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Psychosomatic Medicine 67:759-765 (2005)
© 2005 American Psychosomatic Society

ORIGINAL ARTICLES

Quality of Life Following Cardiac Surgery: Impact of the Severity and Course of Depressive Symptoms

Tanya M. Goyal, PhD, Ellen L. Idler, PhD, Tyrone J. Krause, MD and Richard J. Contrada, PhD

From the Departments of Psychology (T.M.G., R.J.C.) and Sociology (E.L.I.), Rutgers, The State University of New Jersey, Piscataway, New Jersey; and the Department of Surgery, University of Medicine and Dentistry, New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey (T.J.K.).

Address correspondence and reprint requests to Richard J. Contrada, Department of Psychology, Rutgers University, 53 Avenue E, Piscataway, NJ 08854-8040. E-mail: contrada{at}rci.rutgers.edu.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 NOTES
 REFERENCES
 
Objectives: The purpose of this study was to examine the impact of the severity and course of depressive symptoms on change in quality of life (QOL) 6 months after cardiac surgery.

Methods: Ninety patients were interviewed before heart surgery and 2 and 6 months after surgery. Depressive symptoms were assessed using the Beck Depression Inventory, and QOL was assessed using physical and psychosocial functioning indices derived from the Medical Outcomes Study instrument. Multiple regression examined the effects of the severity and course of depressive symptoms on QOL adjusting for demographic and biomedical predictors.

Results: Higher levels of presurgical depressive symptoms predicted poorer physical functioning after cardiac surgery. A similar effect on psychosocial functioning fell short of significance. An increase in depressive symptoms 2 months after surgery was significantly predictive of poorer physical and psychosocial functioning at 6 months. The effect of increased depressive symptoms on psychosocial functioning was significantly stronger in patients with high presurgical Beck Depression Inventory scores.

Conclusions: Both preoperative depressive symptoms and postoperative increases in depressive symptoms seem associated with poorer QOL 6 months after cardiac surgery. Further examination of these associations and the mechanisms they reflect may provide a basis for guiding treatment decisions before and after coronary artery bypass graft surgery.

Key Words: coronary artery bypass graft surgery • depression • quality of life

Abbreviations: BDI = Beck Depression Inventory; CABG = coronary artery bypass graft surgery; MI = myocardial infarction; MOS = Medical Outcomes Study; QOL = quality of life; SF-36 = MOS 36-item short form health survey.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 NOTES
 REFERENCES
 
Quality of life (QOL) outcomes have become a major focus for coronary artery bypass grafting (CABG), a common and effective treatment for coronary artery disease (1). Typically conceptualized in terms of the patient’s subjective experience (2), QOL is multifaceted (3), comprising self-assessments in several areas of functioning (4). Patients with coronary artery disease report problems in a number of domains, including physical activity, social interaction, and emotion (5). Although most experience improved QOL following CABG (6–8), some fail to improve or report worsened functioning (9,10).

Identification of patients less likely to experience improved QOL may inform treatment decisions before and following CABG (11,12). However, predictors such as age and disease severity (13,14), while relevant to other outcomes, are often unrelated to QOL (15,16). Among several promising psychosocial predictors (17–19), depression may be particularly important. Estimates of elevated preoperative depressive symptoms in CABG patients range from 30 to 47% (20–24). Depressive symptoms generally increase soon after hospital discharge, subsequently declining to below preoperative levels (20,24). Presurgical measures of major depressive disorder or subclinical depression have been related to subsequent morbidity and mortality (19,25–29), as well as to lesser improvement in postoperative QOL (30).

Most studies have assessed depression on a single occasion, despite considerable variability in the course of depressive symptoms following CABG. In one, 51.4% of patients were free of depression (Center for Epidemiological Studies Depression Scale <16) both before and 6 months after surgery, 25.2% were depressed (Center for Epidemiological Studies Depression Scale ≥16) before surgery but not at follow-up, 17.9% were depressed both before and after surgery, and 5.5% were not depressed at baseline but became depressed at 6 months (23). Postoperative course of depressive symptoms may be an important predictor of subsequent QOL, operating independently of presurgical levels of depressive symptoms. Fluctuations in depression following CABG may reflect psychological and/or biological processes uniquely related to the occurrence of major surgery. Changes in depressive symptoms have been linked to morbidity and mortality in CABG patients (26,31). For example, both moderate to severe depressive symptoms before surgery, and mild or moderate to severe depressive symptoms persisting for 6 months following surgery, have been associated with elevated mortality rates (31). However, course of depression has yet to be examined as a predictor of QOL in CABG patients.

