heart failure engendering increased survival and quality of life among recipients. However, this surgical intervention causes many psychological problems such as depression and anxiety. Protective factors and personal recourses are significant forces behind healthy adjustments to life stresses. Purpose. The aim of this study was to estimate the prevalence of depression among heart transplant recipients. Procedure. The study consisted of a sample of 46 patients after heart transplantation. Standardized instruments used to measure the key constructs were Beck Depression Inventory Short Form for the prevalence of depression, World Health Organization Quality of Life - BREF for quality of life, Sense of Coherence (SOC-29), and Coping Orientation to Problems Experienced BREF to identify coping strategies. The data were analyzed statistically. Results. We found that sense of coherence and coping strategies were significant predictors for quality of life and prevalence of depression, which were significantly associated with each others. Strategies focused on the problem are moderate quality of life with an age of recipient. Recipients who have a tendency to use emotion-focused strategies and are older showed a poorer quality of life, were less satisfied with their health, and displayed a prevalence of depression. Conclusions. These results suggested that assessment of coping strategies and sense of coherence should be explored in heart transplant recipients with skills training in this domain. EART transplantation (HT) is an established therapy for end-stage disease.1,2 Organ transplantation significantly improves the quality of life (QoL) as well as the psychosocial situation. However, the recipients rarely reach QoL of a healthy person; there are persistent psychological symptoms.3 The transplantation literature has highlighted that the receipt of a new heart may give rise to a new set of stressors, psychological challenges, and adaptive demands.4 Antonovsky advocated the use of sense of coherence (SOC) as a central part of his approach to explain why some individuals stay healthy despite encountering major stressors.5,6 A high SOC level makes people believe in the predictability of life and order, which in turn motivates them to be healthy and functional. The theoretical model of the SOC has been associated with various self-care behav-
H
iors including cigarette smoking, physical activity, food selection, and oral health.6 Whether an individual moves from one end to another along this continuum depends on the encountered stressors and the set of available coping resources. The components of SOC-comprehensibility, manageability, and meaningfulness-express the extent to
From The Department of Cardiovascular Surgery and Transplantology (I.M., P.P., K.W., J.S., F.K.H., J.S.), John Paul II Hospital, Krakow, Poland and Jagiellonian University (E.W.R., P.P., K.W., J.S.), Medical College, Krakow, Poland. Address reprint requests to Irena Milaniak, RN, CETC, MA, Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Pradnicka str 80, 31-202 Krakow, Poland. E-mail: [email protected]
0041-1345/11/$–see front matter doi:10.1016/j.transproceed.2011.07.012
© 2011 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
3076
Transplantation Proceedings, 43, 3076 –3081 (2011)
DEPRESSION AND QoL
3077
Table 1. Background Characteristic of the Sample of HT Patients Characteristic
Age Gender (%) Male Female Years since transplantation Employment status (unemployed; %) Residence Town Village Any concurrent medication (%) Hypertension CAV Kidney failure Diabetes
Table 2. Descriptive Statistics of the Level of SOC and Its Components (n ⴝ 46)
Study Sample (n ⫽ 46)
SOC Components
Mean (max–min)
SD
Average, 52.36; median, 57; max, 68; min, 21
Comprehensibility Manageability Meaningfulness Global SOC
46.95 (18–71) 48.17 (27–74) 40.13 (14–59) 135.21 (59–189)
10.60 7.77 0 18.38
76.19 23.80 Average 10.84; median, 11; max, 18; min, 1 80.95
64.28 35.71 59.52 9.5 35.71 16.66 Average 1,2 illnesses per patient
Abbreviations: CAV, coronary artery vasculopathy; max, maximum; min, minimum.
which one has a pervasive feeling of confidence that the confronted stimuli are structured and predictable (comprehensible), worthy of engagement (meaningful), and that an individual has sufficient resources to meet the demands of life (manageable). The stronger the SOC, the more likely an individual is to select appropriate coping strategies and, therefore, to move toward the “ease” end of the continuum.6 Considering that transplantation management relies heavily on self-management practices, the SOC construct may also prove valuable in this patient group. Psychiatric distress is typical during all stages of the HT process, so the psychosocial adjustment of a heart transplant recipient is important. The assessment of coping may help the transplantation team to identify patients who may benefit from psychological counseling to increase compliance.7 Coping can be defined as the abilities used by people to face a problematic and stressful situation for example
Fig 1. The scores of BDI in heart transplant recipients (%); n⫽46.
