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Psychosomatic Medicine 68:794-800 (2006)
© 2006 American Psychosomatic Society

ORIGINAL ARTICLES

Resource Loss Predicts Depression and Anxiety Among Patients Treated With an Implantable Cardioverter Defibrillator

Faith S. Luyster, MA, Joel W. Hughes, PhD, Donna Waechter, PhD and Richard Josephson, MS, MD

From the Department of Psychology, Kent State University, Kent, Ohio (F.S.L., J.W.H., D.W., R.J.); and Summa Health System, Akron, Ohio (J.W.H., D.W., R.J.).

Address correspondence and reprint requests to Joel W. Hughes, PhD, Department of Psychology, P.O. Box 5190, Kent, OH 44242. E-mail: jhughes1{at}kent.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Objective: Many patients treated with an implantable cardioverter defibrillator (ICD) experience clinically significant depression and anxiety after ICD implantation. As ICD use continues to evolve, it is important to understand the correlates of depression and anxiety to identify patients at greatest risk of poor psychological functioning. Conservation of resources theory, a general theory of stress, states that people experience greater stress if they perceive that they are losing personal, social, and material resources. We hypothesized that perceptions of resource loss would be related to symptoms of depression and anxiety after controlling for other known predictors.

Methods: One hundred patients treated with an ICD completed standardized depression and anxiety questionnaires along with questionnaires assessing social support, physical functioning, and resource loss. Clinical variables for patients were obtained from prospectively obtained medical records.

Results: Over 20% of the sample exhibited elevated symptoms of depression and anxiety. Patients' depression levels were associated with poor social support, poor physical functioning, a history of depression, and a greater length of time since ICD implantation. Having experienced one or more clinical ICD shocks was related to depression but not anxiety. Higher levels of perceived resource loss were associated with higher levels of both depression and anxiety after controlling for all other predictors.

Conclusions: Resource loss may help to determine psychological distress after ICD implantation. Understanding how resource loss contributes to depression and anxiety may help to identify patients at greatest risk of poor psychological functioning and may suggest treatment strategies.

Key Words: implantable cardioverter defibrillator • resource loss • depression • anxiety

Abbreviations: ICD = implantable cardioverter defibrillator; COR = conservation of resources; BDI = Beck Depression Inventory; STAI = State-Trait Anxiety Inventory.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
The annual mortality rate among patients with heart failure ranges from 10% to 50% and 30% to 50% of deaths are sudden (1). Clinical trials have demonstrated the efficacy of the implantable cardioverter defibrillator (ICD) in reducing mortality resulting from sudden cardiac death as well as its superiority over antiarrhythmic therapy in primary and secondary prevention (2–5). Consequently, ICDs have become a common medical treatment for life-threatening arrhythmias. Approximately 69,000 devices were implanted in 2003, the last year for which statistics are available (6); however, the number of procedures has continued to grow as the indications for ICD use expand. Despite its effectiveness in preventing sudden cardiac death, ICDs present patients with a unique situation that encompasses concerns about shocks, body image, driving, lifestyle changes, and death (7). For example, the simple recommendation that an ICD be implanted may alarm patients regarding the serious of their cardiac illness, and subsequently receiving a shock from an ICD can act as a forceful reminder that death may have occurred had the patient not had the device. Additionally, events such as a device recall by the manufacturer may instigate concern about proper functioning of patients' ICDs. In line with these concerns, patients often report problems with depression and anxiety after implantation (8). For example, one study found between 22% and 66% of patients with an ICD have clinically significant levels of depression (9).

However, the level of distress exhibited by patients treated with an ICD and, more broadly, the effects of an ICD on patient quality of life are moving targets. The indications for ICD implantation have expanded to include primary prevention and use of the device is expected to grow rapidly (10,11). The rates of clinically significant depression and anxiety widely vary between studies, and a recent meta-analysis (12) and data from clinical trials (13,14) suggest that patient quality of life does not deteriorate after ICD implantation and improves in some cases (15). As more patients with heart failure are treated with ICDs, it is important to understand the correlates of depression and anxiety among postimplant patients to identify patients at greatest risk for poor psychological functioning.

A number of risk factors for poor quality of life and adverse psychosocial outcomes after ICD implantation have been identified, including younger age, a high rate of ICD shocks, poor social support, and increased medical severity (16,17). In particular, patients with an ICD who received shocks were more anxious than those who had not (18). Another potential determinant of psychological distress is a history of depression or mental health problems. Among patients treated with an ICD, those with diagnosable depression, phobia, or generalized anxiety are more likely to have a history of psychiatric illness than those without a psychiatric disorder (19). This finding suggests that psychological distress after ICD implantation may be more likely among patients with a history of mental illness.