The present study examined depressive symptoms in relation to QOL assessed 6 months postoperatively in patients undergoing CABG and/or valve surgery. Effects of preoperative depressive symptoms and postoperative changes in depressive symptoms were evaluated. The main hypothesis was that postoperative increases in depressive symptoms would predict poorer 6-month QOL independently of preoperative levels of depressive symptoms.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 NOTES
 REFERENCES
 
Participants
Study participants were recruited from the 2,456 patients who underwent CABG and/or valve surgery at University of Medicine and Dentistry, New Jersey-Robert Wood Johnson University Hospital (RWJUH) in New Brunswick, NJ between 1996 and 1998. Patients undergoing valve surgery were included given similarities to CABG with regard to surgical procedures and postsurgical QOL (9,19). Potential participants could be approached only during limited time periods in which recruitment staff and interview facilities were available. During these time periods, all patients were considered eligible for recruitment unless they were not English speaking or had any condition that would interfere with interviewing. Patients scheduled for elective surgery were approached at an outpatient consultation visit. Urgent and emergent surgery patients were approached while in the hospital.

Of 163 patients who consented to participate and who underwent a presurgical interview, 3 (1.8%) died before hospital discharge. Of the remaining 160, 123 (76.9%) completed the 2-month interview and 113 (70.6%) completed the 6-month interview. A total of 90 (56.3%) had complete data from baseline, 2-month and 6-month interviews and were included in this study. Findings for shorter-term outcomes (length of hospital stay, postoperative complications) for an overlapping sample were reported previously (17).

Procedures
Elective surgery patients (N = 77) were interviewed in the hospital at the time of preadmission testing. Hospitalized patients undergoing nonelective surgery (N = 13) were interviewed bedside. All baseline interviews were conducted presurgically and took place an average of 6.6 days before surgery. Follow-up interviews were conducted approximately 2 and 6 months after surgery. Biomedical data were extracted from hospital charts by research assistants blind with respect to psychosocial variables.

Measures
Demographic and Biomedical Factors
Demographic information collected by interview included age (in years), gender (0 = male, 1 = female), education (in years), marital status (0 = nonmarried, 1 = married), and ethnicity (0 = white, 1 = nonwhite).

Preoperative cardiovascular health status was represented by left main stenosis and history of MI (each coded 0 = no, 1 = yes). General health was represented by smoking status (0 = nonsmoker, 1 = smoker) and a comorbidity index computed as a count of the following conditions: peripheral vascular disease, chronic obstructive pulmonary disease, diabetes, and congestive heart failure. Predictors reflecting surgical procedures were duration of anesthesia (in minutes) and number of grafts.

Three additional predictors were available for 89 of the 90 patients. Angina was assessed as the frequency of chest pain and pressure or heaviness in the chest rated on 6-point scales. Scores for these 2 items (r values from 0.20 to 0.57 at each time point) were averaged together. Postoperative length of hospital stay was computed as the number of days from surgery to discharge. Postoperative complication (0 = no, 1 = yes) reflected the occurrence of atrial fibrillation, reoperation for bleeding, postoperative renal failure, pneumonia, pneumothorax, irregular heartbeat, or congestive heart failure.

Depressive Symptomatology
The Beck Depression Inventory (BDI) (32) was used to assess depressive symptoms. Its 21 items assess symptoms such as sad mood, guilty feelings, and fatigue, with total scores that range from 0 to 63 ({alpha} = .81).

Quality of Life
Quality of life was measured using 10 standardized scales from the Medical Outcomes Study (MOS) Patient Questionnaire (33). The scales were drawn from several versions of MOS instruments including the Full and Core Subset versions of the MOS Function and Well-Being Profile and the Short Form General Health Survey (SF-36), and they have been psychometrically evaluated in previous research (33). Scales explicitly measuring depressive symptoms were excluded to minimize confounding that might tend to build in some association with the BDI. Another consideration was the inclusion of dimensions of broad relevance to medical patients, such as physical and social role functioning, as well as those particularly relevant to the population of interest, such as mobility and subjective cognitive functioning in the case of CABG patients. Specific domains represented by the 10 scales were (1) physical functioning (10 items); (2) satisfaction with physical functioning (1 item); (3) physical role functioning (5 items); (4) mobility (2 items); (5) energy (4 items); (6) self-rated health (5 items); (7) anxiety (6 items); (8) positive affect (4 items); (9) social role functioning (2 items); and (10) cognitive functioning (6 items).