transplantation. Coping is basically a process that changes over time in accord with the situational context.8 Depression, colloquially understood as feeling sad, blue, or low in mood, is defined in psychiatry as “a special kind of disorder regarding mood and emotion, which may be classified as a morbid state therefore requiring medical intervention.” Depression is a mental disorder comprising psychological, social, and biological conditions. Nosological classifications recognize 3 groups of depression: reactive, endogenous, and somatogenic.9 QoL was conceptualized as a multidimensional psychological construct with physical, mental, social, and environmental aspects that are self-related by patients. QoL assessments are often used to evaluate the success of a medical intervention.10 In the assessment of cardiac transplantation, QoL may be defined as the patient’s perception of the effects of the therapy (HT) on their ability to live a meaningful, satisfying life.11 The aim of this study was to estimate the prevalence of depression in terms of personal recourses in HT patients. We hypothesized the following: (1) there was a relationship between depression and QoL in HT patients; (2) there was a relationship between depression and personal recourses, namely SOC and coping strategies; (3) there was a relationship between QoL and personal recourses, namely SOC and coping strategies; and (4) the personal recourses of HT patients are variable according to age, depression, and QoL. Table 3. Coping Strategies (n ⴝ 46) Coping Strategies
Mean (SD)
Problem-focused Active coping Planning Use of instrumental support Emotion-focused Positive reframing Acceptance Humor Religion Use of emotional support Self-distraction Denial Venting Substance use Behavioural disengagement Self-blame Adaptation
1.32 (0.91) 1.94 (0.56) 1.91 (0.76) 1.43 (0.70) 1.26 (0.22) 1.63 (0.55) 1.78 (0.63) 0.92 (0.59) 1.24 (0.89) 1.48 (0.61) 1.60 (0.63) 1.03 (0.60) 1.11 (0.50) 0.26 (0.41) 0.90 (0.60) 1.14 (0.61) 1.55 (0.34)
3078
RUZYCZKA, MILANIAK, PRZYBYŁOWSKI ET AL aspects of adults.15 The application of this scale is intended to measure QoL aspects of patients who underwent HT. Depression. We used the Beck Depression Inventory (BDI) Short Form, a prominently and frequently cited, self-reported measure of depression The 13-item questionnaire assesses 4 major components of depression: behavioral, affective, cognitive, and physiological. Numerical values assigned to each statement range from 0 to 3 indicating increasing severity. According to Beck’s clinical criteria, a score between 8 and 15 indicates moderate depression and ⬎16 severe depression.16,17
Table 4. QoL in HT Patients Variables
Mean (SD)
Perception of QoL Perception of satisfaction with health Physical health Psychological Social relationship Environment
3.58 (0.83) 3.69 (0.81) 12.78 (1.75)* 12.61 (1.71) 14.76 (2.65) 14.21 (2.20)
*Transformed scores 4 –20.28
Statistical Analysis
SUBJECTS AND METHODS Participants The study was conducted from January 2011 to May 2011. Following the approval by the institutional review board of the hospital, HT patients were invited to participate. Inclusion criteria included age older than 18 years and a minimum of 3 months after the transplantation. Although the overall cohort included 198 patients, a preliminary sample of 46 patients is described in Table 1.
Data were analyzed using Statistica Software. We examined descriptive statistics by mean values and standard deviations for continuous measures. Comparisons between groups (age, years after transplantation) were performed using Mann Whitney U-tests, Student’s test, and regression. To analyze the bivariate of dependent (depression and QoL) and independent variables (SOC, coping strategies), we performed Pearson correlation. The significance level for a given hypothesis test was P ⬍ .05 and P ⬍ .01.
Instruments
RESULTS
SOC, Polish version (SOC-29).6 The questionnaire consists of 29 7-point Likert-type items, measuring subscales of comprehensibility, manageability, and meaningfulness. The higher the total score of the SOC, the stronger the sense of coherence. Validity and reliability were confirmed in previous studies.6 Coping Orientation to Problems Experienced. An abbreviated version of the Coping Orientation to Problems Experienced (COPE) has been developed—the brief COPE.12 The questionnaire consists of 28 items. The self-administered questionnaire measures 15 coping strategies with 2 items each examining selfdistraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame. Participants are asked to respond to each item on a 4-point Likert scale. The higher the score on each coping strategy, the greater the use of the specific coping strategy. Patients were administered the Polish version of COPE by Juczynski and Oginska Bulik.13
The demographic characteristics of the study participants are shown in Table 1 The preliminary sample consisted of 46 participants, including 76,19% male, and 23.80% females, who ranged in age from 21 to 68 years. The mean age of all participants was 52.36 ⫾ 13.55 years. The mean time from transplantation was 11.27 years. Our study population showed higher depression scores among 36.95% of recipients (Fig 1). SOC
The SOC scores ranged from 59 –189 of a possible 203; the mean was 135.21 ⫾ 18.38 (Table 2). Coping Strategies
Most respondents used active planning coping strategies to achieve adaptation strategies (Table 3). QoL
QoL The data were collected by administering a standardized structured QoL questionnaire. This generic instrument developed by the World Health Organization (WHO QoL-Brief) measures the individuals perception of the impact that diseases make in their lives (Statistica version 9.0). The WHO QOL-Brief consists of 26 closed questions, including 2 general questions about the QoL and 24 questions representing 4 domains of QoL: psychological, physical, social, and environment.14 The Polish version of WHO QOL-Brief has shown good validation and reliability to measure the QoL
With regard to general questions about the QoL, the results represented the patients’ satisfaction with their health (Table 4). Almost half of the study recipients reported good and very good satisfaction to QoL and health aspects (56.52%, 63.04%). Verification of Hypotheses
Correlations among QoL and depression. The prevalence of depression was negatively associated with physical do-
Table 5. Matrix Correlations Among QoL and Depression
BDISF Pearson Significance N
Physical
Social
Physical
Environmental
General QoL
Life Satisfaction
⫺.446* .002 46
⫺.485* .001 46
.148 .327 46
⫺.128 .425 41
⫺.467* .001 46
⫺.431* .003 46
*Correlation is significant on .01 level.
