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Relationships between coronary angiography, mood, anxiety and insomnia
Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Relationships between coronary angiography, mood, anxiety and insomnia Pınar Guzel Ozdemir a,n, Yavuz Selvi b, Murat Boysan c, Mahmut Ozdemir d, Serkan Akdağ e, Fatih Ozturk e a
Yuzuncu Yil University Medicine Faculty, Department of Psychiatry, Van, Turkey Selcuk University, Medicine Faculty, Department of Psychiatry, (SUSAB, Neuroscience Research Unit), Konya, Turkey c Yuzuncu Yil University, School of Science and Arts, Department of Psychology, Van, Turkey d Van Education and Research Hospital, Department of Cardiology, Turkey e Yuzuncu Yil University, Medicine Faculty, Department of Cardiology, Van, Turkey b
art ic l e i nf o
a b s t r a c t
Article history: Received 30 September 2014 Received in revised form 6 May 2015 Accepted 31 May 2015
The purpose of this study was to investigate and compare the anxiety, depression and insomnia levels in the pre- and post-coronary angiography in patients undergoing elective coronary angiography due to suspected coronary artery disease. This prospective cross-sectional study consisted of 120 patients consecutively underwent coronary angiogram (CAG) between January and August 2014 in Departments of Cardiology. The mean age was 57.49 (SD7 9.73), and 58.3% of the sample were women. The Hospital Anxiety and Depression Scale, Profile of Mood States Scale, Spielberger's State-Trait Anxiety Inventory, and Insomnia Severity Index were used. Patients were subsumed under 2 groups as normal and critical according to the presence or the absence of visually severe stenosis in at least one coronary artery. Subjects with significant stenosis had greater mean scores on depression-dejection and anger-hostility sub-scales of the POMS in the post-angiography than pre-angiography scores. We found that older age and having a physical illness significantly contributed to the risk of having significant stenosis in coronary vasculature. Subjects with severe coronary artery stenosis scored higher on depression-dejection and anger-hostility sub-scales at the post-angiography time period relative to pre-angiography scores. Trait and state anxiety levels were found to be moderate higher in both groups. & 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Depression Anxiety Insomnia Coronary artery stenosis
1. Introduction There has been a growing interest in the linkages between psychiatric symptoms and coronary artery disease (CAD). Research points to the adverse effects of negative mood on CAD and vice versa. As the CAD can increase concerns, the diagnosis and treatment methods used in cardiovascular disease may cause anxiety and fear of death as well (Beasley et al., 2003). Coronary angiography (CA) is a method for diagnosing or ruling out CAD and important in deciding on appropriate treatment method. It has become one of the most widely used diagnostic procedures among adults. Several studies have reported that patients experience anxiety prior to coronary angiography (Lundén et al., 2006). n Correspondence to: Yuzuncu Yil University Medicine Faculty, Department of Psychiatry, Van, Turkey, Van 65200, Turkey. Fax: þ 90 4322167519. E-mail addresses: [email protected] (P.G. Ozdemir), [email protected] (Y. Selvi), [email protected] (M. Boysan), [email protected] (M. Ozdemir), [email protected] (F. Ozturk).
It is known that depression and anxiety are risk factors in CAD, and such psychological disorders occur in humans in response to learning that they have a heart disease (Balcı and Enc, 2013). One of the most important causes of anxiety is the lack of knowledge about the diagnosis and treatment methods (Köllner and Bemard, 2006; Karadeniz and Altıparmak, 2005). CA as well as heart disease by itself may increase the level of anxiety in people. Pain and fear of the unknown during the procedure, and the procedure being associated with heart disease make it a source of stress. Depression and anxiety are associated with increased mortality rates, decreased quality of life and increased costs in healthcare of patients with CAD. Incidence of depression and anxiety are also increased in patients with an established diagnosis of CAD, particularly after myocardial infarction (Kent and Shapiro, 2009; Sünbül et al., 2013). In a follow-up study, depression immediate to acute coronary syndrome had detrimental short- and longer-term outcomes (Parker et al., 2011). Although insomnia is prevalent among individuals with psychological distress, the literature on depression and anxiety as risk
http://dx.doi.org/10.1016/j.psychres.2015.05.084 0165-1781/& 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Ozdemir, P.G., et al., Relationships between coronary angiography, mood, anxiety and insomnia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.084i
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factors for CAD morbidity and mortality has largely neglected its potential effects. Instead, research on sleep in patients with heart disease has mainly focused on sleep apnea due to the well-established associations between sleep-disordered breathing (SDB) and cardiovascular morbidity (Coryell et al., 2013). We hypothesized in the current study that an invasive diagnostic procedure such as CA may cause anxiety and insomnia as a result, and insomnia causing anxiety may be completing a vicious cycle. The aim of this study is to investigate and compare the anxiety, depression and insomnia levels before and after coronary angiography in patients undergoing elective coronary angiography for suspected CAD.
Table 1 Demographics for the sample.
2. Study design and methods
Table 2 Logistic regression of demographics and pre-angiography scale scores on coroner artery stenosis.
2.1. Patients This prospective, cross-sectional study consisted of 120 consecutive patients scheduled for elective coronary angiography between January 2014 and July 2014 at the Department of Cardiovascular Diseases in Yüzüncü Yıl University Faculty of Medicine Hospital. Reasons for CA included ongoing chest pain, known CAD and impending acute coronary syndromes. Exclusion criteria were current pregnancy, cardiomyopathy, previous myocardial infarction or any revascularization procedures, history of congenital heart disease, serum creatinine levels 4 2.5 mg/dL, chronic renal failure, and incomplete procedures. A total number of 120 participants were volunteered in the study. All patients were informed about the study protocol and completed written informed consent prior to entering the study. All the participants underwent a baseline examination that included a comprehensive medical interview, medical history questionnaire, psychosocial questionnaire, blood samples and echocardiography. The patients were interviewed and told their results before post-angiography psychological evaluation. According to the results of CA, patients were divided into two groups, normal coronary angiography (CAG) and critical coronary stenosis. The critical coronary stenosis group was defined as patients with coronary artery stenosis equal to or greater than 50% and/or slow flow detected in coronary arteries. The group with normal CAG was defined as patients with normal coronary arteries or stenosis less than 50% (Sharaf et al., 2001). A structured psychiatric interview was conducted immediately before coronary angiography. Socio-demographic data of all patients were recorded. In order to determine the levels of anxiety and depression, the Hospital Anxiety and Depression Scale (HADS), Profile of Mood States Scale (POMS) and Spielberger's State-Trait Anxiety Inventory (STAI) were applied to all participants before coronary angiography. Furthermore, the Insomnia Severity Index (ISI) was completed by all the participants. All scales, except for trait anxiety subscale of the STAI, were reapplied 3 days after CA. 2.2. Psychometric measures 2.2.1. Profile of Mood States Scale (POMS) It is a 65-item scale for quantification of momentary mood profiles and consists of 6 subscales. The original form of the instrument consists of 65 adjectives rated on a 5-point scale from “not at all” to “extremely.” Six sub-scales were derived from these scales: Tension-anxiety, depression-dejection, anger-hostility, fatigue-inertia, vigor-activity, and confusion-bewilderment. A seventh score of total mood disturbance is also calculated by subtracting the score on the one positively scored sub-scale, vigor-activity, from the sum of the other five sub-scales. Psychometric properties of the Turkish version of the POMS were examined in different groups of
Age
(Mean, SD)
M ¼57.49 SD 7 9.73
Sex Coroner artery stenosis (Normal, Critical) Marital status Physical ailment Reason for angiography
Female (N, %) Critical (N, %)
N ¼70 N ¼69
58.33% 57.50%
Married (N, %) Health problem (N, %) Myocardial infarction (N, %) Cardiovascular disease (N, %) Chest pain (N, %)
N ¼115 N ¼29 N ¼5
95.83% 24.17% 4.17%
N ¼29
24.17%
N ¼86
71.67%
Age Sex Marital status Physical ailment Depression-dejection Tension-anxiety Anger-hostility Confusion-bewilderment Fatigue-inertia Vigor-activity Insomnia Severity Index HADS-depression HADS-anxiety State anxiety Trait anxiety
Odds ratio
95% CI
P
1.07 1.18 0.38 5.00 1.02 1.00 1.00 0.85 1.01 0.98 0.99 1.00 1.10 1.02 1.01
1.02–1.12 0.47–2.94 0.05–2.75 1.27–19.75 0.93–1.12 0.89–1.12 0.90–1.12 0.73–0.98 0.93–1.10 0.88–1.08 0.91–1.08 0.84–1.18 0.94–1.28 0.95–1.10 0.94–1.09
0.010 0.723NS 0.337NS 0.022 0.710NS 0.965NS 0.968NS 0.026 0.775NS 0.629NS 0.845NS 0.951NS 0.222NS 0.577NS 0.739NS
HADS: Hospital Anxiety and Depression Scale. NS: non-significant.