Principal components analysis was performed on baseline MOS scale scores to reduce the number of variables. Two factors accounting for 54.7% of the variance were retained and subjected to varimax rotation. Results supported the construction of indices reflecting physical and psychosocial health self-assessments that correspond closely with SF-36 physical and mental health scores (34) and with 2 similar dimensions that have been shown to underlie responses to larger QOL item pools (4). The physical functioning index was defined by physical functioning, satisfaction with physical functioning, physical role functioning, energy, and self-rated health (loadings from 0.61–0.78; baseline {alpha} = .90; 2 months {alpha} = .89; 6 months {alpha} = .91). Psychosocial functioning was defined by positive affect, anxiety, social role functioning, and cognitive functioning (loadings from 0.64–0.82; baseline {alpha} = .91; 2 months {alpha} = .93; 6 months {alpha} = .93). Because the mobility subscale had negligible loadings on both factors (0.06, 0.15), it was examined separately.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 NOTES
 REFERENCES
 
Sample Characteristics
Descriptive data are presented in Table 1. There were 71 men (78.9%) and 19 women (21.1%) aged 41 to 88 (mean = 66, SD = 10.3). The sample was predominantly white (N = 78, 86.7%) and married (N = 73, 81.1%), and reported a mean of 13.4 years of education (SD = 3.5). The majority underwent isolated CABG (N = 66, 73.3%), whereas 14.4% (N = 13) had isolated valve surgery and 12.2% (N = 11) underwent combined CABG/valve surgery.


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  		TABLE 1. Sample Characteristics

 

T tests and {chi}2 analyses compared the 90 patients who completed all 3 assessments with the 70 who did not (for reasons other than operative mortality) with regard to demographics, biomedical factors, baseline depressive symptoms, QOL, angina, hospital length of stay, and complication. The only significant difference was a higher mean baseline BDI score for dropouts compared with study patients (means = 8.7 and 6.6, t = 2.1, p < .05). The study sample also was compared with a subsample of the 2456 patients who underwent CABG and/or valve surgery at RWJUH during the recruitment period. That subsample was formed by selecting those 1089 of the 2456 patients who underwent and survived elective CABG and/or valve surgery at RWJUH during the recruitment period, because most patients in the study sample (77 of 90) underwent elective surgery and all survived. Study patients closely resembled the larger population with regard to age (mean = 65) and ethnicity (89.1% white), but the latter were less likely to be male (71%) and had longer hospitalizations (mean in days = 8.9 versus 7.5).

Depressive Symptomatology
Baseline BDI scores were significantly correlated with 2-month (r = 0.65, p < .001) and 6-month (r = 0.52, p < .001) BDI scores. Mean preoperative BDI scores were 6.6 (SD = 5.4) before surgery, 5.2 (SD = 5.2) at 2 months, and 5.2 (SD = 5.3) at 6 months. Repeated measures ANOVA indicated that this postoperative decline was statistically significant, F(2, 172) = 6.88, p < .01). Based on a BDI cutoff of ≥10, 23.3% of participants (N = 21) were depressed before surgery, 11.1% (N = 10) at 2 months, and 15.6% (N = 14) at 6 months. Change-scores computed by subtracting baseline BDI scores from 2-month scores ranged from –14 to +12 (mean = –1.4, SD = 4.5). The correlation between baseline and 2-month BDI change-scores was modest (r = –0.45, p < .001). Thus, although related, baseline levels and 2-month change in depressive symptoms were separable and therefore capable of influencing QOL independently.

Quality of Life
As shown in Table 2, there was a slight improvement in physical functioning at 2 months followed by a larger improvement at 6 months. Psychosocial functioning showed the same pattern. Repeated-measures ANOVA indicated that changes for both indices were significant, F values (2, 172) ≥19.48, p values <.001).


