International Journal of Cardiology 181 (2015) 73–76
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Cardiac anxiety after sudden cardiac arrest: Severity, predictors and clinical implications☆ Lindsey Rosman a, Amanda Whited a, Rachel Lampert c, Vincent N. Mosesso d, Christine Lawless e, Samuel F. Sears a,b,⁎ a
East Carolina University, Department of Psychology, United States East Carolina University, Department of Cardiovascular Sciences, United States Yale University School of Medicine, United States d University of Pittsburgh School of Medicine, United States e Sports Cardiology Consultants, Chicago, IL, United States b c
a r t i c l e
i n f o
Article history: Received 15 May 2014 Accepted 16 November 2014 Available online 18 November 2014 Keywords: Sudden cardiac arrest Cardiac anxiety Psychosocial adjustment Quality of life
a b s t r a c t Background: Survival from cardiac arrest is a medical success but simultaneously produces psychological challenges related to perception of safety and threat. The current study evaluated symptoms of cardiac-specific anxiety in sudden cardiac arrest (SCA) survivors and examined predictors of cardiac anxiety secondary to cardiac arrest. Methods: A retrospective, cross-sectional study of 188 SCA survivors from the Sudden Cardiac Arrest Association patient registry completed an online questionnaire that included a measure of cardiac anxiety (CAQ) and sociodemographic, cardiac history, and psychosocial adjustment data. CAQ scores were compared to published means from implantable cardioverter defibrillator (ICD), inherited long QT syndrome (LQTS), and hypertrophic cardiomyopathy (HCM) samples and a hierarchical regression was performed. Results: Clinically relevant cardiac anxiety and cardioprotective behaviors were frequently endorsed and 18% of survivors reported persistent worry about their heart even when presented with normal test results. Compared to all other samples, SCA survivors reported significantly higher levels of heart-focused attention (d = 0.3–1.1) and greater cardiac fear and avoidance behaviors than LQTS patients. SCA patients endorsed less severe fear and avoidance symptoms than the HCM sample. Hierarchical regression analyses revealed that younger age (p = 0.02), heart murmur (p = 0.02), history of ICD shock ≥ 1 (p = 0.01), and generalized anxiety (p = 0.008) significantly predicted cardiac anxiety. The overall model explained 29.2% of the total variance. Conclusions: SCA survivors endorse high levels of cardiac-specific fear, avoidance and preoccupation with cardiac symptoms. Successful management of SCA patients requires attention to anxiety about cardiac functioning and security. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Advances in resuscitation and medical technology have revolutionized care and improved survival outcomes for more than 350,000 adults who experience sudden cardiac arrest (SCA) in the United States each year [1]. Although a majority of studies have focused on medical outcomes, the behavioral and psychosocial sequelae of cardiac arrest are a major cause of long-term morbidity and disability among survivors
☆ Funding sources: This work was supported by a research contract with the Sudden Cardiac Arrest Association. The SCAA received grant funds from the Medtronic Foundation in support of this study. ⁎ Corresponding author at: East Carolina University, Department of Psychology, 104 Rawl Hall, Greenville, NC 27858, United States. E-mail address: [email protected] (S.F. Sears).
http://dx.doi.org/10.1016/j.ijcard.2014.11.115 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
[2–5]. This life-threatening event may also lead some survivors to develop disease-specific anxiety or cardiac anxiety, a condition characterized by cardiac specific-fear, avoidance behaviors, and excessive cardiac symptom monitoring [6]. This cluster of symptoms is clinically relevant to cardiology patients, as it has been associated with higher rates of CVD-related distress, avoidance of physical activity, patient-reported disability, and worse perceived health outcomes [6–10]. Cardiac anxiety is equally problematic for health care providers, as patients are more likely to seek medical reassurance for normal alterations in cardiac function, resulting in medically unnecessary emergency department visits, costly diagnostics and procedures, and provider burden [7]. No prior studies have examined the extent to which symptoms are present and predictors of cardiac anxiety in this particular population. Therefore, the purpose of this report is to provide an initial evaluation of the severity of cardiac anxiety in a large cross-section of SCA survivors and identify factors that predict cardiac anxiety following cardiac arrest.
