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From the University of Birmingham, Birmingham, United Kingdom.
Address reprint requests to: Douglas Carroll, PhD, FBPsS, CPsychol, School of Sport and Exercise Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. Email: carrolld@ bham.ac.uk
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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METHODS: The Beck Depression Inventory and the State-Trait Anxiety Inventory were completed by 288 patients hospitalized for MI. Twelve-month survival status was ascertained, and quality of life among survivors was assessed at 12 months using the Dartmouth COOP charts.
RESULTS: Thirty-one (10.8%) patients died, 27 of cardiac causes, during the 12-month follow-up. Symptoms of depression and anxiety predicted neither cardiac nor all-cause mortality. Severity of infarction and evidence of heart failure predicted both cardiac and all-cause mortality. The same findings emerged from supplementary analyses of data from patients who died after discharge from the hospital. Symptoms of depression and anxiety, measured at entry, predicted 12-month quality of life among survivors, as did gender, partner status, employment status, living alone, previous frequency of exercise, and indices of disease severity (Killip class and Peel Index). In a multiple regression model in which all of these variables were entered, initial depression scores provided the best independent prediction of quality of life, although living alone, severity of infarction, and state anxiety also entered the model.
CONCLUSIONS: Symptoms of depression and anxiety did not predict either cardiac or all-cause mortality after MI, but they did predict quality of life among those who lived to 12 months.
Key Words: depression • anxiety • myocardial infarction • quality of life • mortality.
Abbreviations: BDI = Beck Depression Inventory; CHD = coronary heart disease; CI = confidence interval; MI = myocardial infarction; OR = odds ratio; STAI = State-Trait Anxiety Inventory.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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2), were controlled (7). In the same study, anxiety also emerged as a predictor of recurrent cardiac events independent of depression (8). There has been little systematic research on the quality of life of patients after MI (22). However, patients who are depressed after a MI are less likely to return to work (3) or to resume sexual activity (23). In the two studies that specifically examined quality of life in MI survivors, depression emerged as the single best predictor of quality of life, accounting for 49% of the variance, in one study (24), and both anxiety and depression significantly predicted 1-year quality of life in the other (25). In general, depression and anxiety may substantially reduce a person’s quality of life and that of his or her family (26, 27).
The present study examined the relationship between depression and anxiety in the hospital and mortality 12 months after MI. In addition, the study was concerned with the impact of depression and anxiety on the quality of life among survivors.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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25 IU/liter or >5% of a simultaneous creatinine phosphokinase value exceeding the normal limit. Patients were excluded from participation in the study if they had a MI as a result of coronary artery bypass graft surgery or angiography, if they had another medical condition likely to lead to death within the next 12 months, if they were unable to speak English, if they were cognitively impaired, or if they were too unstable medically to complete the baseline assessment within 15 days after their infarction. There were no age or gender restrictions. Overall, 288 (65.9%) of the 437 patients who were eligible for participation provided informed consent and completed the baseline interview ( Figure 1). There were few differences between participants and those who declined to participate, although patients who declined to participate were more likely to be Afro-Caribbean (p < .001), to be nonsmokers (p = .007), and to have diabetes mellitus (p = .002). Those who declined to participate did not have more severe cardiac disease than those who participated, as evidenced by Peel Index scores (a measure of the severity of infarction), Killip class, and length of hospital stay. All patients in the study received routine hospital and postdischarge care.
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Patients also completed a series of questionnaires. The 21-item self-report BDI (29) was used to assess current depressive symptomatology. Scores of 10 or more indicated the presence of depressive symptomatology (6–9). A meta-analysis of the internal consistency of the BDI revealed a Cronbach’s 
of 0.86 for psychiatric patients and 0.81 for nonpsychiatric patients and test-retest reliability coefficients as high as 0.86 and 0.83, respectively (30). The STAI (31), which comprises two self-report scales, was used to assess both state and trait anxiety. Both scales have acceptable internal consistency, with Cronbach’s values of 0.92 and 0.90 for the state and trait scales, respectively. The Health Behaviors Profile, adapted from the Whitehall II study, was used to assess current smoking status; weekly alcohol consumption; and the frequency, intensity, and duration of exercise (32). Patients were asked to rate the frequency of exercise undertaken as follows: three times a week or more, once or twice a week, once to three times a month, or hardly ever. This parameter was scored using a four-point ordinal scale, with higher scores indicating more frequent exercise. These scores were then weighted according to the intensity of exercise; that is, for low, moderate, or vigorous exercise, scores were multiplied by one, two, or three, respectively. Overall scores ranged from 0 to 18. Patients were also asked to indicate the duration of exercise at each intensity, reporting the number of hours per week spent exercising. Duration was weighted for intensity of exercise in the same way as frequency.