participants. The sub-scales of the POMS had high internal reliability, ranging from 0.81 to 0.91 (Agargun et al., 2003; Selvi et al., 2011). Research has utilized the POMS subscales as well as the POMS total mood disturbance (TMD) score. The TMD is an index of overall distress that is obtained by summing all subscale scores except for the score on the vigor/activity subscale; the latter subscale score is subtracted from the sum of the other subscales. 2.2.2. Insomnia Severity Index (ISI) It is is a brief and easy to complete questionnaire and highly valid and reliably measurement device developed for evaluation of insomnia severity (Bastien et al., 2001; Yang et al., 2009). Items evaluated are as follows, sleep maintenance, sleep onset, early morning awakening difficulty, satisfaction with current sleep pattern, sleep difficulties, interference with daily functioning, noticeability of sleep problems by others, distress caused by insomnia and, appearance of impairment attributed to the sleep problem. The ISI consists of 7 items with responses ranging from 0 to 4, producing total scores of 0–28. Total ISI scores are categorized into: no clinically significant insomnia (0–7), subthreshold insomnia mild (8–14), moderate clinical insomnia (15–21), and severe clinical insomnia (22–28). Good psychometric properties for the ISI in a Turkish sample were reported. Internal reliability was α ¼ 0.79 and two-week retest reliability was r¼ 0.82 (Boysan et al., 2010). 2.2.3. Hospital Anxiety and Depression Scale (HADS) The HADS is a 14-item self-report questionnaire particularly designed to screen physically ill patients (Zigmond and Snaith, 1983). It is comprising 4-point Likert- scaled items covering the occurrence of symptoms of anxiety (HADS-A) and depression (HADS-D). The depression scale consists of seven items, with
Please cite this article as: Ozdemir, P.G., et al., Relationships between coronary angiography, mood, anxiety and insomnia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.084i
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Table 3 ANOVA comparisons between coroner artery contraction levels. Coroner Artery Stenosis Normal
Depression-dejection Depression-dejection Tension-anxiety Tension-anxiety Anger-hostility Anger-hostility Confusion-bewilderment Confusion-bewilderment Fatigue-inertia Fatigue-inertia Vigor-activity Vigor-activity POMS Global POMS Global Insomnia Severity Index Insomnia Severity Index HADS-depression HADS-depression HADS-anxiety HADS-anxiety State anxiety State anxiety Trait anxiety
Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography
F(1, 118)
P
η2
0.944 1.695 0.014 0.311 0.472 1.204 2.027 0.030 0.332 0.015 6.499 1.967 0.766 1.714 2.338 0.642 1.635 5.537 5.750 3.187 2.256 0.096 1.086
0.333NS 0.195NS 0.906NS 0.578NS 0.493NS 0.275NS 0.157NS 0.862NS 0.566NS 0.901NS 0.012 0.163NS 0.383NS 0.193NS 0.129NS 0.424NS 0.203NS 0.020 0.018 0.077NS 0.136NS 0.757NS 0.299NS
0.008 0.014 0.000 0.003 0.004 0.010 0.017 0.000 0.003 0.000 0.052 0.016 0.006 0.014 0.019 0.005 0.014 0.045 0.046 0.026 0.019 0.001 0.009
Critical
Mean
SD
Mean
SD
18.84 20.14 16.24 15.98 15.84 16.65 11.98 11.35 11.02 10.78 18.82 18.39 55.10 56.51 6.80 6.75 9.53 9.31 9.49 9.51 41.22 43.92 48.35
7.72 8.45 5.54 5.85 6.64 8.26 4.35 4.04 4.73 5.39 4.78 4.66 25.68 27.01 5.28 5.36 3.22 3.22 3.48 3.26 6.01 5.63 6.63
20.35 22.48 16.12 16.54 16.71 18.38 10.86 11.49 11.83 10.90 16.38 16.93 59.48 62.86 5.28 5.87 10.20 10.91 10.94 10.54 43.09 43.58 47.01
8.85 10.58 5.40 5.03 6.98 8.73 4.23 4.55 9.12 4.65 5.48 6.29 28.10 25.67 5.51 6.29 2.55 3.99 3.12 3.00 7.24 6.21 7.18
POMS: ProfiCod States Scale. ISI: Insomnia Severity Index. HADS: Hospital Anxiety and Depression Scale. NS: non-significant.
depression scores ranging from 0 to 21 and with higher scores indicating higher intensity. The HADS was specifically designed to avoid false-positives when administered in hospital settings and therefore focuses on psychological and cognitive symptoms, rather than somatic symptoms. The HADS was demonstrated to have good validity and reliability in Turkish population. In the reliability study, cronbach's alpha coefficient was 0.85 for anxiety subscale and 0.77 for depression subscale (Aydemir et al., 1997). 2.2.4. State-Trait Anxiety Inventory Test (STAI) The STAI was developed to determine the levels of anxiety symptoms (Spielberger and Saroson 1976). Reliability and validity of the STAI in Turkish population were shown by Öner and Le Compte (1985). The STAI consists of two scales designed to provide separate assessment of the temporary condition of the state anxiety (STAI-1) and of the more general and long-standing quality of trait anxiety (STAI-2). The STAI-1 requires an individual describe how he/she feels at a specific time and in a specific circumstance and takes into account his/her feelings relevant to the situation under consideration. The trait anxiety scale requires the individual to rate generally how he/she feels. Cronbach's alpha coefficient was between 0.83 and 0.87 for trait anxiety inventory and 0.94 and 0.96 for state anxiety in studies. Scores range from 20 to 80 for each scale, higher the scores are rated, greater the anxiety is.
2.4. Coronary angiography Before diagnostic coronary angiography, all patients underwent stress electrocardiography, myocardial perfusion scintigraphy, or (for high-risk patients) symptomatic assessment. Selective coronary angiography by means of the conventional Judkins technique and left ventriculography were performed in all patients. Each angiogram was interpreted by 2 cardiologists who were not aware of the psychiatric diagnosis. A significant obstructive atherosclerotic lesion was defined as stenosis equal to or greater than 50% of the luminal diameter in 1 or more coronary arteries. 2.5. Statistical analysis Following descriptive statistics, logistic regression analysis was performed in which coronary artery stenosis was the dependent variable and demographics and pre-angiography scale scores, namely POMS sub-scales, ISI, HADS, and STAI scores were the independent variables. We performed comparisons of scale scores between the study groups using one-way analysis of variance. We assessed change in mood, sleep, hospital anxiety and depression, and state anxiety in the course of the angiography through repeated measure analysis of variance (rANOVA) comparisons between pre- and post-angiography scale scores. The statistical significance threshold was po.05.
3. Results 2.3. Approval by the ethics committee
3.1. Descriptive statistics
The study was carried out according to the declaration of Helsinki and approved by the Clinical Ethics and Research Committee of the Yuzuncu Yil University, Faculty of Medicine. All participants signed a consent form declaring that they had been properly informed of the purposes of the study. They were not paid for their participation.