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2. Methods 2.1. Study population SCA survivors were recruited from the Sudden Cardiac Arrest Association's (SCAA, Washington, DC) SCA survivor registry. SCA survivors who were aged 18 years or older and able to read and complete study questionnaires were contacted to participate in this retrospective cross-sectional online study. 2.2. Data collection procedures This study is part of a larger project, Cardiovascular Outcomes and Psychosocial Education 2012 (COPE 2012), whose purpose was to determine the acute and chronic needs of SCA survivors affiliated with the SCAA survivor registry. Information about the study was distributed to SCA survivors registered with the SCAA online database between October 2012 and January 2013 and included a link to an online survey. Interested participants completed study questionnaires regarding sociodemographic information, cardiac history, psychosocial adjustment, and cardiac-specific anxiety after SCA. The study protocol was approved by the Internal Review Board at East Carolina University. 2.3. Measurement instruments 2.3.1. Cardiac anxiety questionnaire The CAQ is a previously validated, 18-item self-report measure with three subscales (cardiac fear, avoidance, and heart-focused attention), designed to assess cardiacspecific anxiety [6]. For each item, participants indicated how often they have felt in the described manner or performed the described behavior on a 5-point Likert scale bounded by 0 (never) and 4 (always). Individual items were summed and divided by 18 to obtain a CAQ scale score. Means were also used to calculate subscale scores. Prior research supports the measure's internal consistency (αs = 0.83) and convergent validity with other established measures of psychological distress [6,8]. Cronbach's alpha in the current study was 0.89. 2.3.2. Psychosocial adjustment Two single-item dichotomous measures were used to assess current symptoms of depression and generalized anxiety. Symptoms were rated as present or absent and used as measures of general psychological adjustment in the regression analysis. 2.4. Statistical analysis Descriptive statistics were calculated for sociodemographic data and cardiac history. Dichotomous medical variables were coded as present or absent and coded according to participant response. Cohen's d effect sizes were also calculated to compare participants' scores on the CAQ to published means from implantable cardioverter defibrillator (ICD), inherited long QT syndrome (LQTS), and hypertrophic cardiomyopathy (HCM) samples [9,10]. Total scale scores for the CAQ were not consistently provided in studies of these samples, so only mean subscale scores were analyzed to compare our sample to the ICD, LQTS, and HCM data in this particular analysis. In addition, chi-square tests and t-tests were used to compare differences between SCA survivors with severe and mild cardiac anxiety. As there are no established and validated clinical cutoff scores for the CAQ, total scores were divided into quartiles to examine differences between high and low levels of cardiac anxiety. Severe cardiac anxiety was defined as total scores in the upper quartile (CAQ ≥ 1.81), and scores in the lowest quartile (CAQ ≤ 0.73) were considered mild cardiac anxiety. Finally, a hierarchical multiple regression was performed to identify predictors of cardiac anxiety after SCA. In this model, CAQ total scores for all participants were entered as a continuous dependent variable, and eight independent variables were included as predictors (i.e., female gender, age, history of heart disease, history of heart murmur, having an ICD, history of ICD shock, depression and generalized anxiety). Demographic (gender, age), cardiac (history of heart disease, history of heart murmur, ICD status, history of ICD shock ≥ 1), and psychosocial (depression, generalized anxiety) variables were added to the model in three progressive steps to determine the relative contribution of these domains and whether adding additional predictors increased the amount of variance in CAQ scores that was explained. Differences with a p-value of b0.05 were considered significant. All analyses were performed with SPSS version 20.0 (SPSS Inc., Chicago, Illinois).
Table 1 Sociodemographic and cardiac history for SCA survivors with high and low cardiac anxiety. Characteristic
Entire sample (n = 188)
Mild cardiac anxiety (n = 43)
Age in years Men White/Caucasian Education High school Some college/college grad Graduate school Income Low: $0–49,999 Medium: $50,000–149,999 High: $150,000+ Time since SCA (years) Cardiac characteristics Heart disease prior to SCA ICD History of ICD shock
55.43 ± 12.07 58.02 ± 11.13 50.00 ± 11.27 b0.01⁎ 104 (55.0%) 32 (74.4%) 19 (44.2%) b0.01⁎ 177 (93.7%) 40 (93.0%) 38 (88.4%) 0.71
Severe cardiac anxiety (n = 43)
p
4 (2.1%) 127 (67.5%)
0 (0.0%) 21 (48.8%)
2 (4.7%) 33 (76.7%)
0.49 b0.01⁎
58 (30.7%)
22 (51.2%)
8 (18.6%)
0.01⁎
29 (15.3%) 94 (49.7%)
4 (9.3%) 22 (51.2%)
13 (30.2%) 16 (37.2%)
0.03⁎ 0.28
51 (27.0%) 4.7 ± 3.9
16 (37.2%)
9 (20.9%)
0.15
45 (23.8%)
9 (20.9%)
8 (18.6%)
0.79
148 (78.3%) 68 (36.0%)
32 (74.4%) 10 (23.3%)
38 (88.4%) 20 (46.5%)
0.24 0.15
⁎ p b 0.05.
