- Email: [email protected]
Relationship of physical symptoms and physical functioning to depression in patients with heart failure
Relationship of physical symptoms and physical functioning to depression in patients with heart failure Maureen M. Friedman, PhD, RN,a and Judy A. Griffin, RN, MS,b Rochester and Buffalo, New York
OBJECTIVE: The purpose of this study was to determine the relative contribution of physical symptoms and physical functioning to depression in adult patients with heart failure during hospitalization and the early postdischarge period. DESIGN: An exploratory, correlational longitudinal design was used. PATIENTS: The sample included 170 subjects with heart failure. RESULTS: Subjects’ mean scores on the depression scale indicated that subjects were not depressed on average; however, 30% of the sample (n = 52) had scores indicative of clinical depression. Both physical symptoms (r = 0.48) and physical functioning (r = –0.32) were moderately correlated with depression. Physical symptoms contributed 13% uniquely to the variance in depression while physical functioning contributed only 2% uniquely to the variance in depression. Multiple regression analyses indicated that physical symptomatology is more closely related to depression than is physical functioning in adults with heart failure. CONCLUSIONS: This study showed the patients with heart failure who had increased physical symptoms and poorer physical functioning reported increased symptoms of depression. Physical symptoms explained a greater portion of the variance in depression than did physical functioning. Thus, it appears that patients with heart failure are affected emotionally by both their physical symptoms and their limitations in their physical functioning, but depression is more strongly related to having more physical symptoms than having greater limitations in physical functioning. (Heart Lung® 2001;30:98-104.)
H
eart failure is a clinical syndrome that may lead to progressively severe symptoms including reduced vitality, forced dependency, and early retirement.1 Approximately 1.5% of the adult population in the United States (at least 3 million persons) has heart failure 2 and approximately 400,000 new cases are diagnosed each year.3 According to the Framingham Study, From aNazareth College of Rochester and bBuffalo General Hospital. Funding for this study was received from the New York State Affiliate of the American Heart Association by Maureen Friedman (grant-in-aid # 960133). Reprint requests: Maureen M. Friedman, PhD, RN, Nazareth College, 4245 East Ave, Rochester, NY 14618-3790. Copyright © 2001 by Mosby, Inc. 0147-9563/2001/$35.00 + 0 2/1/114180 doi:10.1067/mhl.2001.114180
98
the incidence of heart failure doubles with each decade of age.4 Older adults have the greatest prevalence of heart failure, with 10% of adults older than 75 years afflicted.5,6 In 1994, heart failure was ranked as the number 1 diagnosis-related group (DRG), with about 850,000 patients hospitalized with a primary diagnosis of heart failure,7 making heart failure the leading hospital discharge diagnosis for patients older than 65 years.3 Heart failure–related symptoms contribute to the restriction of heart failure patients’ daily physical activities.8 The most common symptoms of heart failure reported by patients in previous studies have been fatigue and dyspnea resulting from exertion.1,8,9 The major symptoms identified in the Framingham Study as consistent with the diagnosis of heart failure were orthopnea and paroxysmal nocturnal dyspnea.10 Edema, palpitations, cough,
MARCH/APRIL 2001
HEART & LUNG
Friedman and Griffin
sleeplessness, and angina are additional common symptoms related to heart failure that were reported in previous studies with heart failure patients.1,8,9 A major cause of disability and morbidity, heart failure often hinders the ability of patients to perform activities of daily living and support their families.2 In a study conducted by Stewart and colleagues, health perceptions and physical functioning were evaluated in patients with chronic illnesses.11 Data indicated that patients with heart failure had the poorest health perception (along with patients with gastrointestinal disorders), the poorest physical functioning, and the poorest social functioning (along with patients with a myocardial infarction) compared with patients with all other illnesses studied. Among older adults, physical disease is commonly considered a risk factor for depression.12-14 In a community survey by Frerich and colleagues,15 those patients who scored high on a depression scale were more likely to have reported having physical illnesses than were patients scoring low on the scale. Berkman and colleagues16 found that older persons with a chronic condition or major functional disability had higher mean depression scores on the Center for Epidemiological StudiesDepression scale (CES-D) than did patients without a chronic condition or functional disability. Those subjects with both a functional disability and chronic conditions scored within the clinically depressed range on the depression scale. These findings are consistent with the conclusions of Stewart and colleagues11 that the repercussions of a chronic illness on older adults can be substantial and can involve all aspects of functioning and wellbeing. In some of the studies involving older adults and physical illness, depression has been primarily attributed to the limitations in physical functioning caused by the physical illness.17-20 Stewart and colleagues,11 on the other hand, view chronic illness as having a myriad of factors that may diminish selfworth, with physical limitations being only one of them. Clearly the physical symptoms of the illness itself may have the ability to diminish the person’s feelings of self-worth as the person experiences possible changes in body image, stamina, breathing patterns, sleep, and weight gain. None of the previous studies have clearly determined the relative contributions of physical symptoms versus physical functioning to depression in a chronic illness population. In one of the few studies that examined the degree of depression in cardiac patients, Hawthorne
HEART & LUNG
VOL. 30, NO. 2
Depression in patients with heart failure
and Hixon21 found that significant mood disruption was greater in patients with heart failure than in other cardiac patients. Their explanation was that the patients with heart failure had more symptoms and a greater degree of restricted activities than did other types of cardiac patients. Whether the alteration in mood reported by many patients was related more to the physical limitations imposed by heart failure or the symptoms of the illness themselves was not determined. The purposes of this study were (1) to examine the relationships among physical symptoms, physical functioning, and depression during hospitalization and the early posthospitalization period, and (2) to determine the relative contributions of both physical symptoms and physical functioning to depression in a sample of adults with heart failure during the immediate posthospitalization recovery period.