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  		TABLE 2. Descriptive Statistics for Quality of Life Indices (N = 90)

 

Bivariate Associations
Demographic and biomedical covariates were not significantly related to depressive symptoms, except that younger age was associated with higher 2-month BDI scores (r = –0.24, p < .05) as was female gender (means = 7.31 and 4.67 for women and men, respectively, p = .05).

The physical and psychosocial health indices were significantly correlated at each time point (r values from 0.63 to 0.71, p values <.001), and both showed temporal stability (r values from 0.45 to 0.70, p values <.001). Higher preoperative BDI scores were associated with poorer physical and psychosocial functioning at baseline, 2 months, and 6 months (r values = –0.44 to –0.71, p values <.001). Older age was associated with better psychosocial functioning at baseline (r = 0.21, p < .05). Medical comorbidity at baseline was associated with poorer physical functioning at baseline (r = –0.39, p < .001) and 6 months (r = –0.32, p < .01), and with poorer psychosocial functioning at baseline (r = –0.25, p < .05) and 6 months (r = –0.19, p < .08). None of the other demographic or biomedical predictors showed bivariate relationships with QOL.

Prediction of 6-Month QOL
Multiple regression analysis of each QOL measure began with simultaneous examination of 4 sets of main effects: (1) baseline score for the QOL measure, so that results would reflect 6-month changes in QOL; (2) demographics (age, gender, education, marital status, ethnicity); (3) biomedical factors (comorbidity, smoking status, left main stenosis, history of MI, number of grafts, anesthesia duration); (4) depressive symptoms (baseline BDI and 2-month BDI change). The main effects analysis for 6-month physical functioning is summarized in Table 3. The relationship between baseline and 6-month measures of physical functioning fell short of significance (ß = .188, p < .10). Older age was significantly associated with poorer 6-month physical functioning (ß = –0.227, p < .05), as was history of MI (ß = –0.227, p < .05), and there was a trend toward a similar effect for preoperative comorbidity (ß = –0.190, p < .10). Higher presurgical levels of depressive symptoms were significantly related to poorer 6-month physical functioning (ß = –0.575, p < .001). In addition, as hypothesized, 2-month increases in depressive symptoms also predicted poorer 6-month physical functioning (ß = –0.438, p < .001). The model accounted for 48.5% of the variance, with presurgical depressive symptoms and increases in depressive symptoms independently accounting for 16.2% and 12.9%, respectively.


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  		TABLE 3. Multiple Regression Analysis of 6-Month Physical Functioning (N = 90)

 

The main effects analysis for 6-month psychosocial functioning is summarized in Table 4. Presurgical psychosocial functioning was significantly associated with 6-month psychosocial functioning (ß = .694, p < .001), as was being married (ß = .230, p < .05). Higher baseline levels of depressive symptoms were associated with poorer 6-month psychosocial functioning, but the effect fell short of statistical significance (ß = –0.216, p = .081). By contrast, and as predicted, a similar effect for increases in depressive symptoms was significant (ß = –0.337, p < .001). The model accounted for 58.8% of the variance, with increases in depressive symptoms independently accounting for 7.6%.


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  		TABLE 4. Multiple Regression Analysis of 6-Month Psychosocial Functioning (N = 90)

 

The foregoing analyses were repeated for each individual MOS scale. Both baseline BDI scores and BDI change-scores were independently associated with poorer 6-month QOL as measured by all 5 physical functioning scales (physical functioning, satisfaction with physical functioning, physical role functioning, energy, self-rated health) (ßs from –0.263 to –0.577, p values ≤.01). Increases in depressive symptoms were also associated with poorer 6-month QOL as measured by all 4 psychosocial scales (positive affect, anxiety, social role functioning, cognitive function) (ßs from –0.259 to –0.319, p values <.05). By contrast, baseline depressive symptoms had significant effects on only 3 of 4 psychosocial scales (positive affect, anxiety, cognitive function) (ßs from –0.224 to –0.350, p values <.05). Failure to significantly predict 6-month social role functioning (ß = –0.162, p > .15) evidently accounted for the marginal significance of the effect of baseline depressive symptoms on the global psychosocial index (see Table 4). Neither depression measure was significantly associated with MOS mobility scores (p values >.10).