In addition to age, ICD shocks, social support, illness severity, and history of psychological distress, the many changes in patients' lives that can occur as a result of their illness and its treatment are likely to be associated with psychological distress. Qualitative research as well as clinical impressions of patients with heart failure reveals that they often attribute their distress to changes in their life as a result of the illness and its treatment rather than merely to their risk of mortality or specific treatment events (20,21). For example, patients sometimes report that they are most upset by being unable to work, conflicts with their spouse, mounting medical bills, being unable to drive, changes in sexual intimacy, and being unable to engage in preferred activities (e.g., gardening, hunting) resulting from physical limitations. Prominent health psychologist Wayne Sotile's book for cardiac patients entitled Thriving With Heart Disease (22) reinforces this idea with his description of a "new normal" that patients must embrace after a major cardiac event. The new normal includes not only changes in health behaviors and learning to cope with stress, anger, and depression, but also changes in relationships, ways of thinking, and activities.

One general theory of stress that can account for a number of these changes is conservation of resources (COR) theory, which states that people experience greater stress if they perceive that they are losing personal (e.g., feeling valuable to others), social (e.g., relationship with close friend), and material resources (e.g., adequate food) (23). COR theory has been prominently used in examining work-related stress (24–26) and reactions to traumatic stress (27–29). Few studies have applied COR theory to chronic diseases, but one study of patients with chronic obstructive pulmonary disease showed that resource loss related to disease predicted outwardly expressed anger (30).

COR theory applies well to the understanding of distress experienced by patients treated with an ICD because there are a number of events associated with ICD treatment (e.g., disease symptoms, implantation of the device, device firings) that are often perceived as stressful, and because severe heart failure and treatment with an ICD has the potential to affect resources in multiple domains (e.g., finances, activities, relationships). According to COR theory, individual differences in perceived resource loss are particularly important in determining how stressful people perceive these events as well as the success of efforts to cope with them. It is widely recognized that ICD implantation can be associated with psychological distress, and advances have been made in understanding the correlates of psychological distress. However, there has not been a systematic investigation of how concerns that patients often report (e.g., body image, driving, lifestyle changes, finances) relate to psychological distress, and in particular no research has examined the relationship between perceived resource loss and distress among patients with heart failure treated with an ICD. COR theory states that individuals who perceive less loss or threat of loss of their resources, broadly defined, should be able to cope more successfully and thus experience less psychological distress. Therefore, as COR theory would predict, we hypothesized that patients' perceptions of actual or threatened loss of resources would be related to symptoms of depression and anxiety after controlling for other known predictors.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 
Study Population
Patients with an ICD were approached and invited to participate in the study at a scheduled ICD medical appointment at a large cardiology practice in Akron, Ohio, from January 2005 to June 2005. Of the 125 patients approached, 101 (81%) consented to the study and were enrolled in the study. Those who did not consent largely reported time constraints as the reason for declining. One patient was excluded because they did not sufficiently complete the questionnaires. The final sample size was 100 patients treated with an ICD.

Procedure
Patients were initially contacted through a recruitment letter sent by their cardiologist or the researcher approximately 1 week before a scheduled ICD medical appointment. The letter introduced the study and informed patients that a researcher would be present at the time of their scheduled appointment to further discuss the study, to answer any questions about the study, and to invite them to participate. At the patient's scheduled ICD medical appointment, a researcher approached the patient, explained the study, and asked them to participate. If the patient was unable to complete the packet at their scheduled appointment or preferred to complete the packet at home, the researcher provided the patient with a self-addressed, stamped envelope to return the packet through the mail. Written informed consent was obtained before study participation. The Institutional Review Boards of Summa Health System and Kent State University approved the study protocol.

Measures
Demographic and Clinical Variables
Participants provided demographic data regarding gender, age, marital status, ethnicity, and education. Information on time since ICD implantation (in years), indication for ICD implantation (primary prevention vs. secondary prevention), previous myocardial infarction, previous bypass surgery, and previous cardiac arrest was obtained from medical records. Indication was coded as primary if the implantation was prophylactic and there had not been a primary event (e.g., resuscitated cardiac arrest). For example, patients who qualify for an ICD on the basis of having a prior myocardial infarction, a left ventricular ejection fraction <35, and a documented episode of asymptomatic nonsustained ventricular tachycardia were coded as primary prevention. Indication was coded as secondary prevention if the ICD was implanted because the patient had experienced sustained symptomatic ventricular tachycardia and/or fibrillation or resuscitated cardiac arrest. The total number of clinical shocks (none vs. ≥1 shock) was determined from ICD interrogation data (ie, shocks delivered as part of device testing were not counted).