METHOD Design and subjects An exploratory, correlational longitudinal design was used. To be eligible for the study, potential study subjects had to be 50 years of age or older; mentally alert and able to complete an interview; without myocardial infarction or surgery on the current admission; have a principal diagnosis of heart failure of cardiac origin; and speak English. A sample of older adults (≥60 years of age) was originally planned but the pilot data indicated that the age eligibility criteria needed to be lowered to ≥50 years to gather a sufficient sample in the period of the study. Two hundred twelve subjects completed the Time 1 interview during hospitalization for heart failure. Of the 247 eligible subjects, 35 (14%) refused to participate. The main reasons for refusal were disinterest in participating and fatigue. All subjects had been hospitalized in 1 of 3 acute care institutions in western New York and were interviewed, on average, during the third day of hospitalization. One hundred and seventy of the original 212 subjects (80%) completed a second telephone interview 4 to 6 weeks after hospital discharge. A power analysis indicated that a sample size of 170 subjects would be sufficient to detect correlations of 0.20 or greater (power = 0.80, P < .05). The most frequent reasons for failure to complete the Time 2 interview were that subjects (1) could not be located at the address or telephone number given (n = 24), (2) had died since the initial interview (n = 8), (3) refused to conduct the second interview (n = 7), and (4) were physically unable to conduct the interview because of worsening health
99
Depression in patients with heart failure
(n = 3). Of the 170 subjects who completed both interviews, 51.2% were men and 48.8% were women. Age ranged from 50 to 93 years, with a mean age of 72.7 years (SD = 9.6). Eighty-five percent of the subjects were white and 13% were African American. Forty-six percent of the sample was married and living with their spouse. Years of education varied from 0 (no formal education) to 18 years, with a mean of 11.3 years (SD = 3.0). Seventy-one percent of the subjects had a history of heart failure before the current hospitalization. Sixty-two percent stated that they had had similar symptoms that required them to be hospitalized in the past, with the mean number of times with symptoms in the past being 4. Other cardiac diagnoses present among the sample were coronary artery disease (72%), hypertension (49%), arrhythmia (37%), valvular disease (17%), and peripheral vascular disease (12%). Comorbidities most prevalent in this group included diabetes (44.3%), chronic obstructive pulmonary disease (19.8%), and cerebral vascular accident (10.4%).
Instruments Symptom checklist. A 13-item symptom checklist made for this study was used to assess the quantity of heart failure-related symptoms that subjects reported. The 13 items were generated from the list of heart failure symptoms contained in the Agency for Health Care Policy Research 1994 publication on heart failure practice guidelines22 and were validated by 2 cardiac clinical nursing specialists. The items were also highly correlated with each other in a previous study of heart failure patients by Friedman.23 Symptoms on the scale included shortness of breath with exertion, difficulty breathing when lying flat in bed, waking up breathless at night, swelling in the feet or ankles, weight gain, fatigue, weakness, dry, hacking cough, poor appetite, nausea, dizziness, palpitations, and chest pain. Subjects indicated the presence or absence of each of the 13 symptoms during the previous 2 weeks. Subjects were directed during the hospitalization (Time 1) to reflect back to symptoms experienced during the 2 weeks before admission. The Cronbach α coefficient was .68 in this study. This relatively low coefficient may reflect the brevity of this scale and indicate that some of these symptom items are relatively independent of each other. Physical functioning. The 10-item physical functioning scale from the Medical Outcomes Study Short Form Health Survey (SF-36)24 was used to measure subjects’ physical functioning. The scale reliability (Cronbach α = .93) and validity were both
100
Friedman and Griffin
reported to be high by the original authors.24 The 10 items capture both the presence and extent of physical functioning by using a 3-level response continuum with 1 = limited a lot, 2 = limited a little, and 3 = not limited at all. Scores were transformed linearly to a 0 to 100 scale as suggested by Stewart and colleagues25 to treat them as interval levels of measurement. The possible range of scores was 0 to 100. High scores reflect better physical functioning. The Cronbach α coefficient was .90 in this study. Depression scale. The CES-D scale Short Form26 (10 items) was used to measure depression. The scale is a self-report instrument designed to measure depressive symptomatology in the general population. The original 20-item scale developed by Radloff27 has been widely used in epidemiologic studies. The frequency of depressive symptoms experienced during the past week was rated by each subject. Subjects rated the frequency of each symptom on a 4-point Likert scale ranging from 0 = “rarely or none of the time (less than 1 day)” to 3 = “most or all of the time (5 to 7 days).” Total scores had a possible range of 0 to 30. Scores for the 2 positively worded items were reversed before summing across all items. A high score on the total scale indicated greater depression. Andresen and colleagues26 established 2 week test-retest reliability for the 10-item version of the scale with a correlation of r = 0.71. Validity was determined by comparing the instrument with other measures of emotional distress and physical discomfort. The findings suggested that the CES-D scale measures universal distress and symptoms of depression and not just clinical depression.26 According to Badger,18 the CES-D scale is brief, understandable, and does not confound somatic symptoms that normally accompany aging, thereby making it a useful tool to measure depression in the elderly—even in those persons with a physical illness. The Cronbach α coefficient for this sample was .83. Medical history. Subjects’ history of heart failure, cardiac diagnoses, and comorbidities were obtained from the admitting physician’s history documented in the participants’ hospital records. Sociodemographic data. Age, race, marital status, education, and living arrangements were obtained directly from the subject during the initial interview.
Procedure Data were collected at 2 different time points with a structured interview format. At each of the 3 acute facilities, trained nursing research assistants asked all subjects the questions on each questionnaire
MARCH/APRIL 2001
HEART & LUNG
Friedman and Griffin
Depression in patients with heart failure
Table I Correlation matrix of study variables (N = 170) Variable
1. 2. 3. 4. 5. 6.
1
Physical symptoms (Time 1) Physical symptoms (Time 2) Physical functioning (Time 1) Physical functioning (Time 2) Depression (Time 1) Depression (Time 2)
2
3
.34†
–.25† –.17
4
–.05 –.32† .59†
5
.19* .10 -.30† –.25†
6
.16 .48† –.25† –.38† .51†
Note: Column numbers represent the numbered variables. *P < .01. †P < .001.
and extracted data from subjects’ hospital records. The first interview (Time 1) was done with subjects face to face during the subject’s hospitalizations for heart failure. Written informed consent was obtained at that time. A second telephone interview (Time 2) was conducted 4 to 6 weeks after hospitalization with the subjects at home. The questions were read to subjects slowly by telephone and repeated to clarify each question and the possible responses.