3.1. Cardiac anxiety secondary to SCA Scores on the CAQ ranged from 0 to 3.2 (1.29 ± 0.7). Means and standard deviations for CAQ subscales (cardiac fear, avoidance, and heart-focused attention) are presented in Table 2. Frequently endorsed symptoms of cardiac anxiety and cardioprotective behaviors (i.e., rated as “often” or “always” on the CAQ) are summarized in Table 3. Among the items most salient on the CAQ were: persistent worry about their heart even when presented with normal test results (18%), routinely seeking medical attention for any perceived increase in heart rate or chest discomfort (16.2%), and believing that providers do not believe their symptoms are real (10%). Additional comparisons of SCA survivors with mild and severe levels of cardiac anxiety are shown in Table 1. Significant differences in baseline characteristics were found, such that younger age, female gender, higher education and lower income were associated with more severe cardiac anxiety. 3.2. Cardiac anxiety in SCA survivors compared to other cardiac patients Means and standard deviations for CAQ subscale scores for SCA survivors and comparison groups are summarized in Table 2. Compared to mean scores from other cardiac samples, SCA survivors in this sample reported significantly greater cardiac fear than patients with ICDs (d = 0.2) and long QT syndrome (LQTS, d = 0.1) but less severe fear than patients with hypertrophic cardiomyopathy (HCM, d = 0.4). Statistically significant differences in avoidance were also found, indicating that SCA survivors report more severe avoidance than patients with LQTS (d = 0.5) but less avoidance symptoms than patients with ICDs (d = 0.3), and HCM (d = 0.6). In addition, significant differences in heart-focused attention were found between SCA survivors and patients with ICDs (d = 0.8), LQTS (d = 1.1), and HCM (d = 0.3).
3. Results
3.3. Predictors of cardiac anxiety after SCA
Among 591 SCA survivors from the SCAA registry database who were contacted about the study, 188 (31%) consented to participate and completed study questionnaires. Notably, 76 survivors (13%) initially contacted for this study were unable to be reached due to invalid or expired email addresses associated with their SCAA registry account. Sociodemographic data and cardiac history for respondents are presented in Table 1.
A hierarchical regression (Table 4) revealed that demographic data (age and female gender) entered at Step 1 was significant, F(2,136) = 5.84, p = 0.004, ΔR2 = 0.08. Cardiac variables (history of CVD, heart murmur, ICD, ICD shock) entered at Step 2 were also significant, F(4, 132) = 4.58, p b 0.001, ΔR2 = 0.09. Psychosocial variables (generalized anxiety, depression) added in Step 3 were significant and explained an additional 11.9% of the variance in cardiac anxiety scores, F(2,130) =
L. Rosman et al. / International Journal of Cardiology 181 (2015) 73–76
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Table 2 Comparison of CAQ subscale scores from SCA survivors to other cardiac samples. SCA
Cardiac fear Avoidance HF attentiona a
ICD
LQTS
HCM
n
M (SD)
n
M (SD)
d
n
M (SD)
d
n
M (SD)
d
182 180 185
1.4 (0.8) 1.1 (1.0) 1.4 (0.8)
205 205 205
1.2 (0.9) 1.4 (1.1) 0.7 (0.8)
0.2 0.3 0.8
12 12 12
1.3 (1.0) 0.6 (0.4) 0.8 (0.8)
0.1 0.5 0.7
20 20 20
1.7 (0.8) 1.7 (1.0) 1.3 (0.8)
0.4 0.6 0.1
HF attention = heart focused attention.