Baseline clinical variables, including administration of thrombolytic therapy, history of previous MI, history of hypertension, insulin dependent or non–insulin-dependent diabetes mellitus, hypercholesterolemia (cholesterol 5.2 mmol/liter), angina pectoris, and other comorbid conditions, were obtained from patients’ hospital records. Prescription of aspirin, ß-blockers, angiotensin-converting enzyme inhibitors, statins, and warfarin at discharge was also recorded. The Peel Index (33) was used to gauge the severity of infarction. This index includes important factors covering the immediate prognosis (28 days), namely age, sex, medical history, degree and severity of shock, presence and severity of heart failure, cardiac rhythm, and the nature and extent of electrocardiographic signs. The total score ranges from 1 to 28, with higher scores denoting a poorer prognosis. In addition, Killip class, a standardized four-point clinical assessment of the degree of left ventricular dysfunction, was determined from chest x-ray, heart and lung sounds, and signs of shock (34) by a consulting physician blinded to clinical outcome. The higher the Killip class, the greater the degree of heart failure.
The 12-month survival status of participating patients was established using the patient information system at each hospital. Survival status was determined for all patients 365 days after their MI. Cause of death was established from hospital and general practitioner records and death certificates. Deaths were confirmed as cardiac or noncardiac by a consulting cardiologist blinded to baseline data. Cardiac deaths were classified additionally as secondary to arrhythmia, MI or ischemic heart disease, or heart failure. At 12 months, survivors were sent the COOP chart system to measure their quality of life (35). This system consists of nine charts that assess physical, social, and role functioning; emotional status; overall health; perceived pain; change in health; social support; and perceived quality of life over the previous 4 weeks. Each chart consists of a title, a question, and five response choices, each with a pictorial cue. Each response is scored from 1 to 5; the total score ranges from 9 to 45. Because we were concerned with the relationship between depression and anxiety and quality of life, the COOP chart assessing emotional status, which would be highly influenced by depression and anxiety, was discarded; thus, in this study scores ranged from 8 to 40. High scores denote poor quality of life. The COOP charts have been evaluated on more than 1400 patients sampled from four clinical settings in North America and elsewhere to evaluate their validity, reliability, and acceptability (35). One-hour test-retest correlation coefficients ranged from 0.93 to 0.99, with 
coefficients in the range of 0.80 to 0.97. A test-retest coefficient as high 0.88 was obtained after an interval of 2 weeks (36). The COOP charts are strongly correlated with another well-established measure of quality of life, the Medical Outcomes Study 36-item General Health Survey (37).
Data Analysis
Data were analyzed using SPSS for Windows, version 8.0 (38). All statistical tests were two-tailed; p values 
.05 were considered statistically significant. In comparisons of those with or without elevated BDI scores (BDI score 10 or <10, respectively), categorical variables were compared using the 
2 statistic. Continuity correction was used when there were observed or expected frequencies of <5 in any cell. Continuous variables were compared using independent t tests. The key outcomes were mortality and quality of life 12 months after MI. The mortality analyses were undertaken using logistic regression. All demographic, clinical, and psychological variables that differentiated patients who died by 12 months from those who survived were entered into a multiple logistic regression. Quality-of-life data were analyzed using correlation and multiple linear regression. The demographic, clinical, and psychological variables that were significantly correlated with the quality of life of those surviving to 12 months were included in a multiple linear regression model. In all these analyses, BDI score was treated as both a continuous variable and a dichotomous variable (<10 and 10). Peel Index scores were also analyzed as both continuous and dichotomous variables, using a <17 and 17 split for the latter; scores 17 were considered to signify a mortality risk of at least 50% (33). Given the positively skewed distribution of patients among the four Killip classes, Killip class was reconstituted as a binary variable: class I (no heart failure) and classes II to IV (heart failure). Age was entered at the outset in multiple regression analyses, except in models testing the Peel Index because age contributes to the Peel Index score. Cumulative survival curves for 12-month cardiac mortality, using the Kaplan-Meier method, were constructed for the dichotomized BDI and state anxiety scores (dichotomized as 40 and <40).