RESULTS The mean number of symptoms reported at the Time 1 interview was 7.4 (SD = 2.5) out of a possible 13 symptoms and decreased to 3.98 (SD = 2.7) symptoms at Time 2. Fatigue, shortness of breath, and weakness were the 3 most frequently reported symptoms. The mean physical functioning score was 33.3 (SD = 26.3) at Time 1 and 32 (SD = 26.6) out of a possible 100 at Time 2, indicating a moderate degree of impairment at both time points. Few subjects could perform vigorous activities or walk more than a mile, whereas most subjects could independently bathe and dress themselves. The average score on the depression scale for this sample was 7.9 (SD = 5.9) at Time 1 during hospitalization and 7.3 (SD = 6.6) at Time 2 (4 to 6 weeks after hospital discharge), indicating that subjects were not depressed on average. According to Andresen and colleagues,26 a total score of 10 or greater on the CES-D Short Form is the conservative estimate of a person having depressive symptoms. Thirty percent of the sample (n = 52) had a total score of 10 or more on the depression scale. Half of the subjects (n = 26) with scores of 10 or more were women and half (n = 26) were men. Of
HEART & LUNG
VOL. 30, NO. 2
those subjects with scores of 10 or more, 24% were on antidepressants or antianxiety medications. Moderate correlations were found between physical symptoms and depression and physical functioning and depression at both Time 1 and Time 2 (Table I). Physical symptoms, physical functioning, and depression at the same period were more highly correlated than those same variables at the different time points. Therefore, these data indicate that subjects who reported more physical symptoms and poorer physical functioning also reported greater depressive symptomatology at the same time. Physical symptoms and physical functioning were only moderately correlated with each other, r = –0.25 and r = –0.32 at Time 1 and Time 2, respectively, indicating that the variables were relatively independent measures of each other. A multiple regression equation was calculated to determine the unique contributions of physical symptoms and physical functioning to the variance in Time 2 depression, controlling for Time 1 depression (Table II). The 3 variables, physical symptoms, physical functioning, and Time 1 depression, together explained 46% of the variance in depression at Time 2 (F3, 166 = 47.9, P < .001). Time 1 depression explained the largest amount of the unique variance in Time 2 depression (18%). Physical symptoms contributed 13% to the variance in depression beyond the contribution made by Time 1 depression and Time 2 physical functioning, while physical functioning contributed only 2% to the overall variance in depression beyond the contribution made by Time 1 depression and Time 2 physical symptoms. Therefore, physical symptoms explained more of the unique variance in depression than did physical functioning.
101
Depression in patients with heart failure
Friedman and Griffin
Table II Multiple regression analysis: Time 2 depression regressed on Time 2 physical symptoms and Time 2 physical functioning controlling for Time 1 depression (N = 170) Variables
β
t
Depression (Time 1) Physical symptoms (Time 2) Physical functioning (Time 2)
0.44 0.39 –0.15
7.5† 6.4† –2.3*
Overall model: R2 = 0.46, F166 = 47.9, P < .001. *P < .05. †P < .001.
DISCUSSION In this study, patients with heart failure who experienced more physical symptoms and less physical functioning also experienced greater depression. These findings were an extension from the previous research that measured the common symptoms experienced by heart failure patients, their degree of physical disability, and in some cases their depression.1,2,8-11,21 This is the only study that examined the relative contribution of physical symptoms and physical functioning to depression in a clinical population of heart failure patients. These data are somewhat unique in that the sample contained more women than did previous samples of patients with heart failure and also used a wider age eligibility criteria (≥50 years) than did studies that included only subjects ≥60 years of age. The percentage of subjects with depression scores of 10 or more (30%) in this sample exceeds the 11.7% who had scores of 10 or more in Andresen and colleagues’26 original community sample of well, older adults. The data in this study are more similar to Turner and Noh’s28 data with 35% of the older adults with disabilities (≥65 years) and 39% of middle-aged adults (45 to 64 years) with physical disabilities indicating depression on the full CES-D. Those researchers who intend to design and test interventions to reduce depression in patients with heart failure in the future would be advised to measure and target physical symptoms first and foremost and physical functioning as an additional possible variable related to depression. Since patients with heart failure have activity intolerance as a defining characteristic of their illness, measuring physical functioning and physical
102
symptoms could be expected to yield a high degree of overlap for those 2 measures. However, in this study, the CES-D Short Form and the Medical Outcomes Study Short Form Health Survey scale of physical functioning were quite distinct without a high degree of overlap. These distinct measures offered the opportunity to compare the unique contribution of both physical symptoms and physical functioning to depression. Of the 3 predictor variables, Time 1 depression explained the largest amount of the unique variance in subjects’ depression at Time 2. Because there is some stability in depressive symptoms over time, especially in subjects with a chronic illness like heart failure, Time 1 depression was the largest contributor to the variance of depressive symptoms at Time 2. Of the other 2 predictor variables, physical symptoms made a larger unique contribution to the variance in depression than did physical functioning. Previous research with patients with heart failure has not examined these relationships clearly. However, the data from this study could not clearly establish the causal nature of these relationships since some of the group of subjects with decreased physical functioning, increased symptoms, and indications of depression reported impairments in all 3 variables at the onset of the study. More descriptive research could help illuminate the perceptions of patients with heart failure about the development of depression during the course of the illness. Further study is also needed to determine the causal nature of depression in those patients who have depression by beginning with patients at risk for heart failure or those early in the course of heart failure and measuring changes over a longer peri-
MARCH/APRIL 2001
HEART & LUNG
Friedman and Griffin
od. In addition, future research on the impact of treating physical symptoms on both physical functioning and mood would be beneficial to further the understanding and treatment of patients with heart failure.
Implications for nursing practice Heart failure as a chronic illness affects every aspect of daily life and requires continuous adaptation. It has the potential to seriously diminish psychologic well-being in those persons who have difficulty adjusting to the physical alterations the disease causes. Understanding how physical factors such as physical symptoms and physical functioning are related to depression is essential for determining which variables to target for intervention. Establishing nursing interventions that diminish physical symptoms, improve physical functioning, and diminish depression could promote a more comprehensive level of care for patients with heart failure. Although the goal of heart failure management is to diminish symptoms and maximize patients’ functioning, some patients may continue to have symptoms past hospitalization despite receiving maximal treatment. Ongoing symptoms may make a significant group of patients with heart failure susceptible to depressed mood. As a result, all patients with heart failure who have a chronic physical symptom pattern should be screened for concomitant depression that may merit intervention.