Measures of Social Support, Physical Functioning, and Resource Loss
The ENRICHD Social Support Inventory evaluated functional social support, particularly emotional support, by asking respondents to rate the availability of someone to provide social support (31).

Physical functioning was measured using the Duke Activity Status Index (32). The 12-item scale asked respondents to rate their physical ability to do one or more physical activities in the past month. Higher scores indicate that the subject is better able to engage in physical activities.

The Conservation of Resources Evaluation was used to assess resource loss (COR-E) (23). The original 74-item scale was designed to measure people's resource gains and losses. For the purpose of the current study, only the loss items of the COR-E were used. The content of the loss scale was modified to only include items most relevant to patients treated with an ICD. The modified 33-item scale asked respondents to rate the extent to which they have lost each resource since the implantation of their ICD. For example, some of the resources listed are "adequate income," "feeling valuable to others," and "free time." Higher scores indicate more loss with a range of scores from 33 to 86.

Measures of Depression and Anxiety
Severity of depressive symptoms was assessed using the Beck Depression Inventory (BDI) (33). The BDI is a 21-item scale that asked respondents to choose the responses that best describe how they have been feeling in the past week. Patients with BDI scores of ≥10 are considered to show at least moderate symptoms of depression (34).

History of depression was determined from three items taken from the Brief Patient Health Questionnaire (35). These items ask respondents to indicate if they had ever taken medicine for depression, received therapy for depression, or experienced for more than normal ups and downs for at least 2 weeks. Patients were categorized as having a history of depression if they answered yes to any of the three questions.

The trait items of the State-Trait Anxiety Inventory (STAI) were used to evaluate general anxiety symptomatology (36). Scores range from 20 to 80 with a score of ≥40 indicating a risk for clinical anxiety. Participants scoring greater than 40 on the STAI are more than one standard deviation above the mean score for the reference group (59–80-year-old nonpsychiatric norms) (37), which is considered to indicate the possibility of clinically significant anxiety.

Statistical Analysis
SPSS version 12.0 (SPSS Inc; Chicago, IL) was used for the analyses. Associations between demographic and clinical variables and the dependent variables were analyzed with Pearson and point-biserial correlations. Descriptive statistics were used to determine the rates of depression and anxiety in the sample. Hierarchical regression analyses were performed to examine determinants of depression and anxiety in patients treated with an ICD. Covariates were included in the model if the bivariate correlation significance levels with depression and/or anxiety were p < .05. The covariates (marital status, education, and the continuous variable, years since first ICD implantation) were entered on step 1; gender, social support, and history of depression on step 2; physical functioning and ICD shocks on step 3; and resource loss on step 4. p < .05 was used for all tests to indicate statistical significance.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 NOTES
 REFERENCES
 
Patient Characteristics
Table 1 summarizes the demographic characteristics of the sample of patients with ICDs. Patient age ranged from 35 to 85 years with a mean age of 67.9 years (standard deviation [SD] = 11.8). The majority of the sample was male and married. Most patients were white (90%) and reported having 12 or more years of education (78%). Average time since ICD implantation was 1.9 ± 1.8 SD years ranging from 0.07 years to 8.8 years. Approximately three fourths of the patients (74%) had not experienced a clinical ICD shock in the preceding 3 years. Of the patients who did experience shock, the mean number of shocks was 1.9 with a minimum of one shock and a maximum of five shocks.


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  		TABLE 1. Sociodemographic and Cardiac Characteristics (N = 100)

 

Resource Loss
The average score on the modified COR-E was 42.5 (SD = 11.7). There are no norms for comparison, so to put participants' reports into perspective, the 10 items for which patients reported the most loss are reported in Table 2. Patients reported experiencing the most threat of loss or actual loss of resources related to health and finances. For example, 52% of patients reported some to a great deal of threat or loss of their personal health and 35% reported loss of financial assets. In contrast, patients reported less threat or loss of interpersonal resources. For example, only 12% of patients reported experiencing any loss or threat of loss of affection from others.