In total, 120 patients were enrolled in the study. Sixty-nine patients had critical stenosis in CA while 51 patients had normal findings. Mean age for the sample was 57.49 (SD 79.73). 58.3% of the sample consisted of women (N ¼69); 57.5% had significant stenosis in CA; virtually all of the study participants were married
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Table 4 Repeated ANOVA comparisons between pre-angiography and post-angiography scale scores. Time Periods Pre-angiography
Post-angiography
Mean
SD
Mean
SD
F
df
P
η2
Depression-dejection
Normal Critical Total
18.84 20.35 19.71
7.72 8.85 8.39
20.14 22.48 21.48
8.45 10.58 9,77
1.999 4.150 6.173
1, 50 1, 68 1, 119
0.164NS 0.046 0.014
0.038 0.058 0.049
Tension-anxiety
Normal Critical Total
16.24 16.12 16.17
5.54 5.40 5.44
15.98 16.54 16.30
5.85 5.03 5.38
0.194 0.700 0.124
1, 50 1, 68 1, 119
0.661NS 0.406NS 0.726NS
0.004 0.010 0.001
Anger-hostility
Normal Critical Total
15.84 16.71 16.34
6.64 6.98 6.82
16.65 18.38 17,64
8.26 8.73 8.54
0.702 4.613 4.647
1, 50 1, 68 1, 119
0.406NS 0.035 0.033
0.014 0.064 0.038
Confusion-bewilderment
Normal Critical Total
11.98 10.86 11.33
4.35 4.23 4,30
11.35 11.49 11,43
4.04 4.55 4,32
1.165 1.281 0.060
1, 50 1, 68 1, 119
0.286NS 0.262NS 0.808NS
0.023 0.018 0.001
Fatigue-inertia
Normal Critical Total
11.02 11.83 11.48
4.73 9.12 7.56
10.78 10.90 10.85
5.39 4.65 4.96
0.124 0.797 0.921
1, 50 1, 68 1, 119
0.726NS 0.375NS 0.339NS
0.002 0.012 0.008
Vigor-activity
Normal Critical Total
18.82 16.38 17.42
4.78 5.48 5.32
18.39 16.93 17,55
4.66 6.29 5.68
0.653 0.709 0.092
1, 50 1, 68 1, 119
0.423NS 0.403NS 0.762NS
0.013 0.010 0.001
POMS Global
Normal Critical Total
55.10 59.48 57.62
25.68 28.10 27.07
56.51 62.86 60.16
27.01 25.67 26.32
0.242 1.936 1.894
1, 50 1, 68 1, 119
0.625NS 0.169NS 0.171NS
0.005 0.028 0.016
ISI
Normal Critical Total
6.80 5.28 5.93
5.28 5.51 5.44
6.75 5.87 6.24
5.36 6.29 5.91
0.023 1.492 0.947
1, 50 1, 68 1, 119
0.881NS 0.226NS 0.332NS
o .001 0.021 0.008
HADS-depression
Normal Critical Total
9.53 10.20 9.92
3.22 2.55 2.86
9.31 10.91 10.23
3.22 3.99 3.75
0.558 2.324 1.140
1, 50 1, 68 1, 119
0.459NS 0.132NS 0.288NS
0.011 0.033 0.009
HADS-anxiety
Normal Critical Total
9.49 10.94 10.33
3.48 3.12 3.34
9.51 10.54 10.10
3.26 3.00 3.14
0.003 1.132 0.681
1, 50 1, 68 1, 119
0.959NS 0.291NS 0.411NS
o .001 0.016 0.006
State anxietya
Normal Critical Total
41.22 43.09 42.29
6.01 7.24 6.78
43.92 43.58 43.72
5.63 6.21 5.95
5.911 0.548 3.292
1, 50 1, 68 1, 119
0.019 0.462NS 0.072NS
0.108 0.008 0.027
POMS: Profile of Mood States Scale. ISI: Insomnia Severity Index. HADS: Hospital Anxiety and Depression Scale. a Pre- and post-application state anxiety scores compared using one-way repeated measure analysis of covariance analysis (rANCOVA) in which trait anxiety scores were put as covariate into the model.
(95.8%); and 24% had a physical illness. Majority of the subjects reported having chest pain (71.6%), 24% had previous history of cardiovascular disease, and 4% of the sample reported prior myocardial infarction. Table 1 reports demographics for the sample. 3.2. Risk factors for critical coronary stenosis in CA To explore the predictors of significant stenosis in CA, we constructed a logistic regression model in which age, sex, marital status, and physical ailment were independent variables as well as preangiography scores of the POMS sub-scales, ISI, HADS, and STAI. In
this regression analysis, we found that older age (OR¼1.07, 95% Cl¼1.02–1.12, po0.05) and having another physical illness (OR¼5.00 95%Cl¼1.27–19.75, po0.05) significantly contributed to the risk for coronary artery stenosis. Subjects without a significant coronary artery stenosis reported significantly higher scores on the confusion-bewilderment sub-scale of the POMS (OR¼0.85 95% Cl¼0.73–0.98, po0.05). The findings can be seen in Table 2. 3.3. Comparisons of scale scores between the study groups We compared scale scores between normal and significant coronary artery stenosis groups on the POMS Global and
Please cite this article as: Ozdemir, P.G., et al., Relationships between coronary angiography, mood, anxiety and insomnia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.084i
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Fig. 1. (a) Bars in the diagram represents the mean scores of Depression Dejection subscale of the POMS observed in the pre-angiography and post-angiography by coronary artery stenosis levels. (b) Bars in the diagram represents the mean scores of Anger-Hostility subscale of the POMS observed in the pre-angiography and post-angiography by coronary artery stenosis levels.
sub-scales, ISI, HADS, and STAI administered in the pre- and postangiography periods by running separate one-way analysis of variance. Subjects with significant coronary artery stenosis reported lower pre-angiography vigor-activity scores (F(1,118) ¼ 6.499, po 0.05, η2 ¼0.052), higher pre-angiography hospital anxiety (F(1,118) ¼ 5.750, po .05 η2 ¼0.046) and post-angiography hospital depression scores (F(1,118) ¼ 5.537, p o0.05, η2 ¼0.045). ANOVA results appear in Table 3. 3.4. Comparisons of pre- and post-angiography scale scores To explore the mood changes, sleep, hospital anxiety and depression, state anxiety during the course of the angiography, we compared pre- and post-angiography scores of subjects using repeated analysis of variance (rANOVA). Subjects with critical coronary artery stenosis scored higher on depression-dejection (F (1,68) ¼4.150, po .05, η2 ¼0.058) and anger-hostility (F(1,68) ¼ 4.613, p o0.05, η2 ¼0.064) sub-scales at the post-angiography time period relative to pre-angiography scores. Pre- and post-angiography state anxiety scores compared using an analysis of covariance model in which pre-angiography trait anxiety was covariate. Subjects without critical stenosis in CA had greater state anxiety in the post-angiography (F(1,50) ¼ 5.911, p o0.05, η2 ¼0.108) than pre-angiography compared with pre- and post-angiography scores of subject with coronary artery contraction. Findings are presented in Table 4 and plotted in Figs. 1a and 2a. Additionally, we analyzed the change on scores of vigor-activity subscale of the POMS and anxiety subscale of the HADS through one-way analysis of covariance analysis (ANCOVA) due to the substantial differences between normal and critical groups in preangiography measures. Having adjusted for the pre-treatment scores, the ANCOVA result for either vigor-activity subscale of the POMS (F(1, 117) ¼ 0.034; p¼ 0.854) or anxiety subscale of the HADS (F(1, 117) ¼2.742; p¼ 0.100) was not significant as well. 3.5. Gender differences on scale scores We performed one-way ANOVA to compare both pre- and postangiography scale scores among genders and ran rANOVA to explore changes in mood, sleep, hospital anxiety and depression, and state anxiety scores in the course of the angiography. We could not find any difference between two genders on either pre- or postangiography scale scores. On the contrary, women had greater
score on depression-dejection than that of men (F(1, 69) ¼4.572; po .05; partial η2 ¼ .062), anger-hostility (F(1, 69) ¼5.774; p o.05; partial η2 ¼.077) and global scores of the POMS (F(1, 69) ¼4.053; po .05; partial η2 ¼.055). Findings are plotted in Fig. 2a–c.