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RESULTS |
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2), the mean Peel Index score (SD) was 10.4 (5.0), and the mean length of hospital stay (SD) was 10.0 (6.9) days.
Baseline Characteristics as a Function of BDI Status
Tables 1 and 2 show the baseline demographic, clinical, and psychological data for participants who had relatively high levels of depressive symptomatology (BDI scores 10) and for those with relatively low levels of depressive symptomatology (BDI score <10) during their hospital admission after acute MI. At entry, 89 (30.9%) of the participants scored 10 on the BDI, indicating mild to severe symptoms of depression. There were several differences between groups: Those with high BDI scores were more likely to be female, to be currently unemployed, to have diabetes mellitus, and to have a longer hospital stay. In addition, patients with high BDI scores also had higher levels of both state and trait anxiety and exercised less frequently than patients with low BDI scores. However, patients with relatively high levels of depressive symptomatology did not seem to have more severe cardiac disease, as evidenced by the Peel Index score and Killip class designation.
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10; of the 257 survivors, 78 had BDI scores 10. Figure 2 shows Kaplan-Meier cumulative mortality curves for patients with and without mild to severe symptoms of depression. As can been seen, the cumulative mortality profiles are similar for the two groups.1 Furthermore, as shown in Table 3, the mean BDI scores of survivors and those who died of cardiac causes were not significantly different. Table 3 also makes clear that neither state nor trait anxiety scores at entry differentiated patients who died of cardiac causes from those who survived. The Kaplan-Meier cumulative mortality curves for patients with state anxiety scores 40 and <40 are presented in Figure 3. Overall, 75 (26.1%) participants had state anxiety scores 40. When these analyses were repeated for all 31 deaths, similar outcomes emerged. In separate logistic regression analyses, we examined the possibility that depression and gender, given the significant gender difference in BDI scores, had an interactive effect on cardiac mortality. There were no significant interactive associations for either cardiac or all-cause mortality.
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Other Baseline Predictors of Cardiac and All-Cause Mortality
The data in Tables 3 and 4 indicate that partner status and education were associated with cardiac mortality; patients without a partner and those with fewer years of education were more likely to die. The same relationships emerged from the analysis of all-cause mortality. However, neither of these bivariate associations survived adjustment for age. Tables 3 and 4 also show that 12-month cardiac mortality was associated with age, Peel Index score, Killip class, and length of hospital stay. The patients who died of cardiac causes during the 12-month follow-up period were significantly older than those who survived, had significantly higher Peel Index scores, had a poorer Killip class designation, and had a longer hospital stay. The outcomes reported below are for the 27 patients who died of cardiac causes, although similar results emerged in the analysis of all 31 fatalities. In an analysis that included the dichotomized Peel Index, Killip class, and length of hospital stay, both Peel Index score (OR = 3.33, 95% CI = 1.22–9.08, p = .02) and Killip class (OR = 2.28, 95% CI = 1.30–4.02, p = .004) emerged as significant predictors of 12-month cardiac mortality. Precisely the same predictors, Peel Index and Killip class, emerged from multiple logistic regression analysis of data from only the patients who died, either of cardiac or all causes, after discharge from the hospital.
Predictors of Quality of Life at 12 Months
Table 5 indicates that baseline BDI score, state and trait anxiety, and frequency of exercise before MI correlated significantly with quality of life measured at 12 months. Reported quality of life was also positively associated with being male, having a partner, not living alone, and being employed. Peel index scores, Killip class, and length of hospital stay were also correlated with quality of life among survivors: the higher the Peel Index score, the worse the Killip class designation, and the longer the hospital stay, the poorer the quality of life. The variables significantly associated with quality of life were entered into a stepwise multiple linear regression model.