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  		TABLE 2. The Top 10 Resources From the Conservation of Resources Measure With the Most Reported Loss or Threat of Loss (% of patients; N = 100)

 

Rate of Depression and Anxiety
Depressive symptoms were elevated (BDI score ≥10) in 22% of the patients treated with an ICD. Symptoms of anxiety were elevated in the clinical range (STAI score ≥40) in 21% of the patients treated with an ICD.

Determinants of Depression and Anxiety
Table 3 displays the results of the hierarchical regression analysis for depression and shows the standardized regression coefficients, R2, and F value for each step. The three covariates (marital status, education, and years since ICD implantation) were significantly associated with depression scores when entered on the first step (F [3, 85] = 4.16, p < .00). When gender, social support, and history of depression were entered on step 2, an additional 14% of the variance was accounted for (F [3, 82] = 5.74, p < .000). ICD shocks and physical functioning were entered on step 3 and independently accounted for 15% of the variance in depression (F [2, 80] = 8.09, p < .000). Resource loss was entered on step 4 and independently accounted for 9% of the variance beyond that accounted for on steps 1, 2, and 3 (F [1, 79] = 10.17, p < .000). The full model, which included the three covariates, gender, social support, history of depression, physical functioning, ICD shocks, and resource loss, accounted for 48% of the variance in depression scores. Greater years since first ICD implantation, poor social support, a history of depression, poor physical functioning, having ≥1 ICD shocks, and greater resource loss were related to elevated depression symptoms.


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  		TABLE 3. Regression Coefficients for Predicting Beck Depression Scores

 

The same regression description as in Table 3 was performed with STAI scores regressed on the variables (Table 4). Gender, social support, and history of depression independently accounted for 10% (F [3, 82] = 4.86, p < .000) of the variance in anxiety scores (decreasing from 14% in the previous regression analysis). ICD shocks and physical functioning independently accounted for 16% (F [2, 80] = 7.54, p < .000) of the variance in anxiety scores (increasing from 15% in the previous regression analysis). Finally, resource loss accounted for 16% of the variance in anxiety scores as compared with the 9% of variance that resource loss accounted for in depression scores. Greater years since ICD implantation, not being married, poor social support, a history of depression, poor physical functioning, and greater resource loss were related to an increased risk of anxiety.


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  		TABLE 4. Regression Coefficients for Predicting Trait Anxiety Scores

 


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
NOTES
 REFERENCES
 
Approximately 22% of our sample of patients treated with an ICD had elevated depression scores and 21% had elevated anxiety scores. Rates of depression and anxiety reported for other samples of patients with ICDs have wide ranges such as 22% to 66% for depression and 31% to 83% for anxiety (9). Although our rates fall within the lower end of the ranges reported previously, they are consistent with the rates of diagnosable major depression (20%) and depressive symptoms (20–30%) found in the general cardiac population (38).

Interestingly, a greater length of time since ICD implantation was related to higher levels of depression and anxiety. Although it may be expected that patients would adjust to their ICD with time, and that initially higher levels of depression and anxiety would subside among patients who have had their ICD for a greater length of time, our findings are consistent with previous research. Most of our patients had their ICDs for more than 1 year (66%), and previous studies have shown elevated levels of depression and anxiety to persist at 1 year postimplantation (9,39). Additionally, one study found anxiety levels to decrease over the 6 months after implantation with an increase in anxiety levels at 12 months (40). As years pass since ICD implantation, increasing age and declining health could contribute to increases in anxiety and depression. For example, Wallace et al. (41) found that as the number of years since implantation increased, physical quality of life continued to decrease after controlling for age. In addition to deteriorating health, resource loss may be another potential explanation for these findings. In particular, the effects of resource loss on distress may develop over long periods of time, underscoring the need for future research on resource loss in patients treated with an ICD. Finally, if risk of depression and anxiety varies with time from ICD implantation, this may have profound implications for clinical management of these patients. It may be inadequate to "front load" psychosocial assessments and interventions at and shortly after the time of implantation. Patients may need to be screened for depression and anxiety at regular intervals to detect new cases that emerge with additional time from ICD implantation.

Lower social support, worse physical functioning, and history of depression were significantly related to elevated depression and anxiety scores. Chevalier and colleagues (19) found a personal history of depression to be more prevalent among patients with an ICD with diagnosable depression or generalized anxiety. Future studies using a longitudinal study design are necessary to determine the direction of the relationship between social support and symptoms of anxiety and depression after ICD implantation.