4. Discussion The results of this prospective study can be summarized as follows: (i) patients with severe coronary stenosis had higher preangiographic hospital anxiety and post-angiographic hospital depression scores, lower pre-angiographic vigor-activity scores, than those with normal coronary artery, (ii) subjects with severe coronary artery stenosis had higher scores on depression-dejection and anger-hostility sub-scales in the post-angiography period relative to the scores during the pre-angiography, (iii) patients with normal coronary arteries had higher state anxiety scores in the post-angiographic phase than pre-angiographic phase, while state anxiety scores in severe coronary stenosis group were comparable during pre- and post-angiographic stages, (iv) either pre- or postangiography scale scores did not differ significantly due to gender with an exception that women had greater mean score on depression-dejection subscale of the POMS than those of men. Patients with CAD have severe stressful life experiences. As it is well-established that stressful events typically reveal significant emotional responses and exposure to stress leads to the dysregulation of emotions, which in turn shows negative psychological and physiological health outcomes (Compare et al., 2014a,b). Several studies have investigated possible associations between psychological variables and CAD in patients who have undergone CA, and reported conflicting results (Valkamo et al., 2001; Marzari et al., 2005). On the other hand, to date, there has been a paucity of studies investigating quantitative indicators of and differences in mood, anxiety and insomnia during the pre- and post-coronary angiography yet. The studies assessing depression or anxiety before CA mainly focused on finding the risk factors influencing CAD. Depressive symptomatology poses an increased risk of CAD in men regardless of health behavior, social isolation, and clinical determinants (Marzari et al., 2005). In fact, a stronger relation between clinically defined depression and outcomes of CAD (either fatal or combined fatal and nonfatal) has been found. Individuals with depressed mood and with clinical depression had virtually 2and 3-fold greater risk for CAD, respectively (Rugulies, 2002). It
Please cite this article as: Ozdemir, P.G., et al., Relationships between coronary angiography, mood, anxiety and insomnia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.084i
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Fig. 2. (a) Bars in the diagram represents the mean scores of Depression-Dejection subscale of the POMS observed in the pre-angiography and post-angiography by gender. (b) Bars in the diagram represents the mean scores of Anger-Hostility subscale of the POMS observed in the pre-angiography and post-angiography by gender. (c) Bars in the diagram represents the mean global scores of the POMS observed in the pre-angiography and post-angiography by gender.
was also reported that anxiety and depressive symptoms at cardiac catheterization predicts impairment in physical role of future functioning regardless of the severity of coronary heart disease (Sullivan et al., 2000). Furthermore, Druss et al., pointed out that elderly patients with mental disorders were less likely to accept angiography after myocardial infarction (Druss et al., 2000). Anxiety may also occur due to the circumstances prior to CA. Most of the elective patients with minimal waiting times reported low anxiety levels (Astin et al., 2005); on the contrary, patients who had to live with anginal symptoms while waiting for several weeks to months before the procedure exhibited greater levels of anxiety (Harkness et al., 2003; Uzun et al., 2008; Grunberg et al., 2003). If the patients underwent to a psychoeducation where detailed information is provided, anxiety in these individuals would decline during application of the procedure (Gallagher et al., 2010; Harkness et al., 2003). In our study, all patients received a usual care in the pre-coronary angiography period and had moderate anxiety during pre- and post-coronary angiography. The finding was consistent with previous research which found that almost half of the patients were moderately anxious (Valkamo
et al., 2001). Surprisingly, participants without a significant stenosis in coronary artery had greater state anxiety in the post-angiography period than pre-angiography comparable to pre- and post-angiography scores of subjects with significant coronary stenosis. Nevertheless, patients with significant coronary stenosis were more anxious as compared to others. The state anxiety is more important in evaluating effects of a specific event on anxiety levels. In comparison, trait anxiety depends on the person himself and is indicative of individual's predisposition in the face of adverse events. Furthermore, it was confirmed that trait anxiety increased the state anxiety and trait anxiety cannot be immediately observed but is manifested as state anxiety when experiencing stress (Reiss, 1997). In our study, trait anxiety was only measured in the pre-angiography as a control variable and we observed that the patients' state anxiety was not due to the angiography after controlling for trait anxiety. The evidence has arised from multiple sources that psychological factors like mood disturbances adversely affect mortality in patients with CAD after controlling for differences in underlying disease severity. Park et al. (2012) evaluated whether percutaneous coronary
Please cite this article as: Ozdemir, P.G., et al., Relationships between coronary angiography, mood, anxiety and insomnia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.084i
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intervention (PCI) was associated with the development of depressive symptoms. 171 CAD patients were enrolled in the study, and 63 (37%) cases were assigned to the PCI group predicated on angiography. Accordingly, PCI was independently predictive to higher risk of developing depressive symptoms in CAD patients during hospitalization. Carney et al. (1990) addressed 100 patients who had chest pain referred for coronary angiography for suspected coronary heart disease through a Diagnostic Interview Schedule to assess psychiatric conditions the day before catheterization. Virtually half of the patients with chest pain but without angiographic findings for significant coronary heart disease were diagnosed as suffering from either major depression or a panic disorder, or both. The ratewere greater than did the patients with coronary heart disease. In our study, subjects with significant coronary artery stenosis reported lower pre-angiography vigor-activity scores, greater pre-angiography hospital anxiety and post-angiography hospital depression scores. In comparing pre- and post- angiography scores; patients with critical levels of coronary artery stenosis scored greater on depression dejection and anger-hostility sub-scales in the post-angiography period relative to pre-angiography period. Epidemiological investigations have demonstrated that depression or anxiety can be predictive of the prevalence of CAD in healthy community populations (Ferketich et al., 2000). In a recent review Compare et al. (2013) analyzed the relationships between depression, social support and health outcomes in patients with heart disease and reported that depressive symptoms and the absence of social or marital support are significant risk factors for poor prognosis in cardiac patients (Compare et al., 2013). Additionally, another important article found tight relationships between anxiety, social support and cardiac diseases (Zarbo et al., 2013). In a previous study, Vural et al. (2009) showed that depression was associated with increased abnormal coronary angiographic findings; whilst the linkage between anxiety and CAD was not significant. Depression and anxiety can also be predictive of worse prognosis of known CAD (Smith and Ruiz 2002). Moreover, Sullivan et al.'s analyzed data have demonstrated of that the levels of depressive symptomatology was generally improving throughout the first year in the post-angiography and remained quite stable thereafter (Sullivan et al., 1997, 2000). In terms of risk factors for coronary stenosis, angerpersonality and social inhibition were associated with an increased prevalence and severity of coronary artery plaque (Compare et al., 2013). We found that older age and having a physical ailment significantly contributed to the risk for coronary artery stenosis. This study has several shortcomings. Firstly, our sample size was relatively small and a single center therefore; our findings can be reexamined in more representative samples. Replication study with a larger sample in a longitudinal follow-up research design is needed.
5. Conclusion This study identified that a significant proportion of patients had moderate anxiety before coronary angiography. Older age and having another physical illness significantly contributed to the risk for coronary artery stenosis. Critical levels of coronary artery stenosis increased depression-dejection and anger-hostility scores. Given the negative effects of anxiety, understanding patients' concerns and anxiety and responding to these concerns is essential in the preprocedure phase. Conflict of interest We do not declare any conflict of interest.