Limitations The main limitations of this study are related to the nature of the sample. Although the subjects in this study are generally representative of the patients seen in the participating acute care facilities, they do not represent all patients with heart failure. Patients who were more symptomatic, more depressed, or older may have been the patients who refused to complete the initial interview or failed to complete the second interview. Further examination of the symptom checklist developed by the investigator is needed to more fully determine the reliability and validity of this investigator-developed tool. Further testing and possible modifications of this instrument could assist other researchers interested in the use of a validated and reliable heart failure symptom scale.
CONCLUSION This study showed that patients with heart failure who had increased physical symptoms and poorer physical functioning reported increased symptoms
HEART & LUNG
VOL. 30, NO. 2
Depression in patients with heart failure
of depression. Physical symptoms explained a greater portion of the variance in depression than did physical functioning. Thus, it appears that patients with heart failure are affected emotionally by both their physical symptoms and their limitations in their physical functioning, but depression is more strongly related to having more physical symptoms than having greater limitations in physical functioning. We thank Julie A. Johnson and Kathleen B. King for their comments on an earlier draft of this manuscript and the anonymous reviewers for the Journal. We also thank Patricia Federico-Fields and Kathleen Crowley for their assistance with data collection.
REFERENCES 1. Dracup K, Walden J, Stevenson L, Brecht M. Quality of life in patients with advanced heart failure. J Heart Lung Transplant 1992;11:273-9. 2. Garg R, Packer M, Pitt B, Yusuf S. Heart failure in the 1990’s: evolution of a major health problem in cardiovascular medicine. JACC 1993;22(4):3A-5A. 3. Kannel WB, Belangers AJ. Epidemiology of heart failure. Am Heart J 1991;121:951-7. 4. National Heart, Lung and Blood Institute. Morbidity and mortality chartbook in cardiovascular, lung and blood diseases, 1990. Bethesda (MD): The Institute; 1992. 5. Kannel WB, Ho K, Thom T. Changing epidemiological features of cardiac failure. Brit Heart J 1994;72(Supplement):S3-S9. 6. Schocken DD, Arrieta MI, Leaverton PE. Prevalence and mortality rate of congestive heart failure in the United States. J Am Coll Cardiol 1992;20:301-6. 7. Health Care Financing Administration. National Heart, Lung, and Blood Institute Data Fact Sheet. Available at: http:// www.nhlbi.nih.gov/health/public/heart/other/CHF.txt. Accessed January 12, 2001. 8. Mayou R, Blackwood R, Bryant B, Garnham J. Cardiac failure: symptoms and functional status. J Psychosom Res 1991; 34:399-407. 9. Friedman MM, King K. Correlates of fatigue in older women with heart failure. Heart Lung 1995;24:512-8. 10. McKee P, Castelli W, McNamara P, Kannel W. The natural history of congestive heart failure: the Farmingham Study. New Engl J Med 1971;285:441-6. 11. Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry SD, et al. Functional status and well being of patients with chronic conditions. JAMA 1989;262:907-13. 12. Husaini BA. Predictors of depression among the elderly: racial differences over time. Amer J Orthopsychiatry 1997;67:48-58. 13. Katon W, Sullivan MD. Depression and chronic medical illness. J Clin Psychiatry 1990;51(6):3-10. 14. Nickel JT, Brown KJ, Smith BA. Depression and anxiety among chronically ill heart patients: age differences in risk and predictors. Res Nurs Health 1990;13:87-97. 15. Frerichs RR, Aneshensel CS, Yokopenic PA, Clark VA. Physical health and depression: an epidemiologic survey. Prev Med 1982;11:639-46. 16. Berkman LF, Berkman CS, Kasl S, Freeman Jr DH, Les L, Ostfeld AM, et al. Depressive symptoms in relation to physical health and functioning in the elderly. Am J Epidemiol 1986;124:372-88. 17. Aneshensel CS, Frerichs RR, Huba GJ. Depression and physical illness: a multiwave, nonrecursive causal model. J Health Soc Behav 1984;25:350-71.
103
Depression in patients with heart failure 18. Badger TA. Physical health impairment and depression among older adults. Image J Nurs Sch 1993;25:325-30. 19. Murrell SA, Himmelfarb S, Wright K. Prevalence of depression and its correlates in older adults. Am J Epidemiol 1983;117:173-85. 20. Zeiss AM, Lewinsohn PM, Rohdes P, Seeley JR. Relationship of physical disease and functional impairment to depression in older people. Psychol Aging 1996;11:572-81. 21. Hawthorne MH, Hixon ME. Functional status, mood disturbance and quality of life in patients with heart failure. Prog Cardiovasc Nurs 1994;9(1):22-32. 22. Konstam M, Dracup K, Baker D, et al. Clinical practice guideline no 11: heart failure: evaluation and care of patients with left-ventricular systolic dysfunction. Rockville (MD): Agency for health Care Policy and Research, Public Health Services, US Department of Health and Human Services; 1994. AHCPR Publication No 94-0612.
Friedman and Griffin 23. Friedman MM. Older adults’ symptoms and their duration before hospitalization for heart failure. Heart Lung 1997;26: 169-76. 24. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey. Med Care 1992;30:473-83. 25. Stewart AL, Hays RD, Ware JE. The MOS short-form general health survey. Med Care 1988;26:724-35. 26. Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening for depression in well older adults: evaluation of a short form of the CES-D. Am J Prev Med 1994;10(2):77-84. 27. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Measure 1977;1:385-401. 28. Turner RJ, Noh S. Physical disability and depression: a longitudinal analysis. J Health Soc Behav 1988;29:2337.
AVAILABILITY OF JOURNAL BACK ISSUES As a service to our subscribers, copies of back issues of Heart & Lung: The Journal of Acute and Critical Care for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one-third off on quantities of 24 or more. Please write to Mosby, Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887, or call (800)654-2452 or (407)345-4000 for information on availability of particular issues and prices. If unavailable from the publisher, photocopies of complete issues may be purchased from Bell & Howell Information and Learning, 300 N. Zeeb Rd., Ann Arbor, MI 48106, (734)761-4700 or (800)521-0600.