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DISCUSSION |
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Given that a positive relationship between depression, anxiety, and mortality in MI patients has been reported in samples smaller than the present one (6–9), with fewer fatal cardiac events (6–13), the current failure to find a relationship is difficult to attribute to low power. Furthermore, a priori power calculations indicate that the present study easily had sufficient power to detect effects at an odds ratio with a magnitude of 3.7 to 7.5, which has been reported in some of the previous studies of depression and anxiety (7, 10, 13). The present study clearly had sufficient power to detect the effects of the severity of infarction and the extent of heart failure on mortality. The striking similarity between the mean BDI and STAI scores of survivors and those who died in the present study strongly suggests that our result is a genuine null and not a positive result waiting to happen with inclusion of more cases. It is important to appreciate that low power has consequences not only for Type II errors but also for Type I errors (42).
It is also difficult to explain our negative results in terms of the prevalence of mild to moderate depressive symptomatology and high levels of state anxiety (STAI 40) in the current cohort, which, at 31% and 26%, respectively, are identical to those reported by Frasure-Smith et al. (6–9). With regard to depression, it must be conceded that our failure to clinically assess patients for major depression is undoubtedly a weakness. However, questionnaire measures of depressive symptomatology in MI patients have predicted mortality in other studies (4, 10–13), and in the one study that included both questionnaire and clinical assessments, BDI scores and clinical depression status were equally predictive of mortality. Indeed, in this study only the BDI score provided an independent prediction of mortality at 18 months (6–9).
As evidenced by years in education, the patients in the present study and those described by Frasure-Smith et al. were similar in terms of socioeconomic position (10.1 vs. 10.5 years). The two studies also reported virtually identical 12-month, postdischarge cardiac mortality rates (7.29% vs. 7.21%). However, patients in the present study were slightly older (62.7 vs. 59.6 years). More noticeably, the prevalence of heart failure in the present study at baseline, as evidenced by Killip class, was more than twice that reported by Frasure-Smith et al. (52.0 vs. 21.2%). Accordingly, it is possible that symptoms of depression and anxiety predict mortality mainly in patient groups that are relatively unencumbered by high levels of cardiac morbidity.
When one considers the studies that have reported a positive association between depression, anxiety, and mortality after MI, depression and anxiety would seem to predict mortality primarily in studies that have not controlled for disease severity (13) and in studies in which disease severity is significantly correlated with depression and anxiety (6–11). As Mendes de Leon (43) emphasized in a recent editorial in Psychosomatic Medicine, "One of the main issues regarding the role of depression is the potential confounding with severity of disease." Although those with higher BDI scores, but not higher STAI scores, in the present study tended to have longer initial hospital stays, neither symptoms of depression nor anxiety were significantly associated with our major cardiological indices of disease severity, the Peel Index and Killip class. In those studies in which symptoms of depression were confounded with disease severity, statistical control for disease severity abolished the effect in the Ladwig et al. study (10, 11) and in the Irvine et al. study (44) but not in the Frasure-Smith et al. studies (6–9). However, even where an effect remains after statistical correction for potential confounders, caution is still warranted. It may be premature to declare independence on this basis (45–47). The ability of multivariate statistical models to determine independence depends on the accuracy of the measurement of the potentially confounding variables; any inaccuracy in the measurement of the potential confounder will inevitably lead to underestimation of its true impact (48). It is worth noting that in another recent study (25) on British MI patients, depression and anxiety were not significantly related to initial measures of cardiac impairment. As in the present study, depression and anxiety were not related to mortality, either at 6 or 18 months. Thus, it remains possible that depression and anxiety are markers of disease severity in some previous studies and that disease severity is the underlying cause of death.
Although mortality will necessarily remain a key outcome in managing cardiovascular disease, cardiology is beginning to embrace other outcomes, in particular quality of life (22). In the present study, depressive symptomatology at entry was powerfully related to later quality of life among survivors, a result in line with the findings of previous research that assessed overall quality of life in this context (24, 25). Although the severity of infarction also predicted 12-month quality of life, so too did two other psychosocial measures, living alone and state anxiety. These results and our broad finding, echoing earlier results (1–11), that approximately one-third of MI patients reported mild to severe symptoms of depression and/or high levels of anxiety emphasize the need to both assess mood and develop appropriate intervention strategies for those with high levels of depression and anxiety after MI. As a recent editorial asserted, "We should not lose sight of the fact that an intervention that improves well-being, but fails to change survival, is still a very valuable treatment" (22).
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ACKNOWLEDGMENTS |
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NOTES |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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Received for publication February 2, 2000.
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