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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Relationships between coronary angiography, mood, anxiety and insomnia Pınar Guzel Ozdemir a,n, Yavuz Selvi b, Murat Boysan c, Mahmut Ozdemir d, Serkan Akdağ e, Fatih Ozturk e a
Yuzuncu Yil University Medicine Faculty, Department of Psychiatry, Van, Turkey Selcuk University, Medicine Faculty, Department of Psychiatry, (SUSAB, Neuroscience Research Unit), Konya, Turkey c Yuzuncu Yil University, School of Science and Arts, Department of Psychology, Van, Turkey d Van Education and Research Hospital, Department of Cardiology, Turkey e Yuzuncu Yil University, Medicine Faculty, Department of Cardiology, Van, Turkey b
art ic l e i nf o
a b s t r a c t
Article history: Received 30 September 2014 Received in revised form 6 May 2015 Accepted 31 May 2015
The purpose of this study was to investigate and compare the anxiety, depression and insomnia levels in the pre- and post-coronary angiography in patients undergoing elective coronary angiography due to suspected coronary artery disease. This prospective cross-sectional study consisted of 120 patients consecutively underwent coronary angiogram (CAG) between January and August 2014 in Departments of Cardiology. The mean age was 57.49 (SD7 9.73), and 58.3% of the sample were women. The Hospital Anxiety and Depression Scale, Profile of Mood States Scale, Spielberger's State-Trait Anxiety Inventory, and Insomnia Severity Index were used. Patients were subsumed under 2 groups as normal and critical according to the presence or the absence of visually severe stenosis in at least one coronary artery. Subjects with significant stenosis had greater mean scores on depression-dejection and anger-hostility sub-scales of the POMS in the post-angiography than pre-angiography scores. We found that older age and having a physical illness significantly contributed to the risk of having significant stenosis in coronary vasculature. Subjects with severe coronary artery stenosis scored higher on depression-dejection and anger-hostility sub-scales at the post-angiography time period relative to pre-angiography scores. Trait and state anxiety levels were found to be moderate higher in both groups. & 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Depression Anxiety Insomnia Coronary artery stenosis
1. Introduction There has been a growing interest in the linkages between psychiatric symptoms and coronary artery disease (CAD). Research points to the adverse effects of negative mood on CAD and vice versa. As the CAD can increase concerns, the diagnosis and treatment methods used in cardiovascular disease may cause anxiety and fear of death as well (Beasley et al., 2003). Coronary angiography (CA) is a method for diagnosing or ruling out CAD and important in deciding on appropriate treatment method. It has become one of the most widely used diagnostic procedures among adults. Several studies have reported that patients experience anxiety prior to coronary angiography (Lundén et al., 2006). n Correspondence to: Yuzuncu Yil University Medicine Faculty, Department of Psychiatry, Van, Turkey, Van 65200, Turkey. Fax: þ 90 4322167519. E-mail addresses: [email protected] (P.G. Ozdemir), [email protected] (Y. Selvi), [email protected] (M. Boysan), [email protected] (M. Ozdemir), [email protected] (F. Ozturk).
It is known that depression and anxiety are risk factors in CAD, and such psychological disorders occur in humans in response to learning that they have a heart disease (Balcı and Enc, 2013). One of the most important causes of anxiety is the lack of knowledge about the diagnosis and treatment methods (Köllner and Bemard, 2006; Karadeniz and Altıparmak, 2005). CA as well as heart disease by itself may increase the level of anxiety in people. Pain and fear of the unknown during the procedure, and the procedure being associated with heart disease make it a source of stress. Depression and anxiety are associated with increased mortality rates, decreased quality of life and increased costs in healthcare of patients with CAD. Incidence of depression and anxiety are also increased in patients with an established diagnosis of CAD, particularly after myocardial infarction (Kent and Shapiro, 2009; Sünbül et al., 2013). In a follow-up study, depression immediate to acute coronary syndrome had detrimental short- and longer-term outcomes (Parker et al., 2011). Although insomnia is prevalent among individuals with psychological distress, the literature on depression and anxiety as risk
http://dx.doi.org/10.1016/j.psychres.2015.05.084 0165-1781/& 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Ozdemir, P.G., et al., Relationships between coronary angiography, mood, anxiety and insomnia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.084i
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factors for CAD morbidity and mortality has largely neglected its potential effects. Instead, research on sleep in patients with heart disease has mainly focused on sleep apnea due to the well-established associations between sleep-disordered breathing (SDB) and cardiovascular morbidity (Coryell et al., 2013). We hypothesized in the current study that an invasive diagnostic procedure such as CA may cause anxiety and insomnia as a result, and insomnia causing anxiety may be completing a vicious cycle. The aim of this study is to investigate and compare the anxiety, depression and insomnia levels before and after coronary angiography in patients undergoing elective coronary angiography for suspected CAD.
Table 1 Demographics for the sample.
2. Study design and methods
Table 2 Logistic regression of demographics and pre-angiography scale scores on coroner artery stenosis.
2.1. Patients This prospective, cross-sectional study consisted of 120 consecutive patients scheduled for elective coronary angiography between January 2014 and July 2014 at the Department of Cardiovascular Diseases in Yüzüncü Yıl University Faculty of Medicine Hospital. Reasons for CA included ongoing chest pain, known CAD and impending acute coronary syndromes. Exclusion criteria were current pregnancy, cardiomyopathy, previous myocardial infarction or any revascularization procedures, history of congenital heart disease, serum creatinine levels 4 2.5 mg/dL, chronic renal failure, and incomplete procedures. A total number of 120 participants were volunteered in the study. All patients were informed about the study protocol and completed written informed consent prior to entering the study. All the participants underwent a baseline examination that included a comprehensive medical interview, medical history questionnaire, psychosocial questionnaire, blood samples and echocardiography. The patients were interviewed and told their results before post-angiography psychological evaluation. According to the results of CA, patients were divided into two groups, normal coronary angiography (CAG) and critical coronary stenosis. The critical coronary stenosis group was defined as patients with coronary artery stenosis equal to or greater than 50% and/or slow flow detected in coronary arteries. The group with normal CAG was defined as patients with normal coronary arteries or stenosis less than 50% (Sharaf et al., 2001). A structured psychiatric interview was conducted immediately before coronary angiography. Socio-demographic data of all patients were recorded. In order to determine the levels of anxiety and depression, the Hospital Anxiety and Depression Scale (HADS), Profile of Mood States Scale (POMS) and Spielberger's State-Trait Anxiety Inventory (STAI) were applied to all participants before coronary angiography. Furthermore, the Insomnia Severity Index (ISI) was completed by all the participants. All scales, except for trait anxiety subscale of the STAI, were reapplied 3 days after CA. 2.2. Psychometric measures 2.2.1. Profile of Mood States Scale (POMS) It is a 65-item scale for quantification of momentary mood profiles and consists of 6 subscales. The original form of the instrument consists of 65 adjectives rated on a 5-point scale from “not at all” to “extremely.” Six sub-scales were derived from these scales: Tension-anxiety, depression-dejection, anger-hostility, fatigue-inertia, vigor-activity, and confusion-bewilderment. A seventh score of total mood disturbance is also calculated by subtracting the score on the one positively scored sub-scale, vigor-activity, from the sum of the other five sub-scales. Psychometric properties of the Turkish version of the POMS were examined in different groups of
Age
(Mean, SD)
M ¼57.49 SD 7 9.73
Sex Coroner artery stenosis (Normal, Critical) Marital status Physical ailment Reason for angiography
Female (N, %) Critical (N, %)
N ¼70 N ¼69
58.33% 57.50%
Married (N, %) Health problem (N, %) Myocardial infarction (N, %) Cardiovascular disease (N, %) Chest pain (N, %)
N ¼115 N ¼29 N ¼5
95.83% 24.17% 4.17%
N ¼29
24.17%
N ¼86
71.67%
Age Sex Marital status Physical ailment Depression-dejection Tension-anxiety Anger-hostility Confusion-bewilderment Fatigue-inertia Vigor-activity Insomnia Severity Index HADS-depression HADS-anxiety State anxiety Trait anxiety
Odds ratio
95% CI
P
1.07 1.18 0.38 5.00 1.02 1.00 1.00 0.85 1.01 0.98 0.99 1.00 1.10 1.02 1.01
1.02–1.12 0.47–2.94 0.05–2.75 1.27–19.75 0.93–1.12 0.89–1.12 0.90–1.12 0.73–0.98 0.93–1.10 0.88–1.08 0.91–1.08 0.84–1.18 0.94–1.28 0.95–1.10 0.94–1.09
0.010 0.723NS 0.337NS 0.022 0.710NS 0.965NS 0.968NS 0.026 0.775NS 0.629NS 0.845NS 0.951NS 0.222NS 0.577NS 0.739NS
HADS: Hospital Anxiety and Depression Scale. NS: non-significant.