104
MARCH/APRIL 2001
HEART & LUNG
OBJECTIVE: The purpose of this study was to determine the relative contribution of physical symptoms and physical functioning to depression in adult patients with heart failure during hospitalization and the early postdischarge period. DESIGN: An exploratory, correlational longitudinal design was used. PATIENTS: The sample included 170 subjects with heart failure. RESULTS: Subjects’ mean scores on the depression scale indicated that subjects were not depressed on average; however, 30% of the sample (n = 52) had scores indicative of clinical depression. Both physical symptoms (r = 0.48) and physical functioning (r = –0.32) were moderately correlated with depression. Physical symptoms contributed 13% uniquely to the variance in depression while physical functioning contributed only 2% uniquely to the variance in depression. Multiple regression analyses indicated that physical symptomatology is more closely related to depression than is physical functioning in adults with heart failure. CONCLUSIONS: This study showed the patients with heart failure who had increased physical symptoms and poorer physical functioning reported increased symptoms of depression. Physical symptoms explained a greater portion of the variance in depression than did physical functioning. Thus, it appears that patients with heart failure are affected emotionally by both their physical symptoms and their limitations in their physical functioning, but depression is more strongly related to having more physical symptoms than having greater limitations in physical functioning. (Heart Lung® 2001;30:98-104.)
H
eart failure is a clinical syndrome that may lead to progressively severe symptoms including reduced vitality, forced dependency, and early retirement.1 Approximately 1.5% of the adult population in the United States (at least 3 million persons) has heart failure 2 and approximately 400,000 new cases are diagnosed each year.3 According to the Framingham Study, From aNazareth College of Rochester and bBuffalo General Hospital. Funding for this study was received from the New York State Affiliate of the American Heart Association by Maureen Friedman (grant-in-aid # 960133). Reprint requests: Maureen M. Friedman, PhD, RN, Nazareth College, 4245 East Ave, Rochester, NY 14618-3790. Copyright © 2001 by Mosby, Inc. 0147-9563/2001/$35.00 + 0 2/1/114180 doi:10.1067/mhl.2001.114180
98
the incidence of heart failure doubles with each decade of age.4 Older adults have the greatest prevalence of heart failure, with 10% of adults older than 75 years afflicted.5,6 In 1994, heart failure was ranked as the number 1 diagnosis-related group (DRG), with about 850,000 patients hospitalized with a primary diagnosis of heart failure,7 making heart failure the leading hospital discharge diagnosis for patients older than 65 years.3 Heart failure–related symptoms contribute to the restriction of heart failure patients’ daily physical activities.8 The most common symptoms of heart failure reported by patients in previous studies have been fatigue and dyspnea resulting from exertion.1,8,9 The major symptoms identified in the Framingham Study as consistent with the diagnosis of heart failure were orthopnea and paroxysmal nocturnal dyspnea.10 Edema, palpitations, cough,
MARCH/APRIL 2001
HEART & LUNG
Friedman and Griffin
sleeplessness, and angina are additional common symptoms related to heart failure that were reported in previous studies with heart failure patients.1,8,9 A major cause of disability and morbidity, heart failure often hinders the ability of patients to perform activities of daily living and support their families.2 In a study conducted by Stewart and colleagues, health perceptions and physical functioning were evaluated in patients with chronic illnesses.11 Data indicated that patients with heart failure had the poorest health perception (along with patients with gastrointestinal disorders), the poorest physical functioning, and the poorest social functioning (along with patients with a myocardial infarction) compared with patients with all other illnesses studied. Among older adults, physical disease is commonly considered a risk factor for depression.12-14 In a community survey by Frerich and colleagues,15 those patients who scored high on a depression scale were more likely to have reported having physical illnesses than were patients scoring low on the scale. Berkman and colleagues16 found that older persons with a chronic condition or major functional disability had higher mean depression scores on the Center for Epidemiological StudiesDepression scale (CES-D) than did patients without a chronic condition or functional disability. Those subjects with both a functional disability and chronic conditions scored within the clinically depressed range on the depression scale. These findings are consistent with the conclusions of Stewart and colleagues11 that the repercussions of a chronic illness on older adults can be substantial and can involve all aspects of functioning and wellbeing. In some of the studies involving older adults and physical illness, depression has been primarily attributed to the limitations in physical functioning caused by the physical illness.17-20 Stewart and colleagues,11 on the other hand, view chronic illness as having a myriad of factors that may diminish selfworth, with physical limitations being only one of them. Clearly the physical symptoms of the illness itself may have the ability to diminish the person’s feelings of self-worth as the person experiences possible changes in body image, stamina, breathing patterns, sleep, and weight gain. None of the previous studies have clearly determined the relative contributions of physical symptoms versus physical functioning to depression in a chronic illness population. In one of the few studies that examined the degree of depression in cardiac patients, Hawthorne
HEART & LUNG
VOL. 30, NO. 2
Depression in patients with heart failure
and Hixon21 found that significant mood disruption was greater in patients with heart failure than in other cardiac patients. Their explanation was that the patients with heart failure had more symptoms and a greater degree of restricted activities than did other types of cardiac patients. Whether the alteration in mood reported by many patients was related more to the physical limitations imposed by heart failure or the symptoms of the illness themselves was not determined. The purposes of this study were (1) to examine the relationships among physical symptoms, physical functioning, and depression during hospitalization and the early posthospitalization period, and (2) to determine the relative contributions of both physical symptoms and physical functioning to depression in a sample of adults with heart failure during the immediate posthospitalization recovery period.