DEPRESSION AND QoL
3079 Table 6. Correlation Between SOC and Prevalence of Depression
BDISF Pearson Significance N
Global SOC
Comprehensibility
Manageability
Meaningfulness
Problem-Focused Coping
⫺.591 .000 46
⫺.526 .000 46
⫺.517 .000 46
⫺.464 .001 46
⫺.037 .806 46
Emotion-Focused Coping
Adaptation
.100 .507 46
.005 .974 46
*Correlation is significant on .01 level.
main (r ⫽ ⫺0.45; P ⬍ .01), social domain (r ⫽ ⫺0.49; P ⬍ .05), and psychological domain (r ⫽ ⫺0.3; P ⬍ .05). The worst QoL signified a high prevalence of depression. The subjective assessment of QoL negatively correlated with the prevalence of depression (r ⫽ ⫺0.43; P ⫽ .01; Table 5). The prevalence of depression significantly correlated with the global SOC (r ⫽ ⫺0.59; P ⬍ .001), and its components: comprehensibility (r ⫽ ⫺0.53; P ⬍ .001); manageability (r ⫽ ⫺0.52; P ⬍ .001), and meaningfulness (r ⫽ ⫺0.46; P ⬍ .01). There was no significant association between prevalence of depression and coping strategies (Table 6). QoL and personal recourses. We assumed that there was a relationship between QoL and personal recourses (SOC and coping strategies). The physical domain of QoL and not correlate significantly with SOC. There were tendencies between physical domain and comprehensibility (r ⫽ 0.25; P ⫽ .092), meaningfulness (r ⫽ 0.28; P ⫽ .057), and global SOC (r ⫽ 0.29; P ⫽ .052). A strong SOC, was associated
with QoL in the social domain and general QoL (r ⫽ 0.29; P ⫽ .054; Table 7). The personal resources (SOC and coping strategies) are moderator variables of QoL and the prevalence of depression. Personal resources of HT patients have a protective impact on the prevalence of depression and on a high level of QoL. The SOC significantly moderates the QoL, age, and prevalence of depression (Table 8). Active patients do not display depression; they report well-being in the physical domain. Active pensioners mostly tend to use adaptation strategies, which impact the QoL (Table 9). The older patient, the less the use of adaptative strategies, the worse the QoL, and health satisfaction (Table 8). Strategies focused on the problem moderate QoL with recipient age. Recipients who have a tendency to use emotion-focused strategies and are older show a poorer QoL, are less satisfied with their health, and have a prevalence of depression.
Table 7. Correlation Between SOC, QoL, and Coping Strategies Comprehensibility
Manageability
Meaningfulness
Global SOC
.251 .092 46
.203 .176 46
.283 .057 46
.289 .052 46
.354* .016 46
.285 .054 46
.414† .004 46
.412† .004 46
.113 .455 46
.234 .117 46
.028 .854 46
.148 .327 46
.072 .653 41
.229 .150 41
.161 .315 41
.178 .265 41
.290 .050 46
.417† .004 46
.271 .069 46
.384† .008 46
.179 .235 46
.313* .034 46
.254 .089 46
.293* .049 46
Physical Pearson Significance N Social Pearson Significance N Psychological Pearson Significance N Environmental Pearson Significance N General QoL Pearson Significance N Satisfaction with life Pearson Significance N *Correlation is significant on .05 level. † Correlation is significant on .01 level.
3080
RUZYCZKA, MILANIAK, PRZYBYŁOWSKI ET AL Table 8. Sense of Coherence as a Moderator of Age, QOL and BDI Physical
Low SOC Age Correlation Pearson Significance N High SOC Age Correlation Pearson Significance N
Social
Environmental
General QOL
Satisfaction
BDI
.125 .561 24
.087 .687 24
.052 .822 21
⫺.023 .913 24
⫺.389 .060 24
.200 .348 24
⫺.256 .262 21
⫺.448* .041 21
⫺.300 .212 19
⫺.452* .040 21
⫺.542* .011 21
.503* .020 21
*Correlation is significant on .05.
DISCUSSION
Our results confirmed the importance of personal recourses on psychological adaptation to live with a transplanted heart. The SOC was strongly associated with the prevalence of depression and the QoL. A higher SOC accompanied a better QoL without symptoms of depression. Young, active recipients showed better scores on the scale of subjective satisfaction with health, social, and physical domains of QoL. The SOC, a specific resource for this group of patients, beneficial to evaluate psychosocial adaptation in all of the distinguished components. In turn, strategies for coping with stress, a style focused on the problem, were associated with a better QoL and a lack of depression, whereas emotion was associated with depression, a poorer QoL, and a poorer subjective QoL assessment. Based on these results we should pay attention to the emotional state of patients after transplantation because 27% of recipients show depressive disorders and 12.2% show severe depression. The Dew et al study revealed similar results of depressive disorders among 25.5% of the study population.18 HT patients displayed a slightly lower mean SOC (135) compared with Antonovsky’s norm (130 –160).6 Because
SOC norms do not exist for transplant recipients or the general population in Poland, a lower SOC does not necessarily mean that this population shows a weak SOC. The results of Polish studies concerning SOC have shown that the level of global SOC was 118.75 for the lung cancer population,19 for with hypertensive patients it was 113.5,20 for leukemic patients it was 144.9,21 for cardiosurgery patients it was 146.12,22 and for elderly people it was 116.3.23 In our study patients used problem (ie, active coping and planning) and emotion-focused (ie positive reinterpretation and acceptance) coping strategies to deal with the stressful situation after HT. The literature has shown that HT patients use a variety of coping strategies.24,25 The results obtained in the assessment of QoL of respondents point to the fact that most important is the assessment of the psychological area in the posttransplantation period. Our study population moderately showed physical and psychological metrics (median level ⫽ 13 among scores of 4 –20). In the Freire de Aduiar et al study, 62% of recipients evaluated. There QoL as satisfied in somatic and psychological domains.26 In the study by Salyer et al patients rated
Table 9. Adaptive Strategies as a Moderator of the Impact of Activity on Quality of Life and Depression†
Low SOC Mann-Whitney U Wilcoxon W Z Significance asymptotic (2-sided) Significance of the exact (2*[1-sided]) High SOC Mann-Whitney U Wilcoxon W Z Significance asymptotic (2-sided) Significance of the exact (2*[1-sided]) *Uncategorized due to binding. † Grouping variable–active.