participants. The sub-scales of the POMS had high internal reliability, ranging from 0.81 to 0.91 (Agargun et al., 2003; Selvi et al., 2011). Research has utilized the POMS subscales as well as the POMS total mood disturbance (TMD) score. The TMD is an index of overall distress that is obtained by summing all subscale scores except for the score on the vigor/activity subscale; the latter subscale score is subtracted from the sum of the other subscales. 2.2.2. Insomnia Severity Index (ISI) It is is a brief and easy to complete questionnaire and highly valid and reliably measurement device developed for evaluation of insomnia severity (Bastien et al., 2001; Yang et al., 2009). Items evaluated are as follows, sleep maintenance, sleep onset, early morning awakening difficulty, satisfaction with current sleep pattern, sleep difficulties, interference with daily functioning, noticeability of sleep problems by others, distress caused by insomnia and, appearance of impairment attributed to the sleep problem. The ISI consists of 7 items with responses ranging from 0 to 4, producing total scores of 0–28. Total ISI scores are categorized into: no clinically significant insomnia (0–7), subthreshold insomnia mild (8–14), moderate clinical insomnia (15–21), and severe clinical insomnia (22–28). Good psychometric properties for the ISI in a Turkish sample were reported. Internal reliability was α ¼ 0.79 and two-week retest reliability was r¼ 0.82 (Boysan et al., 2010). 2.2.3. Hospital Anxiety and Depression Scale (HADS) The HADS is a 14-item self-report questionnaire particularly designed to screen physically ill patients (Zigmond and Snaith, 1983). It is comprising 4-point Likert- scaled items covering the occurrence of symptoms of anxiety (HADS-A) and depression (HADS-D). The depression scale consists of seven items, with
Please cite this article as: Ozdemir, P.G., et al., Relationships between coronary angiography, mood, anxiety and insomnia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.084i
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Table 3 ANOVA comparisons between coroner artery contraction levels. Coroner Artery Stenosis Normal
Depression-dejection Depression-dejection Tension-anxiety Tension-anxiety Anger-hostility Anger-hostility Confusion-bewilderment Confusion-bewilderment Fatigue-inertia Fatigue-inertia Vigor-activity Vigor-activity POMS Global POMS Global Insomnia Severity Index Insomnia Severity Index HADS-depression HADS-depression HADS-anxiety HADS-anxiety State anxiety State anxiety Trait anxiety
Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography Post-angiography Pre-angiography
F(1, 118)
P
η2
0.944 1.695 0.014 0.311 0.472 1.204 2.027 0.030 0.332 0.015 6.499 1.967 0.766 1.714 2.338 0.642 1.635 5.537 5.750 3.187 2.256 0.096 1.086
0.333NS 0.195NS 0.906NS 0.578NS 0.493NS 0.275NS 0.157NS 0.862NS 0.566NS 0.901NS 0.012 0.163NS 0.383NS 0.193NS 0.129NS 0.424NS 0.203NS 0.020 0.018 0.077NS 0.136NS 0.757NS 0.299NS
0.008 0.014 0.000 0.003 0.004 0.010 0.017 0.000 0.003 0.000 0.052 0.016 0.006 0.014 0.019 0.005 0.014 0.045 0.046 0.026 0.019 0.001 0.009
Critical
Mean
SD
Mean
SD
18.84 20.14 16.24 15.98 15.84 16.65 11.98 11.35 11.02 10.78 18.82 18.39 55.10 56.51 6.80 6.75 9.53 9.31 9.49 9.51 41.22 43.92 48.35
7.72 8.45 5.54 5.85 6.64 8.26 4.35 4.04 4.73 5.39 4.78 4.66 25.68 27.01 5.28 5.36 3.22 3.22 3.48 3.26 6.01 5.63 6.63
20.35 22.48 16.12 16.54 16.71 18.38 10.86 11.49 11.83 10.90 16.38 16.93 59.48 62.86 5.28 5.87 10.20 10.91 10.94 10.54 43.09 43.58 47.01
8.85 10.58 5.40 5.03 6.98 8.73 4.23 4.55 9.12 4.65 5.48 6.29 28.10 25.67 5.51 6.29 2.55 3.99 3.12 3.00 7.24 6.21 7.18
POMS: ProfiCod States Scale. ISI: Insomnia Severity Index. HADS: Hospital Anxiety and Depression Scale. NS: non-significant.
depression scores ranging from 0 to 21 and with higher scores indicating higher intensity. The HADS was specifically designed to avoid false-positives when administered in hospital settings and therefore focuses on psychological and cognitive symptoms, rather than somatic symptoms. The HADS was demonstrated to have good validity and reliability in Turkish population. In the reliability study, cronbach's alpha coefficient was 0.85 for anxiety subscale and 0.77 for depression subscale (Aydemir et al., 1997). 2.2.4. State-Trait Anxiety Inventory Test (STAI) The STAI was developed to determine the levels of anxiety symptoms (Spielberger and Saroson 1976). Reliability and validity of the STAI in Turkish population were shown by Öner and Le Compte (1985). The STAI consists of two scales designed to provide separate assessment of the temporary condition of the state anxiety (STAI-1) and of the more general and long-standing quality of trait anxiety (STAI-2). The STAI-1 requires an individual describe how he/she feels at a specific time and in a specific circumstance and takes into account his/her feelings relevant to the situation under consideration. The trait anxiety scale requires the individual to rate generally how he/she feels. Cronbach's alpha coefficient was between 0.83 and 0.87 for trait anxiety inventory and 0.94 and 0.96 for state anxiety in studies. Scores range from 20 to 80 for each scale, higher the scores are rated, greater the anxiety is.
2.4. Coronary angiography Before diagnostic coronary angiography, all patients underwent stress electrocardiography, myocardial perfusion scintigraphy, or (for high-risk patients) symptomatic assessment. Selective coronary angiography by means of the conventional Judkins technique and left ventriculography were performed in all patients. Each angiogram was interpreted by 2 cardiologists who were not aware of the psychiatric diagnosis. A significant obstructive atherosclerotic lesion was defined as stenosis equal to or greater than 50% of the luminal diameter in 1 or more coronary arteries. 2.5. Statistical analysis Following descriptive statistics, logistic regression analysis was performed in which coronary artery stenosis was the dependent variable and demographics and pre-angiography scale scores, namely POMS sub-scales, ISI, HADS, and STAI scores were the independent variables. We performed comparisons of scale scores between the study groups using one-way analysis of variance. We assessed change in mood, sleep, hospital anxiety and depression, and state anxiety in the course of the angiography through repeated measure analysis of variance (rANOVA) comparisons between pre- and post-angiography scale scores. The statistical significance threshold was po.05.
3. Results 2.3. Approval by the ethics committee
3.1. Descriptive statistics
The study was carried out according to the declaration of Helsinki and approved by the Clinical Ethics and Research Committee of the Yuzuncu Yil University, Faculty of Medicine. All participants signed a consent form declaring that they had been properly informed of the purposes of the study. They were not paid for their participation.