Further analysis examined whether 3 postsurgical biomedical variables, available for 89 of the 90 patients, accounted for effects of depressive symptoms on QOL. Postoperative length of hospital stay, postoperative complication, and 2-month change in angina were added to each of the 2 main effects models presented in Tables 3 and 4. Smaller improvements in angina were associated with poorer 6-month physical functioning (ß = – 0.197, p < .05). However, there was no significant effect for either postoperative complication or length of stay (p values >.35). Addition of these 3 predictors strengthened the effect for baseline physical functioning (p < .05), and slightly weakened the effects of age and history of MI (p values <.10), but had no effect on other findings, including those for BDI baseline and change-scores (p values <.001).

Results for the psychosocial index also indicated that smaller improvements in angina were associated with poorer 6-month functioning (ß = –0.217, p < .05), and once again there was no significant effect for either postoperative complication or length of stay (p values >.07). These additional predictors slightly strengthened the effect of baseline BDI (p = .055) but had virtually no impact on other results, including those for BDI change (p = .001).

We then sought to determine whether results were affected by inclusion in the sample of 3 patients taking antidepressant medication before admission and/or following discharge. Deletion of data for these patients had no impact. The associations linking severity and course of depressive symptoms to each QOL measure were virtually unaltered.

Next we examined the baseline depression x depression change interaction and interactions between either age or gender and each of the depression predictors. Results for 6-month psychosocial functioning indicated a significant interaction between presurgical BDI and BDI change-scores (B = –0.096, ß = –0.219, sr2 = 0.025, p < .05). As can be seen in Figure 1, there was a stronger relationship between BDI change-scores and psychosocial functioning for patients with higher preoperative BDI scores. There was no significant baseline depression x depression change interaction for 6-month physical functioning, nor was the age x depression or gender x depression interaction significant for either QOL measure (ps > .20).



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  		Figure 1. The plot depicts the interaction between baseline depressive symptoms and change in depressive symptoms from baseline to the 2-month follow-up using coefficients from the regression analysis of 6-month psychosocial functioning. Predicted values of 6-month psychosocial functioning are plotted for patients scoring 1SD below and above the mean for baseline depression (BDI scores of 1.2 and 12.0, respectively) and scoring 1SD below and above the mean for 2-month change in depression (BDI change scores of –5.9 and 3.1, respectively).

 

In effect, by including baseline MOS scores, all regression models described above examined 6-month QOL change. There is therefore a degree of temporal overlap between the 2-month depression-change predictor and QOL outcomes. That overlap would appear to be minimal, however, because virtually all of the net change in 6-month QOL occurred between months 2 and 6 (see Table 2). Nonetheless, to address this issue, 2-month MOS scores were added to the models summarized in Tables 3 and 4 to adjust the outcome measures to reflect changes in QOL from 2 months to 6 months. This had no effect on the results.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 NOTES
 REFERENCES
 
Results of this study indicate that the course of depressive symptoms following heart surgery has effects on postoperative QOL above and beyond the effect of presurgical levels of depressive symptoms. Moreover, postoperative increases in BDI scores interacted with presurgical BDI scores in the analysis of psychosocial functioning, indicating that the effect of increased depressive symptoms was stronger among patients with high compared with low presurgical depressive symptom levels. Both the main effects of depressive symptom change-scores and their interaction with presurgical depressive symptoms are novel findings in research on QOL following heart surgery.

The association linking presurgical BDI scores to postsurgical physical functioning accords with previous work demonstrating effects of depressive symptoms on various aspects of QOL (19,29,30). In the present study, higher levels of preoperative depressive symptoms predicted poorer 6-month physical functioning independently of preoperative physical functioning, demographics, and biomedical factors. Indeed, preoperative depressive symptoms predicted 6-month physical functioning more strongly than any other predictor, including preoperative physical functioning (see Table 3).

Higher preoperative BDI scores showed a significant bivariate association with poorer 6-month psychosocial functioning. However, the association failed to attain significance in multivariate analysis. This is inconsistent with previous findings linking level of preoperative depressive symptoms to psychological and social functioning following cardiac surgery (22,30,35). On the other hand, analyses using individual MOS subscales accorded with previous work by indicating effects for positive affect, anxiety, and cognitive function. Given that p values for effects of preoperative depressive symptoms on the social role functioning subscale and composite psychosocial index were <0.20 and <0.10, respectively, low statistical power attributed to modest sample size provides a plausible explanation for lack of significance.