METHOD Design and subjects An exploratory, correlational longitudinal design was used. To be eligible for the study, potential study subjects had to be 50 years of age or older; mentally alert and able to complete an interview; without myocardial infarction or surgery on the current admission; have a principal diagnosis of heart failure of cardiac origin; and speak English. A sample of older adults (≥60 years of age) was originally planned but the pilot data indicated that the age eligibility criteria needed to be lowered to ≥50 years to gather a sufficient sample in the period of the study. Two hundred twelve subjects completed the Time 1 interview during hospitalization for heart failure. Of the 247 eligible subjects, 35 (14%) refused to participate. The main reasons for refusal were disinterest in participating and fatigue. All subjects had been hospitalized in 1 of 3 acute care institutions in western New York and were interviewed, on average, during the third day of hospitalization. One hundred and seventy of the original 212 subjects (80%) completed a second telephone interview 4 to 6 weeks after hospital discharge. A power analysis indicated that a sample size of 170 subjects would be sufficient to detect correlations of 0.20 or greater (power = 0.80, P < .05). The most frequent reasons for failure to complete the Time 2 interview were that subjects (1) could not be located at the address or telephone number given (n = 24), (2) had died since the initial interview (n = 8), (3) refused to conduct the second interview (n = 7), and (4) were physically unable to conduct the interview because of worsening health
99
Depression in patients with heart failure
(n = 3). Of the 170 subjects who completed both interviews, 51.2% were men and 48.8% were women. Age ranged from 50 to 93 years, with a mean age of 72.7 years (SD = 9.6). Eighty-five percent of the subjects were white and 13% were African American. Forty-six percent of the sample was married and living with their spouse. Years of education varied from 0 (no formal education) to 18 years, with a mean of 11.3 years (SD = 3.0). Seventy-one percent of the subjects had a history of heart failure before the current hospitalization. Sixty-two percent stated that they had had similar symptoms that required them to be hospitalized in the past, with the mean number of times with symptoms in the past being 4. Other cardiac diagnoses present among the sample were coronary artery disease (72%), hypertension (49%), arrhythmia (37%), valvular disease (17%), and peripheral vascular disease (12%). Comorbidities most prevalent in this group included diabetes (44.3%), chronic obstructive pulmonary disease (19.8%), and cerebral vascular accident (10.4%).
Instruments Symptom checklist. A 13-item symptom checklist made for this study was used to assess the quantity of heart failure-related symptoms that subjects reported. The 13 items were generated from the list of heart failure symptoms contained in the Agency for Health Care Policy Research 1994 publication on heart failure practice guidelines22 and were validated by 2 cardiac clinical nursing specialists. The items were also highly correlated with each other in a previous study of heart failure patients by Friedman.23 Symptoms on the scale included shortness of breath with exertion, difficulty breathing when lying flat in bed, waking up breathless at night, swelling in the feet or ankles, weight gain, fatigue, weakness, dry, hacking cough, poor appetite, nausea, dizziness, palpitations, and chest pain. Subjects indicated the presence or absence of each of the 13 symptoms during the previous 2 weeks. Subjects were directed during the hospitalization (Time 1) to reflect back to symptoms experienced during the 2 weeks before admission. The Cronbach α coefficient was .68 in this study. This relatively low coefficient may reflect the brevity of this scale and indicate that some of these symptom items are relatively independent of each other. Physical functioning. The 10-item physical functioning scale from the Medical Outcomes Study Short Form Health Survey (SF-36)24 was used to measure subjects’ physical functioning. The scale reliability (Cronbach α = .93) and validity were both
100
Friedman and Griffin
reported to be high by the original authors.24 The 10 items capture both the presence and extent of physical functioning by using a 3-level response continuum with 1 = limited a lot, 2 = limited a little, and 3 = not limited at all. Scores were transformed linearly to a 0 to 100 scale as suggested by Stewart and colleagues25 to treat them as interval levels of measurement. The possible range of scores was 0 to 100. High scores reflect better physical functioning. The Cronbach α coefficient was .90 in this study. Depression scale. The CES-D scale Short Form26 (10 items) was used to measure depression. The scale is a self-report instrument designed to measure depressive symptomatology in the general population. The original 20-item scale developed by Radloff27 has been widely used in epidemiologic studies. The frequency of depressive symptoms experienced during the past week was rated by each subject. Subjects rated the frequency of each symptom on a 4-point Likert scale ranging from 0 = “rarely or none of the time (less than 1 day)” to 3 = “most or all of the time (5 to 7 days).” Total scores had a possible range of 0 to 30. Scores for the 2 positively worded items were reversed before summing across all items. A high score on the total scale indicated greater depression. Andresen and colleagues26 established 2 week test-retest reliability for the 10-item version of the scale with a correlation of r = 0.71. Validity was determined by comparing the instrument with other measures of emotional distress and physical discomfort. The findings suggested that the CES-D scale measures universal distress and symptoms of depression and not just clinical depression.26 According to Badger,18 the CES-D scale is brief, understandable, and does not confound somatic symptoms that normally accompany aging, thereby making it a useful tool to measure depression in the elderly—even in those persons with a physical illness. The Cronbach α coefficient for this sample was .83. Medical history. Subjects’ history of heart failure, cardiac diagnoses, and comorbidities were obtained from the admitting physician’s history documented in the participants’ hospital records. Sociodemographic data. Age, race, marital status, education, and living arrangements were obtained directly from the subject during the initial interview.
Procedure Data were collected at 2 different time points with a structured interview format. At each of the 3 acute facilities, trained nursing research assistants asked all subjects the questions on each questionnaire
MARCH/APRIL 2001
HEART & LUNG
Friedman and Griffin
Depression in patients with heart failure
Table I Correlation matrix of study variables (N = 170) Variable
1. 2. 3. 4. 5. 6.
1
Physical symptoms (Time 1) Physical symptoms (Time 2) Physical functioning (Time 1) Physical functioning (Time 2) Depression (Time 1) Depression (Time 2)
2
3
.34†
–.25† –.17
4
–.05 –.32† .59†
5
.19* .10 -.30† –.25†
6
.16 .48† –.25† –.38† .51†
Note: Column numbers represent the numbered variables. *P < .01. †P < .001.
and extracted data from subjects’ hospital records. The first interview (Time 1) was done with subjects face to face during the subject’s hospitalizations for heart failure. Written informed consent was obtained at that time. A second telephone interview (Time 2) was conducted 4 to 6 weeks after hospitalization with the subjects at home. The questions were read to subjects slowly by telephone and repeated to clarify each question and the possible responses.