In total, 120 patients were enrolled in the study. Sixty-nine patients had critical stenosis in CA while 51 patients had normal findings. Mean age for the sample was 57.49 (SD 79.73). 58.3% of the sample consisted of women (N ¼69); 57.5% had significant stenosis in CA; virtually all of the study participants were married
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Table 4 Repeated ANOVA comparisons between pre-angiography and post-angiography scale scores. Time Periods Pre-angiography
Post-angiography
Mean
SD
Mean
SD
F
df
P
η2
Depression-dejection
Normal Critical Total
18.84 20.35 19.71
7.72 8.85 8.39
20.14 22.48 21.48
8.45 10.58 9,77
1.999 4.150 6.173
1, 50 1, 68 1, 119
0.164NS 0.046 0.014
0.038 0.058 0.049
Tension-anxiety
Normal Critical Total
16.24 16.12 16.17
5.54 5.40 5.44
15.98 16.54 16.30
5.85 5.03 5.38
0.194 0.700 0.124
1, 50 1, 68 1, 119
0.661NS 0.406NS 0.726NS
0.004 0.010 0.001
Anger-hostility
Normal Critical Total
15.84 16.71 16.34
6.64 6.98 6.82
16.65 18.38 17,64
8.26 8.73 8.54
0.702 4.613 4.647
1, 50 1, 68 1, 119
0.406NS 0.035 0.033
0.014 0.064 0.038
Confusion-bewilderment
Normal Critical Total
11.98 10.86 11.33
4.35 4.23 4,30
11.35 11.49 11,43
4.04 4.55 4,32
1.165 1.281 0.060
1, 50 1, 68 1, 119
0.286NS 0.262NS 0.808NS
0.023 0.018 0.001
Fatigue-inertia
Normal Critical Total
11.02 11.83 11.48
4.73 9.12 7.56
10.78 10.90 10.85
5.39 4.65 4.96
0.124 0.797 0.921
1, 50 1, 68 1, 119
0.726NS 0.375NS 0.339NS
0.002 0.012 0.008
Vigor-activity
Normal Critical Total
18.82 16.38 17.42
4.78 5.48 5.32
18.39 16.93 17,55
4.66 6.29 5.68
0.653 0.709 0.092
1, 50 1, 68 1, 119
0.423NS 0.403NS 0.762NS
0.013 0.010 0.001
POMS Global
Normal Critical Total
55.10 59.48 57.62
25.68 28.10 27.07
56.51 62.86 60.16
27.01 25.67 26.32
0.242 1.936 1.894
1, 50 1, 68 1, 119
0.625NS 0.169NS 0.171NS
0.005 0.028 0.016
ISI
Normal Critical Total
6.80 5.28 5.93
5.28 5.51 5.44
6.75 5.87 6.24
5.36 6.29 5.91
0.023 1.492 0.947
1, 50 1, 68 1, 119
0.881NS 0.226NS 0.332NS
o .001 0.021 0.008
HADS-depression
Normal Critical Total
9.53 10.20 9.92
3.22 2.55 2.86
9.31 10.91 10.23
3.22 3.99 3.75
0.558 2.324 1.140
1, 50 1, 68 1, 119
0.459NS 0.132NS 0.288NS
0.011 0.033 0.009
HADS-anxiety
Normal Critical Total
9.49 10.94 10.33
3.48 3.12 3.34
9.51 10.54 10.10
3.26 3.00 3.14
0.003 1.132 0.681
1, 50 1, 68 1, 119
0.959NS 0.291NS 0.411NS
o .001 0.016 0.006
State anxietya
Normal Critical Total
41.22 43.09 42.29
6.01 7.24 6.78
43.92 43.58 43.72
5.63 6.21 5.95
5.911 0.548 3.292
1, 50 1, 68 1, 119
0.019 0.462NS 0.072NS
0.108 0.008 0.027
POMS: Profile of Mood States Scale. ISI: Insomnia Severity Index. HADS: Hospital Anxiety and Depression Scale. a Pre- and post-application state anxiety scores compared using one-way repeated measure analysis of covariance analysis (rANCOVA) in which trait anxiety scores were put as covariate into the model.
(95.8%); and 24% had a physical illness. Majority of the subjects reported having chest pain (71.6%), 24% had previous history of cardiovascular disease, and 4% of the sample reported prior myocardial infarction. Table 1 reports demographics for the sample. 3.2. Risk factors for critical coronary stenosis in CA To explore the predictors of significant stenosis in CA, we constructed a logistic regression model in which age, sex, marital status, and physical ailment were independent variables as well as preangiography scores of the POMS sub-scales, ISI, HADS, and STAI. In
this regression analysis, we found that older age (OR¼1.07, 95% Cl¼1.02–1.12, po0.05) and having another physical illness (OR¼5.00 95%Cl¼1.27–19.75, po0.05) significantly contributed to the risk for coronary artery stenosis. Subjects without a significant coronary artery stenosis reported significantly higher scores on the confusion-bewilderment sub-scale of the POMS (OR¼0.85 95% Cl¼0.73–0.98, po0.05). The findings can be seen in Table 2. 3.3. Comparisons of scale scores between the study groups We compared scale scores between normal and significant coronary artery stenosis groups on the POMS Global and
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Fig. 1. (a) Bars in the diagram represents the mean scores of Depression Dejection subscale of the POMS observed in the pre-angiography and post-angiography by coronary artery stenosis levels. (b) Bars in the diagram represents the mean scores of Anger-Hostility subscale of the POMS observed in the pre-angiography and post-angiography by coronary artery stenosis levels.
sub-scales, ISI, HADS, and STAI administered in the pre- and postangiography periods by running separate one-way analysis of variance. Subjects with significant coronary artery stenosis reported lower pre-angiography vigor-activity scores (F(1,118) ¼ 6.499, po 0.05, η2 ¼0.052), higher pre-angiography hospital anxiety (F(1,118) ¼ 5.750, po .05 η2 ¼0.046) and post-angiography hospital depression scores (F(1,118) ¼ 5.537, p o0.05, η2 ¼0.045). ANOVA results appear in Table 3. 3.4. Comparisons of pre- and post-angiography scale scores To explore the mood changes, sleep, hospital anxiety and depression, state anxiety during the course of the angiography, we compared pre- and post-angiography scores of subjects using repeated analysis of variance (rANOVA). Subjects with critical coronary artery stenosis scored higher on depression-dejection (F (1,68) ¼4.150, po .05, η2 ¼0.058) and anger-hostility (F(1,68) ¼ 4.613, p o0.05, η2 ¼0.064) sub-scales at the post-angiography time period relative to pre-angiography scores. Pre- and post-angiography state anxiety scores compared using an analysis of covariance model in which pre-angiography trait anxiety was covariate. Subjects without critical stenosis in CA had greater state anxiety in the post-angiography (F(1,50) ¼ 5.911, p o0.05, η2 ¼0.108) than pre-angiography compared with pre- and post-angiography scores of subject with coronary artery contraction. Findings are presented in Table 4 and plotted in Figs. 1a and 2a. Additionally, we analyzed the change on scores of vigor-activity subscale of the POMS and anxiety subscale of the HADS through one-way analysis of covariance analysis (ANCOVA) due to the substantial differences between normal and critical groups in preangiography measures. Having adjusted for the pre-treatment scores, the ANCOVA result for either vigor-activity subscale of the POMS (F(1, 117) ¼ 0.034; p¼ 0.854) or anxiety subscale of the HADS (F(1, 117) ¼2.742; p¼ 0.100) was not significant as well. 3.5. Gender differences on scale scores We performed one-way ANOVA to compare both pre- and postangiography scale scores among genders and ran rANOVA to explore changes in mood, sleep, hospital anxiety and depression, and state anxiety scores in the course of the angiography. We could not find any difference between two genders on either pre- or postangiography scale scores. On the contrary, women had greater
score on depression-dejection than that of men (F(1, 69) ¼4.572; po .05; partial η2 ¼ .062), anger-hostility (F(1, 69) ¼5.774; p o.05; partial η2 ¼.077) and global scores of the POMS (F(1, 69) ¼4.053; po .05; partial η2 ¼.055). Findings are plotted in Fig. 2a–c.