Physical
Social
Environmental
General QOL
Satisfaction
BDI
6,000 12,000 ⫺2.250 .024
16,000 22,000 ⫺1.379 .168
24,500 30,500 ⫺.253 .800
13,500 19,500 ⫺1.698 .089
26,000 32,000 ⫺.516 .606
7,500 238,500 ⫺2.104 .035
.023*
35,000 171,000 ⫺.979 .328 .367*
.202*
48,000 69,000 .000 1.000 1.000*
.814*
39,000 144,000 ⫺.248 .804 .841*
.122*
37,500 58,500 ⫺.845 .398 .449*
.680*
39,000 60,000 ⫺.707 .480 .541*
.031*
28,000 49,000 ⫺1.487 .137 .154*
DEPRESSION AND QoL
their health as good and were moderately satisfied with life.27 The psychological domain correlates with the subjective QoL and prevalence of depression. The higher the scores in this domain, the better the assessment of QoL and the lower prevalence of depression. The findings may provide help to health professionals about ways to improve support for HT patients and their families. Analysis of personal resources as moderators of QoL and depression can be used to describe impacts on the patients, seeking to enrich the psychological resources and their use to improve healthy behaviors to adapt to a difficult situation and life with a transplanted heart. These results suggested that assessment of coping strategies and SOC should be explored in the evaluation of the coping strategy and SOC before surgery and to start skills training in this domain for HT patients. REFERENCES 1. D’Amico CL: Cardiac transplant: patient selection in the current era. J Cardiovasc Nurs 20:504, 2005 2. White-Williams C: Heart transplant over the life span. J Cardiovasc Nurs 20:51, 2005 3. Dew MA, Switzer GE, Goycoolea JM, et al: Does transplantation produce quality of life benefits. A quantities analysis of literature. Transplantation 15:1261, 1997 4. Cupples S, Dew MA, Grady LK, Report of the Psychosocial Outcomes Workgroup of the Nursing and Social Sciences Council of the International Society for Heart and Lung Transplantation. Present status of research on psychosocial outcomes in cardiothoracic transplantation: review and recommendation for the field. J Heart Lung Transplant 25:716, 2006 5. Delgado C: Sense of coherence, spirituality, stress and quality of life in chronic illness. J Nurs Scholarship 3:229, 2007 6. Antonovsky A: Unraveling The Mystery of Health - How People Manage Stress and Stay Well. Instit Psychiatry Neurol 32:35, 2005 7. Kaba E, Thompson DR, Burnard F: Coping after heart transplantation: a descriptive study of heart transplant recipients’ methods of coping. Advanced Nursing 32:930, 2000 8. Golfieri L, Lauro A, Tossani E, et al: Coping strategies in intestinal transplantation. Transplant Proc 39:1992, 2007 9. Wilczek Ruzyczka E: Social support for people suffering from depression and their families. New Med 1:19, 2009 10. Goetzman L, Klaghofer R, Wagner Huber R, et al: Quality of life and psychosocial situation before and after a lung, liver or an allogenic bone marrow transplant. Swiss Med Wkly 136:281, 2006 11. White Williams C: Quality of life after heart transplantation. In Kirklin JK, Young JB, McGriffin DC (eds): Heart Transplantation. Philadelphia, Pa: Churchil Livingstone; 2002, p 703
3081 12. Carver CS: You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behavioral Med 4:92, 1997 13. Juczynski Z, Oginska Bulik N: Tools to measure stress and coping. Psychological testing lab 14th World Health Organization. Quality of Live (WHOQOL) - Brief. In Wolowicka (ed): Quality of Life in Medical Science. Poznan: University Publishing; 2005 p 235 14. Skrócona wersja ankiety oceniaja¸cej jakos´´c ´zycia. Available at: http://www.who.int/substance_abuse/research_tools/en/polish_ whoqol.pdf. Accessed January 2011 15. Wołlowicka L, Jaracz K: Polska wersja WHOQOL 100 i ˙ ycia w naukach WHOQOL Bref. In Wołlowicka L (ed): Jakos´´cZ medycznych. Poznan ´: Wydawnictwo Uczelniane AM; 2001, p 235 16. Chibnall JT, Tait RC: The short form of the Beck Depression Inventory: validity issues with chronic pain patients. Clin J Pain 10:261, 1994 17. Furlanetto LM, Mendlowicz MV, Romildo Bueno J: The validity of the Beck Depression Inventory-Short Form as a screening and diagnostic instrument for moderate and severe depression in medical inpatients. J Affect Disord 86:87, 2005 18. Dew MA, Kormos RL, DiMartini AF, et al: Prevalence and risk of depression and anxiety related disorders During the first year after heart transplantation. Psychosomatics 42:300, 2001 19. Kurowska K, Weilandt K: Sense of coherence and coping with the diseases in patient with diagnosis of lung cancer. Nursing Topics 1:11, 2010 20. Kurowska K, Dabrowska A: The sense of coherence and styles of coping with disease in patients with diagnosed arterial hypertension. Arterial Hypertension 12:432, 2008 21. Jablon ´ski M: Sense of coherence and risk of depression in leukemic patients. Psychoonkologia 1–2:1, 2009 22. Kurowska K, Trzeciak D, Głlowacka M, et al: Sense of coherence versus health behavior of people qualified for cardiosurgical operation. Pielegniarstwo Chirurgiczne I Angiologiczne 4:130, 2010 23. Wilczek Ruzyczka E: Psychosocial adjustment of elderly people to the situation of illness. Annales Universitias Mariae Curie Sklodowska Lublin Polonia LV (suppl 50):258, 2000 24. Kaba E, Thompson DR, Burnard F: Coping after heart transplantation: a descriptive study of heart transplant recipients’ methods of coping. J Advanced Nursing 32:930, 2000 25. Lin CS, Wang SS, Chang CL, et al: Dark-recovery experiences, coping strategies, and needs of adult heart transplant recipients in Taiwan. Transplant Proc 42:940, 2010 26. Freire de Aguiar M, Rios Farias D, Leite Pinheiro M, et al: Quality of life of patients that had a heart transplant: application of Whoqol-Bref Scale. Arq Bras Cardiol 96:60, 2011 27. Salyer J, Flattery MP, Joyner PL, et al: Lifestyle and quality of life in long-term cardiac transplant recipients. J Heart Lung Transplant 22:309, 2003 28. Bergner M, Bobbitt RA, Carter WB, et al: The Sickness Impact Profile: development and final revision of health status measure. Med Care 19:787, 1981
H
