Page 793 - Cardiac Nursing

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P P P P Psychosocial Risk Factors: Assessment and
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M M M Management Interventions
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Simone K. Madan / Erika S. Sivarajan Froelicher
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D Despiite extensive resear hch a dnd addvances iin kno lwl dedge abbo tut coro- po popula ion, 17,18 and theirr ddepression leaads to worse cardiiovascular
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na nary heart disease (CHD) overr thee past several decades, traditional l ou outcomes, eespecially in younger women. 19 Besides women, indi-
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risk factors and genetics fail to fully explain either the develop- viduals with low income and lless education experience significanttlly
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ment or he course off thee diseasee. Con i tstentt iwith biiopsychhoso ici lal higher rates of depression. 17 Regardless of the severity of CHD,
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models of health, studies have now shown that psychological and patients with depression are three to four times more likely to die
social factors are also related to the development of and recovery in the first year after a myocardial infarction (MI) than those with-
from CHD. In health schemas of the mind and body, emotions out depression. 20,21 Six months after an MI, patients with depres-
have often been linked to specific organs. The English language is sion had a 17% event rate compared with 3% for nondepressed
replete with expressions that describe this assignation. For exam- patients ; at 18 months, premature ventricular contractions and
20
ple, jubilation “makes the heart flutter” or anxiety causes “butter- mortality were reported for 50% of patients with depression com-
flies in one’s stomach.” Throughout the ages, the heart has been pared with 17% for those without. 22
seen as the “seat of emotions.” William Harvey (1578 to 1657), Combined depression and CHD is a significant challenge for
the English physician who first described the circulatory system, patients recovering from a cardiac event. Depression can lead to
wrote, “Every affliction of the mind that is attended with either social withdrawal and less participation in activities such as exer-
pain or pleasure, hope or fear, is the cause of an agitation whose cise. 23,24 Depressed patients have more difficulty adopting and
1
influence extends to the heart.” In this chapter, we summarize maintaining healthy lifestyle behaviors, 25 and they consistently
the evidence that links psychological and social factors to CHD report higher smoking rates compared with nondepressed CHD
and describe how nurses can assess and manage selected psy- patients. 11,26 For example, in older patients who suffered an MI,
chosocial risk factors to promote cardiovascular and psychosocial depression scores predicted the performance of risk-reducing,
health. self-care behaviors. 27 In patients attending cardiac rehabilitation
programs, anxiety, depression, and coping abilities predicted
leisure-time activity and higher smoking cessation at 1-year follow
PSYCHOSOCIAL RISK FACTORS up. 28 In relation to functional impairments, only 38% of patients
FOR CHD with depression returned to work within 3 months of a cardiac
event compared with 63% of nondepressed patients. 29 Depres-
Several psychosocial risk or prognostic factors have been identified sion is also associated with decreased compliance in taking med-
for CHD: acute life events, anxiety, depression, hostility, job ications 12,30 and a delay in seeking medical treatment, because
stress, low-perceived social support, social isolation, socioeco- affected patients often minimize the significance of cardiac
nomic status, and Type A personality. 2–5 Of these, depression and symptoms. 31,32 Besides the individual health consequences of de-
low-perceived social support have been well established as inde- pression in CHD patients, tremendous economic costs affect soci-
33
pendent risk factors for CHD, as shown in Table 33-1. 6 ety. The cost of increased hospitalization admissions for recurrent
cardiac events and longer hospital stays are also associated with
Depression higher emotional distress. The average hospital cost for a depressed
cardiac patient is more than four times the cost of a nondepressed
The complex clinical diagnosis of depression, as defined in the Di- patient. 25
agnostic and Statistical Manual of Mental Disorders, Fourth Edi-
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tion, classifies the disorders as either major or minor based, in Social Support
part, on the number, frequency, and duration of symptoms and
signs. In this chapter, the term depression will be all inclusive. Sub- Social support is defined by the quality of the structure and func-
stantial empirical evidence from well-designed population stud- tion of social relationships. Structural support reflects the number
ies 8,9 and review papers 2,4,10 have shown that depression is a risk and frequency of social interactions, social ties, and networks. 34,35
factor for CHD. Furthermore, depression is also a prognostic fac- Functional support focuses on tangible aid, emotional comfort
tor for CHD patients, 2,4,10–16 and high prevalence rates of the and care, and the value an individual places on the support. 34,35
disorder have been found in CHD populations. Studies have re- Structural and functional support, however, fail to account for
ported that 16% to 25% of the CHD population has depression, individual perceptions and beliefs about the support. Further,
as compared with 6% of the general population. 11–14 Women in they do not account for (a) the social skills needed to elicit sup-
the g general population are especially at higher risk because they y p port from others; (b) how much support, if any, is needed or ac-
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are twice as likely to be depressed than men, thus one would ex- ceptable and who should provide it; (c) whether an individual is
pect the same gender distribution to be observed in the cardiac deserving of support; or (d) the concern of the cost of seeking
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