4. Discussion The results of this prospective study can be summarized as follows: (i) patients with severe coronary stenosis had higher preangiographic hospital anxiety and post-angiographic hospital depression scores, lower pre-angiographic vigor-activity scores, than those with normal coronary artery, (ii) subjects with severe coronary artery stenosis had higher scores on depression-dejection and anger-hostility sub-scales in the post-angiography period relative to the scores during the pre-angiography, (iii) patients with normal coronary arteries had higher state anxiety scores in the post-angiographic phase than pre-angiographic phase, while state anxiety scores in severe coronary stenosis group were comparable during pre- and post-angiographic stages, (iv) either pre- or postangiography scale scores did not differ significantly due to gender with an exception that women had greater mean score on depression-dejection subscale of the POMS than those of men. Patients with CAD have severe stressful life experiences. As it is well-established that stressful events typically reveal significant emotional responses and exposure to stress leads to the dysregulation of emotions, which in turn shows negative psychological and physiological health outcomes (Compare et al., 2014a,b). Several studies have investigated possible associations between psychological variables and CAD in patients who have undergone CA, and reported conflicting results (Valkamo et al., 2001; Marzari et al., 2005). On the other hand, to date, there has been a paucity of studies investigating quantitative indicators of and differences in mood, anxiety and insomnia during the pre- and post-coronary angiography yet. The studies assessing depression or anxiety before CA mainly focused on finding the risk factors influencing CAD. Depressive symptomatology poses an increased risk of CAD in men regardless of health behavior, social isolation, and clinical determinants (Marzari et al., 2005). In fact, a stronger relation between clinically defined depression and outcomes of CAD (either fatal or combined fatal and nonfatal) has been found. Individuals with depressed mood and with clinical depression had virtually 2and 3-fold greater risk for CAD, respectively (Rugulies, 2002). It
Please cite this article as: Ozdemir, P.G., et al., Relationships between coronary angiography, mood, anxiety and insomnia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.084i
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Fig. 2. (a) Bars in the diagram represents the mean scores of Depression-Dejection subscale of the POMS observed in the pre-angiography and post-angiography by gender. (b) Bars in the diagram represents the mean scores of Anger-Hostility subscale of the POMS observed in the pre-angiography and post-angiography by gender. (c) Bars in the diagram represents the mean global scores of the POMS observed in the pre-angiography and post-angiography by gender.
was also reported that anxiety and depressive symptoms at cardiac catheterization predicts impairment in physical role of future functioning regardless of the severity of coronary heart disease (Sullivan et al., 2000). Furthermore, Druss et al., pointed out that elderly patients with mental disorders were less likely to accept angiography after myocardial infarction (Druss et al., 2000). Anxiety may also occur due to the circumstances prior to CA. Most of the elective patients with minimal waiting times reported low anxiety levels (Astin et al., 2005); on the contrary, patients who had to live with anginal symptoms while waiting for several weeks to months before the procedure exhibited greater levels of anxiety (Harkness et al., 2003; Uzun et al., 2008; Grunberg et al., 2003). If the patients underwent to a psychoeducation where detailed information is provided, anxiety in these individuals would decline during application of the procedure (Gallagher et al., 2010; Harkness et al., 2003). In our study, all patients received a usual care in the pre-coronary angiography period and had moderate anxiety during pre- and post-coronary angiography. The finding was consistent with previous research which found that almost half of the patients were moderately anxious (Valkamo
et al., 2001). Surprisingly, participants without a significant stenosis in coronary artery had greater state anxiety in the post-angiography period than pre-angiography comparable to pre- and post-angiography scores of subjects with significant coronary stenosis. Nevertheless, patients with significant coronary stenosis were more anxious as compared to others. The state anxiety is more important in evaluating effects of a specific event on anxiety levels. In comparison, trait anxiety depends on the person himself and is indicative of individual's predisposition in the face of adverse events. Furthermore, it was confirmed that trait anxiety increased the state anxiety and trait anxiety cannot be immediately observed but is manifested as state anxiety when experiencing stress (Reiss, 1997). In our study, trait anxiety was only measured in the pre-angiography as a control variable and we observed that the patients' state anxiety was not due to the angiography after controlling for trait anxiety. The evidence has arised from multiple sources that psychological factors like mood disturbances adversely affect mortality in patients with CAD after controlling for differences in underlying disease severity. Park et al. (2012) evaluated whether percutaneous coronary
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intervention (PCI) was associated with the development of depressive symptoms. 171 CAD patients were enrolled in the study, and 63 (37%) cases were assigned to the PCI group predicated on angiography. Accordingly, PCI was independently predictive to higher risk of developing depressive symptoms in CAD patients during hospitalization. Carney et al. (1990) addressed 100 patients who had chest pain referred for coronary angiography for suspected coronary heart disease through a Diagnostic Interview Schedule to assess psychiatric conditions the day before catheterization. Virtually half of the patients with chest pain but without angiographic findings for significant coronary heart disease were diagnosed as suffering from either major depression or a panic disorder, or both. The ratewere greater than did the patients with coronary heart disease. In our study, subjects with significant coronary artery stenosis reported lower pre-angiography vigor-activity scores, greater pre-angiography hospital anxiety and post-angiography hospital depression scores. In comparing pre- and post- angiography scores; patients with critical levels of coronary artery stenosis scored greater on depression dejection and anger-hostility sub-scales in the post-angiography period relative to pre-angiography period. Epidemiological investigations have demonstrated that depression or anxiety can be predictive of the prevalence of CAD in healthy community populations (Ferketich et al., 2000). In a recent review Compare et al. (2013) analyzed the relationships between depression, social support and health outcomes in patients with heart disease and reported that depressive symptoms and the absence of social or marital support are significant risk factors for poor prognosis in cardiac patients (Compare et al., 2013). Additionally, another important article found tight relationships between anxiety, social support and cardiac diseases (Zarbo et al., 2013). In a previous study, Vural et al. (2009) showed that depression was associated with increased abnormal coronary angiographic findings; whilst the linkage between anxiety and CAD was not significant. Depression and anxiety can also be predictive of worse prognosis of known CAD (Smith and Ruiz 2002). Moreover, Sullivan et al.'s analyzed data have demonstrated of that the levels of depressive symptomatology was generally improving throughout the first year in the post-angiography and remained quite stable thereafter (Sullivan et al., 1997, 2000). In terms of risk factors for coronary stenosis, angerpersonality and social inhibition were associated with an increased prevalence and severity of coronary artery plaque (Compare et al., 2013). We found that older age and having a physical ailment significantly contributed to the risk for coronary artery stenosis. This study has several shortcomings. Firstly, our sample size was relatively small and a single center therefore; our findings can be reexamined in more representative samples. Replication study with a larger sample in a longitudinal follow-up research design is needed.
5. Conclusion This study identified that a significant proportion of patients had moderate anxiety before coronary angiography. Older age and having another physical illness significantly contributed to the risk for coronary artery stenosis. Critical levels of coronary artery stenosis increased depression-dejection and anger-hostility scores. Given the negative effects of anxiety, understanding patients' concerns and anxiety and responding to these concerns is essential in the preprocedure phase. Conflict of interest We do not declare any conflict of interest.
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Please cite this article as: Ozdemir, P.G., et al., Relationships between coronary angiography, mood, anxiety and insomnia. Psychiatry Research (2015), http://dx.doi.org/10.1016/j.psychres.2015.05.084i