Findings demonstrating the importance of postoperative changes in depressive symptoms are noteworthy. Increases in depressive symptoms from the preoperative assessment to the 2-month follow-up assessment significantly predicted poorer 6-month QOL using measures reflecting both physical and psychosocial functioning, after adjusting for presurgical depressive symptoms and demographic and biomedical predictors. This extends previous research by demonstrating for the first time that, in addition to effects on cardiac morbidity and mortality (31), increases in depressive symptoms have an adverse impact on QOL outcomes following heart surgery.

The interactive effect of baseline BDI and BDI change-scores on psychosocial functioning has interesting implications. It suggests that high presurgical levels of depressive symptoms may create vulnerability to processes that occur following surgery. The latter may involve negative appraisals of the course of recovery, perhaps attributed to a failure to meet presurgical expectations, which over time may undermine QOL. Other possibilities include biological effects of surgical procedures. Whatever the explanation, the interaction suggests that a high level of baseline depressive symptoms is not critical as long as it is followed by a subsequent decrease in symptoms. This argues for obtaining both presurgical and (multiple) postsurgical assessments of depressive symptoms and points to the importance of knowing why some patients with high baseline levels do not exhibit decreases as would be expected on the basis of the –0.45 correlation between baseline and subsequent change in depressive symptoms.

Mechanisms that explain the effects of depression on QOL following cardiac surgery may be related to those underlying increased cardiac morbidity and mortality in depressed individuals. Depression is associated with alterations in autonomic (36), neuroendocrine (37), immune (38), and platelet function (39). Depressed individuals also have been shown to be less physically active, less medically compliant, and more likely to engage in health-damaging behaviors (40,41). Cognitive and affective symptoms of depression may undermine QOL either by impairing actual functioning or by coloring patients’ perceptions of their health status (3). Whereas these factors have not been examined as mediators of the association between depression and QOL in CABG patients, some have been shown to predict changes in QOL in older adults and patients with atrial fibrillation (42–44). Although the aforementioned mechanisms were not addressed in the current study, several related variables were examined: length of hospital stay, postoperative complication, and angina. Of the 3, only changes in angina were associated with QOL, and none influenced the effects of preoperative depressive symptoms and course of depressive symptoms.

Limitations of this study include small sample size, self-report measurement of depression and QOL, and less than comprehensive assessment of biomedical variables. Despite a prospective design and adjustments for demographic and biomedical predictors, it is possible that unmeasured variables influenced the findings. Moreover, although the QOL measures were broad and multifaceted, it is possible that different assessment approaches would have yielded different results. Selective recruitment and attrition represent additional limitations. Dropouts reported significantly higher preoperative levels of depressive symptoms than those who completed later interviews. Both dropouts and completers may have had lower levels of depressive symptoms than the larger population of CABG patients and may have differed from them with respect to socio-demographic and biomedical factors, questions that could not be thoroughly addressed within the available data. Therefore, the findings may not generalize to the larger population of CABG patients. On the other hand, the fact that study patients were psychologically healthier than average may have produced a conservative bias, because the restricted range and moderate level of depressive symptoms may have attenuated associations with QOL. The issues of sampling and attrition are complex, however (26). As sample size increases, the number of deaths will increase, and as follow-up intervals increase, there will be corresponding increases in rates of morbidity and mortality. This may produce selective loss to follow-up that obfuscates the impact of depression on QOL.


   CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
NOTES
 REFERENCES
 
The severity and course of depressive symptoms may undermine QOL despite successful cardiac surgery. Further research is needed to determine optimal timing for the assessment of depression in this population and to identify pathways by which depression influences QOL. Understanding the impact of depression on QOL may facilitate identification of patients likely to benefit from heart surgery, thereby informing treatment decisions. In addition, it may help to guide development of interventions to enhance QOL following surgery.

We thank Erich Labouvie for valuable comments on earlier versions of this paper.


   NOTES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 NOTES
REFERENCES
 
Tanya Goyal is presently affiliated with the Columbia University Medical Center, New York City, New York.

This research was conducted in partial fulfillment of requirements for a doctoral degree in clinical psychology at Rutgers University.

Supported by grants from the Fetzer Institute and from the National Institute on Aging (AG15160 and AG16750).

Received for publication July 20, 2004; revision received March 29, 2005.

DOI:10.1097/01.psy.0000174046.40566.80


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 NOTES
 REFERENCES
 

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