RESULTS The mean number of symptoms reported at the Time 1 interview was 7.4 (SD = 2.5) out of a possible 13 symptoms and decreased to 3.98 (SD = 2.7) symptoms at Time 2. Fatigue, shortness of breath, and weakness were the 3 most frequently reported symptoms. The mean physical functioning score was 33.3 (SD = 26.3) at Time 1 and 32 (SD = 26.6) out of a possible 100 at Time 2, indicating a moderate degree of impairment at both time points. Few subjects could perform vigorous activities or walk more than a mile, whereas most subjects could independently bathe and dress themselves. The average score on the depression scale for this sample was 7.9 (SD = 5.9) at Time 1 during hospitalization and 7.3 (SD = 6.6) at Time 2 (4 to 6 weeks after hospital discharge), indicating that subjects were not depressed on average. According to Andresen and colleagues,26 a total score of 10 or greater on the CES-D Short Form is the conservative estimate of a person having depressive symptoms. Thirty percent of the sample (n = 52) had a total score of 10 or more on the depression scale. Half of the subjects (n = 26) with scores of 10 or more were women and half (n = 26) were men. Of
HEART & LUNG
VOL. 30, NO. 2
those subjects with scores of 10 or more, 24% were on antidepressants or antianxiety medications. Moderate correlations were found between physical symptoms and depression and physical functioning and depression at both Time 1 and Time 2 (Table I). Physical symptoms, physical functioning, and depression at the same period were more highly correlated than those same variables at the different time points. Therefore, these data indicate that subjects who reported more physical symptoms and poorer physical functioning also reported greater depressive symptomatology at the same time. Physical symptoms and physical functioning were only moderately correlated with each other, r = –0.25 and r = –0.32 at Time 1 and Time 2, respectively, indicating that the variables were relatively independent measures of each other. A multiple regression equation was calculated to determine the unique contributions of physical symptoms and physical functioning to the variance in Time 2 depression, controlling for Time 1 depression (Table II). The 3 variables, physical symptoms, physical functioning, and Time 1 depression, together explained 46% of the variance in depression at Time 2 (F3, 166 = 47.9, P < .001). Time 1 depression explained the largest amount of the unique variance in Time 2 depression (18%). Physical symptoms contributed 13% to the variance in depression beyond the contribution made by Time 1 depression and Time 2 physical functioning, while physical functioning contributed only 2% to the overall variance in depression beyond the contribution made by Time 1 depression and Time 2 physical symptoms. Therefore, physical symptoms explained more of the unique variance in depression than did physical functioning.
101
Depression in patients with heart failure
Friedman and Griffin
Table II Multiple regression analysis: Time 2 depression regressed on Time 2 physical symptoms and Time 2 physical functioning controlling for Time 1 depression (N = 170) Variables
β
t
Depression (Time 1) Physical symptoms (Time 2) Physical functioning (Time 2)
0.44 0.39 –0.15
7.5† 6.4† –2.3*
Overall model: R2 = 0.46, F166 = 47.9, P < .001. *P < .05. †P < .001.
DISCUSSION In this study, patients with heart failure who experienced more physical symptoms and less physical functioning also experienced greater depression. These findings were an extension from the previous research that measured the common symptoms experienced by heart failure patients, their degree of physical disability, and in some cases their depression.1,2,8-11,21 This is the only study that examined the relative contribution of physical symptoms and physical functioning to depression in a clinical population of heart failure patients. These data are somewhat unique in that the sample contained more women than did previous samples of patients with heart failure and also used a wider age eligibility criteria (≥50 years) than did studies that included only subjects ≥60 years of age. The percentage of subjects with depression scores of 10 or more (30%) in this sample exceeds the 11.7% who had scores of 10 or more in Andresen and colleagues’26 original community sample of well, older adults. The data in this study are more similar to Turner and Noh’s28 data with 35% of the older adults with disabilities (≥65 years) and 39% of middle-aged adults (45 to 64 years) with physical disabilities indicating depression on the full CES-D. Those researchers who intend to design and test interventions to reduce depression in patients with heart failure in the future would be advised to measure and target physical symptoms first and foremost and physical functioning as an additional possible variable related to depression. Since patients with heart failure have activity intolerance as a defining characteristic of their illness, measuring physical functioning and physical
102
symptoms could be expected to yield a high degree of overlap for those 2 measures. However, in this study, the CES-D Short Form and the Medical Outcomes Study Short Form Health Survey scale of physical functioning were quite distinct without a high degree of overlap. These distinct measures offered the opportunity to compare the unique contribution of both physical symptoms and physical functioning to depression. Of the 3 predictor variables, Time 1 depression explained the largest amount of the unique variance in subjects’ depression at Time 2. Because there is some stability in depressive symptoms over time, especially in subjects with a chronic illness like heart failure, Time 1 depression was the largest contributor to the variance of depressive symptoms at Time 2. Of the other 2 predictor variables, physical symptoms made a larger unique contribution to the variance in depression than did physical functioning. Previous research with patients with heart failure has not examined these relationships clearly. However, the data from this study could not clearly establish the causal nature of these relationships since some of the group of subjects with decreased physical functioning, increased symptoms, and indications of depression reported impairments in all 3 variables at the onset of the study. More descriptive research could help illuminate the perceptions of patients with heart failure about the development of depression during the course of the illness. Further study is also needed to determine the causal nature of depression in those patients who have depression by beginning with patients at risk for heart failure or those early in the course of heart failure and measuring changes over a longer peri-
MARCH/APRIL 2001
HEART & LUNG
Friedman and Griffin
od. In addition, future research on the impact of treating physical symptoms on both physical functioning and mood would be beneficial to further the understanding and treatment of patients with heart failure.
Implications for nursing practice Heart failure as a chronic illness affects every aspect of daily life and requires continuous adaptation. It has the potential to seriously diminish psychologic well-being in those persons who have difficulty adjusting to the physical alterations the disease causes. Understanding how physical factors such as physical symptoms and physical functioning are related to depression is essential for determining which variables to target for intervention. Establishing nursing interventions that diminish physical symptoms, improve physical functioning, and diminish depression could promote a more comprehensive level of care for patients with heart failure. Although the goal of heart failure management is to diminish symptoms and maximize patients’ functioning, some patients may continue to have symptoms past hospitalization despite receiving maximal treatment. Ongoing symptoms may make a significant group of patients with heart failure susceptible to depressed mood. As a result, all patients with heart failure who have a chronic physical symptom pattern should be screened for concomitant depression that may merit intervention.