6.70, p b 0.001. The overall model explained 29.2% of the total variance in cardiac anxiety scores. Younger age (p = 0.02), heart murmur (p = 0.02), history of ICD shock ≥ 1 (p = 0.01), and generalized anxiety (p = 0.008) significantly predicted cardiac anxiety. 4. Discussion The current study demonstrated that SCA patients report high levels of cardiac-specific fear, avoidance and excessive preoccupation with cardiac symptoms. Further, predictors of cardiac anxiety secondary to SCA were identified and include younger age, history of heart murmur, history of at least one ICD shock, and generalized anxiety. Collectively, these data highlight that many survivors of cardiac arrest experience mild to severe levels of cardiac-specific anxiety, which for some, may increase their risk for adverse functional outcomes. Prior investigations have not directly examined cardiac anxiety secondary to SCA, but have focused on other clinically relevant behavioral and psychological symptoms that contribute to long-term morbidity and disability among SCA survivors [2–5]. The current data extend these findings by examining a maladaptive pattern of intrusive thoughts, avoidance behaviors and excessive cardiac symptom monitoring known to exacerbate CVD-related distress and worsen medical outcomes. Compared to other cardiac samples, our data revealed that SCA survivors reported greater attention to cardiac symptoms than patients with LQTS, HCM, and ICDs. Symptoms of cardiac-specific avoidance, fear and heartTable 3 Frequently endorsed symptoms of cardiac anxiety. CAQ items
Fear If tests come out normal, I still worry about my heart I feel safe being around a hospital, physician or other medical facility I worry that doctors do not believe my symptoms are real When I have chest discomfort or when my heart is beating fast: … I worry that I may have a heart attack … I have difficulty concentrating on anything else … I get frightened … I like to be checked out by a doctor … I tell my family or friends Avoidance I avoid physical exertion I take it easy as much as possible I avoid exercise or other physical work I avoid activities that make my heart beat faster I avoid activities that make me sweat Heart focused attention I pay attention to my heart beat My racing heart wakes me up at night Chest pain/discomfort wakes me up at night I check my pulse I can feel my heart in my chest
Total n Mean SD
% Sx rated as “often” or “always”
focused attention were also more severe in this population than LQTS patients. In contrast, our sample reported less severe avoidance and fear than HCM patients. Findings with regard to data from the ICD sample are particularly interesting, as over 78% of SCA survivors in this study had an ICD. It is important to note that 100% of SCA survivors with ICDs in this sample received a device for secondary prevention compared to only 49% of ICD patients from the comparison group [10]. Although it cannot be concluded with certainty due to the cross-sectional nature our data, it appears unlikely that having an ICD alone conveys risk for cardiac anxiety. Rather, our findings suggest that the acute severity and high lethality of SCA may independently increase risk for persistent cardiac fear and excessive preoccupation with cardiac symptoms. In addition, our results suggest that providers should consider SCA survivors who are younger in age, with comorbidities or significant cardiac history (heart murmur and ICD shock), and/or with pre-existing or current symptoms of generalized anxiety, to be at risk for experiencing significant cardiac-specific anxiety. These findings are consistent with previous research which has found younger age, comorbid anxiety, and shock to be associated with worse long-term psychological adjustment among ICD recipients [11]. Further, the association between benign heart palpitations and a broad spectrum of anxiety disorders is well documented in the literature [12]. A novel contribution of this study was the examination of heart murmur as a cardiac symptom prone to excessive self-monitoring in anxious patients and assessing its predictive value for the development of cardiac anxiety after SCA. Finally, our data does not allow us to determine to what degree cardiacspecific anxiety may be problematic for patient outcomes above and beyond generalized anxiety. However, the association between generalized anxiety and cardiac anxiety for our sample was only weak to moderate in strength, suggesting that the two constructs are distinct. 4.1. Limitations
188
1.37
1.19 17.6
188
2.22
1.47 47.9
187
0.66
1.09
185 185
1.24 1.28
1.07 14.1 1.17 14.6
While results from the current study are compelling, several limitations should be noted. First, the cross-sectional nature of this study limits the extent to which causal inferences can be drawn. Second, the current study evaluated cardiac anxiety in relationship to single-item measures of psychological distress (depression and generalized anxiety). Although prior research has demonstrated the reliability and validity of single-item symptom measures [13], future studies should include comprehensive measures of depression and anxiety in order to provide
185 185 186
1.48 1.40 1.34
1.22 18.4 1.19 16.2 1.17 14.5
Table 4 Predictors of cardiac anxiety secondary to SCA.