iors including cigarette smoking, physical activity, food selection, and oral health.6 Whether an individual moves from one end to another along this continuum depends on the encountered stressors and the set of available coping resources. The components of SOC-comprehensibility, manageability, and meaningfulness-express the extent to
From The Department of Cardiovascular Surgery and Transplantology (I.M., P.P., K.W., J.S., F.K.H., J.S.), John Paul II Hospital, Krakow, Poland and Jagiellonian University (E.W.R., P.P., K.W., J.S.), Medical College, Krakow, Poland. Address reprint requests to Irena Milaniak, RN, CETC, MA, Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Pradnicka str 80, 31-202 Krakow, Poland. E-mail: [email protected]
0041-1345/11/$–see front matter doi:10.1016/j.transproceed.2011.07.012
© 2011 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
3076
Transplantation Proceedings, 43, 3076 –3081 (2011)
DEPRESSION AND QoL
3077
Table 1. Background Characteristic of the Sample of HT Patients Characteristic
Age Gender (%) Male Female Years since transplantation Employment status (unemployed; %) Residence Town Village Any concurrent medication (%) Hypertension CAV Kidney failure Diabetes
Table 2. Descriptive Statistics of the Level of SOC and Its Components (n ⴝ 46)
Study Sample (n ⫽ 46)
SOC Components
Mean (max–min)
SD
Average, 52.36; median, 57; max, 68; min, 21
Comprehensibility Manageability Meaningfulness Global SOC
46.95 (18–71) 48.17 (27–74) 40.13 (14–59) 135.21 (59–189)
10.60 7.77 0 18.38
76.19 23.80 Average 10.84; median, 11; max, 18; min, 1 80.95
64.28 35.71 59.52 9.5 35.71 16.66 Average 1,2 illnesses per patient
Abbreviations: CAV, coronary artery vasculopathy; max, maximum; min, minimum.
which one has a pervasive feeling of confidence that the confronted stimuli are structured and predictable (comprehensible), worthy of engagement (meaningful), and that an individual has sufficient resources to meet the demands of life (manageable). The stronger the SOC, the more likely an individual is to select appropriate coping strategies and, therefore, to move toward the “ease” end of the continuum.6 Considering that transplantation management relies heavily on self-management practices, the SOC construct may also prove valuable in this patient group. Psychiatric distress is typical during all stages of the HT process, so the psychosocial adjustment of a heart transplant recipient is important. The assessment of coping may help the transplantation team to identify patients who may benefit from psychological counseling to increase compliance.7 Coping can be defined as the abilities used by people to face a problematic and stressful situation for example
Fig 1. The scores of BDI in heart transplant recipients (%); n⫽46.
transplantation. Coping is basically a process that changes over time in accord with the situational context.8 Depression, colloquially understood as feeling sad, blue, or low in mood, is defined in psychiatry as “a special kind of disorder regarding mood and emotion, which may be classified as a morbid state therefore requiring medical intervention.” Depression is a mental disorder comprising psychological, social, and biological conditions. Nosological classifications recognize 3 groups of depression: reactive, endogenous, and somatogenic.9 QoL was conceptualized as a multidimensional psychological construct with physical, mental, social, and environmental aspects that are self-related by patients. QoL assessments are often used to evaluate the success of a medical intervention.10 In the assessment of cardiac transplantation, QoL may be defined as the patient’s perception of the effects of the therapy (HT) on their ability to live a meaningful, satisfying life.11 The aim of this study was to estimate the prevalence of depression in terms of personal recourses in HT patients. We hypothesized the following: (1) there was a relationship between depression and QoL in HT patients; (2) there was a relationship between depression and personal recourses, namely SOC and coping strategies; (3) there was a relationship between QoL and personal recourses, namely SOC and coping strategies; and (4) the personal recourses of HT patients are variable according to age, depression, and QoL. Table 3. Coping Strategies (n ⴝ 46) Coping Strategies
Mean (SD)
Problem-focused Active coping Planning Use of instrumental support Emotion-focused Positive reframing Acceptance Humor Religion Use of emotional support Self-distraction Denial Venting Substance use Behavioural disengagement Self-blame Adaptation
1.32 (0.91) 1.94 (0.56) 1.91 (0.76) 1.43 (0.70) 1.26 (0.22) 1.63 (0.55) 1.78 (0.63) 0.92 (0.59) 1.24 (0.89) 1.48 (0.61) 1.60 (0.63) 1.03 (0.60) 1.11 (0.50) 0.26 (0.41) 0.90 (0.60) 1.14 (0.61) 1.55 (0.34)
3078
RUZYCZKA, MILANIAK, PRZYBYŁOWSKI ET AL aspects of adults.15 The application of this scale is intended to measure QoL aspects of patients who underwent HT. Depression. We used the Beck Depression Inventory (BDI) Short Form, a prominently and frequently cited, self-reported measure of depression The 13-item questionnaire assesses 4 major components of depression: behavioral, affective, cognitive, and physiological. Numerical values assigned to each statement range from 0 to 3 indicating increasing severity. According to Beck’s clinical criteria, a score between 8 and 15 indicates moderate depression and ⬎16 severe depression.16,17
Table 4. QoL in HT Patients Variables
Mean (SD)
Perception of QoL Perception of satisfaction with health Physical health Psychological Social relationship Environment
3.58 (0.83) 3.69 (0.81) 12.78 (1.75)* 12.61 (1.71) 14.76 (2.65) 14.21 (2.20)
*Transformed scores 4 –20.28
Statistical Analysis
SUBJECTS AND METHODS Participants The study was conducted from January 2011 to May 2011. Following the approval by the institutional review board of the hospital, HT patients were invited to participate. Inclusion criteria included age older than 18 years and a minimum of 3 months after the transplantation. Although the overall cohort included 198 patients, a preliminary sample of 46 patients is described in Table 1.