In our sample, experiencing ICD shock was associated with higher levels of depression but was not associated with higher levels of anxiety. Likewise, no significant differences on anxiety measures were found in another study of shock versus no shock ICD patients (19). It has been suggested that anticipatory anxiety associated with ICD shock may be a more important contributor to psychological distress than the actual occurrence of ICD shock (42). However, it is yet to be determined whether anxiety leads to more shocks or whether anticipatory anxiety associated with shocks leads to elevated anxiety symptoms. Furthermore, Whang et al. (43) reported that depression prospectively predicted appropriate ICD shock. Therefore, the direction of the relationship between distress and ICD shock may be the reverse of how we have interpreted our cross-sectional findings. Future studies should use a longitudinal study design to determine the directionality of the relationship between anxiety and ICD shock.

The current study extends previous examinations of risk factors for poor psychological functioning in patients treated with an ICD by also assessing resource loss as a potential risk factor for distress. Higher levels of perceived resource loss were related to higher levels of both depression and anxiety. The resource loss that patients report after ICD implantation related to their illness or as a result of limiting activities resulting from fear of ICD shock may in turn prevent patients from obtaining necessary resources such as financial stability or feeling valuable to others. Results of this study demonstrate the importance of COR theory in understanding psychological distress among cardiac patients, in particular, ICD recipients. Future research should investigate the mechanisms whereby resource loss affects depression and anxiety among patients with an ICD.

Findings of the present study also present a possible avenue for innovative interventions for patients treated with an ICD at risk for poor psychological functioning. Thus far, only one intervention study has been shown to be effective in reducing distress levels among ICD recipients (44). It would certainly be feasible to incorporate components aimed at minimizing resource loss. This could include acclimating patients to performing daily activities or bolstering patients' self-efficacy and self-esteem toward the goal of attaining or preserving social, personal, and material resources. Consequently, such an intervention may enable patients to retain or regain control over their lives and improve psychosocial adjustment to not only their ICD, but also to their cardiac illness. In fact, exercise rehabilitation may be an appropriate intervention for patients treated with an ICD. Research has shown exercise training to be safe and beneficial in this population (45,46). Furthermore, a randomized, controlled trial of a cardiac rehabilitation program for patients with ICDs found improvements in exercise duration and decreases in levels of anxiety and depression from baseline to after cardiac rehabilitation (46). Cardiac rehabilitation is a comprehensive intervention program for cardiac patients consisting of exercise training, cardiac risk factor modification, education, and counseling (47). Involvement in rehabilitation may enhance quality of life and psychosocial functioning among patients treated with an ICD. Thus, the structure and function of cardiac rehabilitation would be well suited to incorporating efforts to minimize perceived and actual loss of resources.

The present study has several limitations. First, the cross-sectional design of the present study precludes determining causality and the directionality of the relationships. Although it is likely that poor social support, resource loss, and ICD shocks predict the development of psychological distress, it is also possible that distress may lead to a diminished social network, a loss of resources, and more ICD shocks. Future research is needed to clarify this relationship. Second, psychological distress was based on self-report measures of depression and anxiety. Although these measures are widely used and well-validated, other methods may provide different outcomes. Third, our findings may not generalize to younger patients treated with an ICD. "Young" patients treated with an ICD have typically been categorized as 50 or younger (48), which is younger than our sample (mean age = 68 years). "Young" patients may experience greater difficulty adjusting after implantation and experience different adjustment issues than older patients (48). Finally, although our sample was representative of the community from which patients were obtained, the homogeneity of the sample may limit the generalizability of the findings to other patient populations (ie, black, low income, less educated). Despite these potential limitations, our study was the first to demonstrate that resource loss may be a key component in explaining the severity of depression and anxiety symptoms among patients treated with an ICD.

These results suggest that a significant proportion of ICD recipients experience psychological distress and that resource loss may be an important determinant of anxiety and depressive symptoms. Interventions aimed at improving patients' confidence in their capability to perform activities, including cardiac rehabilitation, may help to improve their ability to obtain necessary resources and alleviate psychological distress.

We thank Bonnie Newell. This research was supported by the Applied Psychology Center of the Department of Psychology at Kent State University.


   NOTES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
REFERENCES
 

Received for publication October 7, 2005; revision received April 19, 2006.

DOI:10.1097/01.psy.0000227722.92307.35


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 NOTES
 REFERENCES
 

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