186 188 185 187
1.25 1.31 1.03 1.12
1.14 1.14 1.09 1.20
186
0.83
1.11 10.2
187 186 188
2.50 0.60 0.42
1.18 52.9 0.91 4.8 0.75 2.7
188 188
1.52 1.66
1.18 19.7 1.26 27.7
9.6
13.4 14.9 11.4 15.0
Demographic variables Age Female Cardiac history History of heart disease Heart murmur ICD ICD shock ≥ 1 Psychosocial adjustment Depression Generalized anxiety ⁎ p b .05.
β (SE)
Standardized β
p
−0.01 (0.01) 0.21 (0.12)
−0.20 0.15
0.02⁎ 0.08
−0.13 (0.13) 0.30 (0.12) 0.08 (0.14) 0.28 (0.11)
−0.08 0.20 0.05 0.21
0.31 0.02⁎ 0.55 0.01⁎
0.22 (0.12) 0.35 (0.13)
0.17 0.25
0.06 0.008⁎
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a more robust evaluation of cardiac anxiety in relationship to other biobehavioral variables. Third, differences in baseline sample characteristics between survivors with mild and severe cardiac anxiety were determined by data-driven quartiles. Although quartile comparisons are frequently used in cardiovascular disease research, this approach often assumes homogeneity of risk within groups and can make comparisons across studies difficult. Selection bias is another important limitation, as it is possible that SCA survivors who chose to participate in an online patient registry and were willing to participate in quality of life research may have had a special interest in survivor outcomes. This may limit the generalizability of study findings to the broader SCA survivor population. Nonetheless, we felt that the strengths of our sampling strategy outweighed the potential limitations, as it allowed us to recruit a large, nationally-representative sample of SCA survivors from diverse age groups, educational and socioeconomic backgrounds. Finally, other medical and psychosocial variables that were not examined in the current study may predict cardiac anxiety after SCA, including the frequency of appropriate and inappropriate shocks in SCA survivors with an implantable cardioverter defibrillator. These and other important variables should be considered in future investigations. 5. Conclusions Researchers and healthcare providers have called for a more comprehensive study of the psychological experience of cardiac arrest survivors, including examination of disease-specific factors that affect clinically meaningful outcomes. The current study takes a significant step toward this goal by documenting cardiac anxiety in this population, while also contributing to our understanding of factors related to the development of cardiac anxiety following SCA. Findings from this preliminary study and extant research suggest that providers may consider the role of cardiac anxiety in interpreting behavior of SCA survivors. For example, patients with severe levels of cardiac anxiety may remain concerned about their heart despite medical tests that are within normal limits. Awareness of cardiac anxiety symptoms could provide clarification on these types of issues and facilitate patient referrals for further psychological assessment or treatment. Identifying and addressing this maladaptive cycle of fear-induced avoidance and cardiac hypervigilance are important targets for psychosocial intervention to improve quality of life outcomes in SCA survivors. Disclosures Lindsey Rosman: None. Amanda Whited: None. Rachel Lampert: Dr. Lampert has received research grants from the Medtronic, Boston Scientific, and St. Jude Medical in the past two years. Vincent Mosesso: Research grant from the Zoll LifeCor; medical director of SCAA.