Data were analyzed using Statistica Software. We examined descriptive statistics by mean values and standard deviations for continuous measures. Comparisons between groups (age, years after transplantation) were performed using Mann Whitney U-tests, Student’s test, and regression. To analyze the bivariate of dependent (depression and QoL) and independent variables (SOC, coping strategies), we performed Pearson correlation. The significance level for a given hypothesis test was P ⬍ .05 and P ⬍ .01.
Instruments
RESULTS
SOC, Polish version (SOC-29).6 The questionnaire consists of 29 7-point Likert-type items, measuring subscales of comprehensibility, manageability, and meaningfulness. The higher the total score of the SOC, the stronger the sense of coherence. Validity and reliability were confirmed in previous studies.6 Coping Orientation to Problems Experienced. An abbreviated version of the Coping Orientation to Problems Experienced (COPE) has been developed—the brief COPE.12 The questionnaire consists of 28 items. The self-administered questionnaire measures 15 coping strategies with 2 items each examining selfdistraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame. Participants are asked to respond to each item on a 4-point Likert scale. The higher the score on each coping strategy, the greater the use of the specific coping strategy. Patients were administered the Polish version of COPE by Juczynski and Oginska Bulik.13
The demographic characteristics of the study participants are shown in Table 1 The preliminary sample consisted of 46 participants, including 76,19% male, and 23.80% females, who ranged in age from 21 to 68 years. The mean age of all participants was 52.36 ⫾ 13.55 years. The mean time from transplantation was 11.27 years. Our study population showed higher depression scores among 36.95% of recipients (Fig 1). SOC
The SOC scores ranged from 59 –189 of a possible 203; the mean was 135.21 ⫾ 18.38 (Table 2). Coping Strategies
Most respondents used active planning coping strategies to achieve adaptation strategies (Table 3). QoL
QoL The data were collected by administering a standardized structured QoL questionnaire. This generic instrument developed by the World Health Organization (WHO QoL-Brief) measures the individuals perception of the impact that diseases make in their lives (Statistica version 9.0). The WHO QOL-Brief consists of 26 closed questions, including 2 general questions about the QoL and 24 questions representing 4 domains of QoL: psychological, physical, social, and environment.14 The Polish version of WHO QOL-Brief has shown good validation and reliability to measure the QoL
With regard to general questions about the QoL, the results represented the patients’ satisfaction with their health (Table 4). Almost half of the study recipients reported good and very good satisfaction to QoL and health aspects (56.52%, 63.04%). Verification of Hypotheses
Correlations among QoL and depression. The prevalence of depression was negatively associated with physical do-
Table 5. Matrix Correlations Among QoL and Depression
BDISF Pearson Significance N
Physical
Social
Physical
Environmental
General QoL
Life Satisfaction
⫺.446* .002 46
⫺.485* .001 46
.148 .327 46
⫺.128 .425 41
⫺.467* .001 46
⫺.431* .003 46
*Correlation is significant on .01 level.
DEPRESSION AND QoL
3079 Table 6. Correlation Between SOC and Prevalence of Depression
BDISF Pearson Significance N
Global SOC
Comprehensibility
Manageability
Meaningfulness
Problem-Focused Coping
⫺.591 .000 46
⫺.526 .000 46
⫺.517 .000 46
⫺.464 .001 46
⫺.037 .806 46
Emotion-Focused Coping
Adaptation
.100 .507 46
.005 .974 46
*Correlation is significant on .01 level.
main (r ⫽ ⫺0.45; P ⬍ .01), social domain (r ⫽ ⫺0.49; P ⬍ .05), and psychological domain (r ⫽ ⫺0.3; P ⬍ .05). The worst QoL signified a high prevalence of depression. The subjective assessment of QoL negatively correlated with the prevalence of depression (r ⫽ ⫺0.43; P ⫽ .01; Table 5). The prevalence of depression significantly correlated with the global SOC (r ⫽ ⫺0.59; P ⬍ .001), and its components: comprehensibility (r ⫽ ⫺0.53; P ⬍ .001); manageability (r ⫽ ⫺0.52; P ⬍ .001), and meaningfulness (r ⫽ ⫺0.46; P ⬍ .01). There was no significant association between prevalence of depression and coping strategies (Table 6). QoL and personal recourses. We assumed that there was a relationship between QoL and personal recourses (SOC and coping strategies). The physical domain of QoL and not correlate significantly with SOC. There were tendencies between physical domain and comprehensibility (r ⫽ 0.25; P ⫽ .092), meaningfulness (r ⫽ 0.28; P ⫽ .057), and global SOC (r ⫽ 0.29; P ⫽ .052). A strong SOC, was associated
with QoL in the social domain and general QoL (r ⫽ 0.29; P ⫽ .054; Table 7). The personal resources (SOC and coping strategies) are moderator variables of QoL and the prevalence of depression. Personal resources of HT patients have a protective impact on the prevalence of depression and on a high level of QoL. The SOC significantly moderates the QoL, age, and prevalence of depression (Table 8). Active patients do not display depression; they report well-being in the physical domain. Active pensioners mostly tend to use adaptation strategies, which impact the QoL (Table 9). The older patient, the less the use of adaptative strategies, the worse the QoL, and health satisfaction (Table 8). Strategies focused on the problem moderate QoL with recipient age. Recipients who have a tendency to use emotion-focused strategies and are older show a poorer QoL, are less satisfied with their health, and have a prevalence of depression.