Limitations The main limitations of this study are related to the nature of the sample. Although the subjects in this study are generally representative of the patients seen in the participating acute care facilities, they do not represent all patients with heart failure. Patients who were more symptomatic, more depressed, or older may have been the patients who refused to complete the initial interview or failed to complete the second interview. Further examination of the symptom checklist developed by the investigator is needed to more fully determine the reliability and validity of this investigator-developed tool. Further testing and possible modifications of this instrument could assist other researchers interested in the use of a validated and reliable heart failure symptom scale.
CONCLUSION This study showed that patients with heart failure who had increased physical symptoms and poorer physical functioning reported increased symptoms
HEART & LUNG
VOL. 30, NO. 2
Depression in patients with heart failure
of depression. Physical symptoms explained a greater portion of the variance in depression than did physical functioning. Thus, it appears that patients with heart failure are affected emotionally by both their physical symptoms and their limitations in their physical functioning, but depression is more strongly related to having more physical symptoms than having greater limitations in physical functioning. We thank Julie A. Johnson and Kathleen B. King for their comments on an earlier draft of this manuscript and the anonymous reviewers for the Journal. We also thank Patricia Federico-Fields and Kathleen Crowley for their assistance with data collection.
REFERENCES 1. Dracup K, Walden J, Stevenson L, Brecht M. Quality of life in patients with advanced heart failure. J Heart Lung Transplant 1992;11:273-9. 2. Garg R, Packer M, Pitt B, Yusuf S. Heart failure in the 1990’s: evolution of a major health problem in cardiovascular medicine. JACC 1993;22(4):3A-5A. 3. Kannel WB, Belangers AJ. Epidemiology of heart failure. Am Heart J 1991;121:951-7. 4. National Heart, Lung and Blood Institute. Morbidity and mortality chartbook in cardiovascular, lung and blood diseases, 1990. Bethesda (MD): The Institute; 1992. 5. Kannel WB, Ho K, Thom T. Changing epidemiological features of cardiac failure. Brit Heart J 1994;72(Supplement):S3-S9. 6. Schocken DD, Arrieta MI, Leaverton PE. Prevalence and mortality rate of congestive heart failure in the United States. J Am Coll Cardiol 1992;20:301-6. 7. Health Care Financing Administration. National Heart, Lung, and Blood Institute Data Fact Sheet. Available at: http:// www.nhlbi.nih.gov/health/public/heart/other/CHF.txt. Accessed January 12, 2001. 8. Mayou R, Blackwood R, Bryant B, Garnham J. Cardiac failure: symptoms and functional status. J Psychosom Res 1991; 34:399-407. 9. Friedman MM, King K. Correlates of fatigue in older women with heart failure. Heart Lung 1995;24:512-8. 10. McKee P, Castelli W, McNamara P, Kannel W. The natural history of congestive heart failure: the Farmingham Study. New Engl J Med 1971;285:441-6. 11. Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry SD, et al. Functional status and well being of patients with chronic conditions. JAMA 1989;262:907-13. 12. Husaini BA. Predictors of depression among the elderly: racial differences over time. Amer J Orthopsychiatry 1997;67:48-58. 13. Katon W, Sullivan MD. Depression and chronic medical illness. J Clin Psychiatry 1990;51(6):3-10. 14. Nickel JT, Brown KJ, Smith BA. Depression and anxiety among chronically ill heart patients: age differences in risk and predictors. Res Nurs Health 1990;13:87-97. 15. Frerichs RR, Aneshensel CS, Yokopenic PA, Clark VA. Physical health and depression: an epidemiologic survey. Prev Med 1982;11:639-46. 16. Berkman LF, Berkman CS, Kasl S, Freeman Jr DH, Les L, Ostfeld AM, et al. Depressive symptoms in relation to physical health and functioning in the elderly. Am J Epidemiol 1986;124:372-88. 17. Aneshensel CS, Frerichs RR, Huba GJ. Depression and physical illness: a multiwave, nonrecursive causal model. J Health Soc Behav 1984;25:350-71.
103
Depression in patients with heart failure 18. Badger TA. Physical health impairment and depression among older adults. Image J Nurs Sch 1993;25:325-30. 19. Murrell SA, Himmelfarb S, Wright K. Prevalence of depression and its correlates in older adults. Am J Epidemiol 1983;117:173-85. 20. Zeiss AM, Lewinsohn PM, Rohdes P, Seeley JR. Relationship of physical disease and functional impairment to depression in older people. Psychol Aging 1996;11:572-81. 21. Hawthorne MH, Hixon ME. Functional status, mood disturbance and quality of life in patients with heart failure. Prog Cardiovasc Nurs 1994;9(1):22-32. 22. Konstam M, Dracup K, Baker D, et al. Clinical practice guideline no 11: heart failure: evaluation and care of patients with left-ventricular systolic dysfunction. Rockville (MD): Agency for health Care Policy and Research, Public Health Services, US Department of Health and Human Services; 1994. AHCPR Publication No 94-0612.
Friedman and Griffin 23. Friedman MM. Older adults’ symptoms and their duration before hospitalization for heart failure. Heart Lung 1997;26: 169-76. 24. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey. Med Care 1992;30:473-83. 25. Stewart AL, Hays RD, Ware JE. The MOS short-form general health survey. Med Care 1988;26:724-35. 26. Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening for depression in well older adults: evaluation of a short form of the CES-D. Am J Prev Med 1994;10(2):77-84. 27. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Measure 1977;1:385-401. 28. Turner RJ, Noh S. Physical disability and depression: a longitudinal analysis. J Health Soc Behav 1988;29:2337.
AVAILABILITY OF JOURNAL BACK ISSUES As a service to our subscribers, copies of back issues of Heart & Lung: The Journal of Acute and Critical Care for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one-third off on quantities of 24 or more. Please write to Mosby, Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887, or call (800)654-2452 or (407)345-4000 for information on availability of particular issues and prices. If unavailable from the publisher, photocopies of complete issues may be purchased from Bell & Howell Information and Learning, 300 N. Zeeb Rd., Ann Arbor, MI 48106, (734)761-4700 or (800)521-0600.
104
MARCH/APRIL 2001
HEART & LUNG