Table 7. Correlation Between SOC, QoL, and Coping Strategies Comprehensibility
Manageability
Meaningfulness
Global SOC
.251 .092 46
.203 .176 46
.283 .057 46
.289 .052 46
.354* .016 46
.285 .054 46
.414† .004 46
.412† .004 46
.113 .455 46
.234 .117 46
.028 .854 46
.148 .327 46
.072 .653 41
.229 .150 41
.161 .315 41
.178 .265 41
.290 .050 46
.417† .004 46
.271 .069 46
.384† .008 46
.179 .235 46
.313* .034 46
.254 .089 46
.293* .049 46
Physical Pearson Significance N Social Pearson Significance N Psychological Pearson Significance N Environmental Pearson Significance N General QoL Pearson Significance N Satisfaction with life Pearson Significance N *Correlation is significant on .05 level. † Correlation is significant on .01 level.
3080
RUZYCZKA, MILANIAK, PRZYBYŁOWSKI ET AL Table 8. Sense of Coherence as a Moderator of Age, QOL and BDI Physical
Low SOC Age Correlation Pearson Significance N High SOC Age Correlation Pearson Significance N
Social
Environmental
General QOL
Satisfaction
BDI
.125 .561 24
.087 .687 24
.052 .822 21
⫺.023 .913 24
⫺.389 .060 24
.200 .348 24
⫺.256 .262 21
⫺.448* .041 21
⫺.300 .212 19
⫺.452* .040 21
⫺.542* .011 21
.503* .020 21
*Correlation is significant on .05.
DISCUSSION
Our results confirmed the importance of personal recourses on psychological adaptation to live with a transplanted heart. The SOC was strongly associated with the prevalence of depression and the QoL. A higher SOC accompanied a better QoL without symptoms of depression. Young, active recipients showed better scores on the scale of subjective satisfaction with health, social, and physical domains of QoL. The SOC, a specific resource for this group of patients, beneficial to evaluate psychosocial adaptation in all of the distinguished components. In turn, strategies for coping with stress, a style focused on the problem, were associated with a better QoL and a lack of depression, whereas emotion was associated with depression, a poorer QoL, and a poorer subjective QoL assessment. Based on these results we should pay attention to the emotional state of patients after transplantation because 27% of recipients show depressive disorders and 12.2% show severe depression. The Dew et al study revealed similar results of depressive disorders among 25.5% of the study population.18 HT patients displayed a slightly lower mean SOC (135) compared with Antonovsky’s norm (130 –160).6 Because
SOC norms do not exist for transplant recipients or the general population in Poland, a lower SOC does not necessarily mean that this population shows a weak SOC. The results of Polish studies concerning SOC have shown that the level of global SOC was 118.75 for the lung cancer population,19 for with hypertensive patients it was 113.5,20 for leukemic patients it was 144.9,21 for cardiosurgery patients it was 146.12,22 and for elderly people it was 116.3.23 In our study patients used problem (ie, active coping and planning) and emotion-focused (ie positive reinterpretation and acceptance) coping strategies to deal with the stressful situation after HT. The literature has shown that HT patients use a variety of coping strategies.24,25 The results obtained in the assessment of QoL of respondents point to the fact that most important is the assessment of the psychological area in the posttransplantation period. Our study population moderately showed physical and psychological metrics (median level ⫽ 13 among scores of 4 –20). In the Freire de Aduiar et al study, 62% of recipients evaluated. There QoL as satisfied in somatic and psychological domains.26 In the study by Salyer et al patients rated
Table 9. Adaptive Strategies as a Moderator of the Impact of Activity on Quality of Life and Depression†
Low SOC Mann-Whitney U Wilcoxon W Z Significance asymptotic (2-sided) Significance of the exact (2*[1-sided]) High SOC Mann-Whitney U Wilcoxon W Z Significance asymptotic (2-sided) Significance of the exact (2*[1-sided]) *Uncategorized due to binding. † Grouping variable–active.
Physical
Social
Environmental
General QOL
Satisfaction
BDI
6,000 12,000 ⫺2.250 .024
16,000 22,000 ⫺1.379 .168
24,500 30,500 ⫺.253 .800
13,500 19,500 ⫺1.698 .089
26,000 32,000 ⫺.516 .606
7,500 238,500 ⫺2.104 .035
.023*
35,000 171,000 ⫺.979 .328 .367*
.202*
48,000 69,000 .000 1.000 1.000*
.814*
39,000 144,000 ⫺.248 .804 .841*
.122*
37,500 58,500 ⫺.845 .398 .449*
.680*
39,000 60,000 ⫺.707 .480 .541*
.031*
28,000 49,000 ⫺1.487 .137 .154*
DEPRESSION AND QoL
their health as good and were moderately satisfied with life.27 The psychological domain correlates with the subjective QoL and prevalence of depression. The higher the scores in this domain, the better the assessment of QoL and the lower prevalence of depression. The findings may provide help to health professionals about ways to improve support for HT patients and their families. Analysis of personal resources as moderators of QoL and depression can be used to describe impacts on the patients, seeking to enrich the psychological resources and their use to improve healthy behaviors to adapt to a difficult situation and life with a transplanted heart. These results suggested that assessment of coping strategies and SOC should be explored in the evaluation of the coping strategy and SOC before surgery and to start skills training in this domain for HT patients. REFERENCES 1. D’Amico CL: Cardiac transplant: patient selection in the current era. J Cardiovasc Nurs 20:504, 2005 2. White-Williams C: Heart transplant over the life span. J Cardiovasc Nurs 20:51, 2005 3. Dew MA, Switzer GE, Goycoolea JM, et al: Does transplantation produce quality of life benefits. A quantities analysis of literature. Transplantation 15:1261, 1997 4. Cupples S, Dew MA, Grady LK, Report of the Psychosocial Outcomes Workgroup of the Nursing and Social Sciences Council of the International Society for Heart and Lung Transplantation. Present status of research on psychosocial outcomes in cardiothoracic transplantation: review and recommendation for the field. J Heart Lung Transplant 25:716, 2006 5. Delgado C: Sense of coherence, spirituality, stress and quality of life in chronic illness. J Nurs Scholarship 3:229, 2007 6. Antonovsky A: Unraveling The Mystery of Health - How People Manage Stress and Stay Well. Instit Psychiatry Neurol 32:35, 2005 7. Kaba E, Thompson DR, Burnard F: Coping after heart transplantation: a descriptive study of heart transplant recipients’ methods of coping. Advanced Nursing 32:930, 2000 8. Golfieri L, Lauro A, Tossani E, et al: Coping strategies in intestinal transplantation. Transplant Proc 39:1992, 2007 9. Wilczek Ruzyczka E: Social support for people suffering from depression and their families. New Med 1:19, 2009 10. Goetzman L, Klaghofer R, Wagner Huber R, et al: Quality of life and psychosocial situation before and after a lung, liver or an allogenic bone marrow transplant. Swiss Med Wkly 136:281, 2006 11. White Williams C: Quality of life after heart transplantation. In Kirklin JK, Young JB, McGriffin DC (eds): Heart Transplantation. Philadelphia, Pa: Churchil Livingstone; 2002, p 703
3081 12. Carver CS: You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behavioral Med 4:92, 1997 13. Juczynski Z, Oginska Bulik N: Tools to measure stress and coping. Psychological testing lab 14th World Health Organization. Quality of Live (WHOQOL) - Brief. In Wolowicka (ed): Quality of Life in Medical Science. Poznan: University Publishing; 2005 p 235 14. Skrócona wersja ankiety oceniaja¸cej jakos´´c ´zycia. Available at: http://www.who.int/substance_abuse/research_tools/en/polish_ whoqol.pdf. Accessed January 2011 15. Wołlowicka L, Jaracz K: Polska wersja WHOQOL 100 i ˙ ycia w naukach WHOQOL Bref. In Wołlowicka L (ed): Jakos´´cZ medycznych. Poznan ´: Wydawnictwo Uczelniane AM; 2001, p 235 16. Chibnall JT, Tait RC: The short form of the Beck Depression Inventory: validity issues with chronic pain patients. Clin J Pain 10:261, 1994 17. Furlanetto LM, Mendlowicz MV, Romildo Bueno J: The validity of the Beck Depression Inventory-Short Form as a screening and diagnostic instrument for moderate and severe depression in medical inpatients. J Affect Disord 86:87, 2005 18. Dew MA, Kormos RL, DiMartini AF, et al: Prevalence and risk of depression and anxiety related disorders During the first year after heart transplantation. Psychosomatics 42:300, 2001 19. Kurowska K, Weilandt K: Sense of coherence and coping with the diseases in patient with diagnosis of lung cancer. Nursing Topics 1:11, 2010 20. Kurowska K, Dabrowska A: The sense of coherence and styles of coping with disease in patients with diagnosed arterial hypertension. Arterial Hypertension 12:432, 2008 21. Jablon ´ski M: Sense of coherence and risk of depression in leukemic patients. Psychoonkologia 1–2:1, 2009 22. Kurowska K, Trzeciak D, Głlowacka M, et al: Sense of coherence versus health behavior of people qualified for cardiosurgical operation. Pielegniarstwo Chirurgiczne I Angiologiczne 4:130, 2010 23. Wilczek Ruzyczka E: Psychosocial adjustment of elderly people to the situation of illness. Annales Universitias Mariae Curie Sklodowska Lublin Polonia LV (suppl 50):258, 2000 24. Kaba E, Thompson DR, Burnard F: Coping after heart transplantation: a descriptive study of heart transplant recipients’ methods of coping. J Advanced Nursing 32:930, 2000 25. Lin CS, Wang SS, Chang CL, et al: Dark-recovery experiences, coping strategies, and needs of adult heart transplant recipients in Taiwan. Transplant Proc 42:940, 2010 26. Freire de Aguiar M, Rios Farias D, Leite Pinheiro M, et al: Quality of life of patients that had a heart transplant: application of Whoqol-Bref Scale. Arq Bras Cardiol 96:60, 2011 27. Salyer J, Flattery MP, Joyner PL, et al: Lifestyle and quality of life in long-term cardiac transplant recipients. J Heart Lung Transplant 22:309, 2003 28. Bergner M, Bobbitt RA, Carter WB, et al: The Sickness Impact Profile: development and final revision of health status measure. Med Care 19:787, 1981