Christine Lawless: None. Samuel Sears: Dr. Sears serves as a consultant to Medtronic and has had research grants from the Medtronic in the past 2 years. Dr. Sears also has received speaker honoraria from Medtronic, Boston Scientific, St. Jude Medical, Spectranetics, and Biotronik. Conflict of interests The authors report no relationships that could be construed as a conflict of interest. References [1] V.L. Roger, A.S. Go, D.M. Lloyd-Jones, E.J. Benjamin, J.D. Berry, W.B. Borden, D.M. Bravata, S. Dai, E.S. Ford, C.S. Fox, H.J. Fullerton, C. Gillespie, S.M. Hailpern, J.A. Heit, V.J. Howard, B.M. Kissela, S.J. Kittner, D.T. Lackland, J.H. Lichtman, L.D. Lisabeth, D.M. Makuc, G.M. Marcus, A. Marelli, D.B. Matchar, C.S. Moy, D. Mozaffarian, M.E. Mussolino, G. Nichol, N.P. Paynter, E.Z. Soliman, P.D. Sorlie, N. Sotoodehnia, T.N. Turan, S.S. Virani, N.D. Wong, D. Woo, M.B. Turner, American Heart Association Statistics Committee and Stroke Statistics Subcommittee, Circulation 125 (2012) 188–197. [2] E.M. Wachelder, V.R. Moulaert, C. Van heugten, J.A. Verbunt, S.C. Bekkers, D.T. Wade, Life after survival: long-term daily functioning and quality of life after an out-ofhospital cardiac arrest, Resuscitation 80 (2009) 517–522. [3] K.P. Wilder Schaaf, L.K. Artman, M.A. Peberdy, W.C. Walker, J.P. Ornato, M.R. Gossip, J.S. Kreutzer, Anxiety, depression, and PTSD following cardiac arrest: a systematic review of the literature, Resuscitation 84 (2013) 873–877. [4] M.J. Sauve, Long-term physical functioning and psychological adjustment in survivors of sudden cardiac death, Heart Lung 24 (1995) 133–144. [5] T.J. Bunch, R.D. White, B.J. Gersh, R.A. Meverden, D.O. Hodge, K.V. Ballman, S.C. Hammill, W.K. Shen, D.L. Packer, Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation, N. Engl. J. Med. 348 (2003) 2626–2633. [6] G.H. Eifert, R.N. Thompson, M.J. Zvolensky, K. Edwards, N.L. Frazer, J.W. Haddad, J. Davig, The Cardiac Anxiety Questionnaire: development and preliminary validity, Behav. Res. Ther. 38 (2000) 1039–1053. [7] C.D. Marker, C.N. Carmin, R.L. Ownby, Cardiac anxiety in people with and without coronary atherosclerosis, Depress. Anxiety 25 (2008) 824–831. [8] J. Hoyer, G.H. Eifert, F. Einsle, K. Zimmerman, S. Krauss, M. Knaut, et al., Heartfocused anxiety before and after cardiac surgery, J. Psychosom. Res. 64 (2008) 291–297. [9] A. Hamang, G.E. Eide, B. Rokne, K. Nordin, N. Oyen, General anxiety, depression, and physical health in relation to symptoms of heart-focused anxiety — a cross sectional study among patients living with the risk of serious arrhythmias and sudden cardiac death, Health Qual. Life Outcomes 9 (2011) 100–110. [10] K. Broek, I. Nyklícek, J. Denollet, Anxiety predicts poor perceived health in patients with an implantable defibrillator, Psychosomatics 50 (2009) 483–492. [11] S.B. Dunbar, C.M. Dougherty, S.F. Sears, D.L. Carroll, N.E. Goldstein, D.B. Mark, G. McDaniel, S.J. Pressler, E. Schron, P. Wang, V.L. Zeigler, on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Cardiovascular Disease in the Young, Educational and psychological interventions to improve outcomes for recipients of implantable cardioverter defibrillators and their families: a scientific statement from the American Heart Association, Circulation 126 (17) (2012) 2146–2172. [12] A.J. Barsky, P.D. Cleary, M.K. Sarnie, J.N. Ruskin, Panic disorder, palpitations, and the awareness of cardiac activity, J. Nerv. Ment. Dis. 182 (2) (1994) 63–71. [13] M. Zimmerman, C.J. Ruggero, I. Chelminski, D. Young, M.A. Posternak, M. Friedman, Developing brief scales for use in clinical practice: the reliability and validity of single-item self-report measures of depression symptom severity, psychosocial impairment due to depression, and quality of life, J. Clin. Psychiatry 67 (2006) 1536–1541.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Cardiac anxiety after sudden cardiac arrest: Severity, predictors and clinical implications☆ Lindsey Rosman a, Amanda Whited a, Rachel Lampert c, Vincent N. Mosesso d, Christine Lawless e, Samuel F. Sears a,b,⁎ a
East Carolina University, Department of Psychology, United States East Carolina University, Department of Cardiovascular Sciences, United States Yale University School of Medicine, United States d University of Pittsburgh School of Medicine, United States e Sports Cardiology Consultants, Chicago, IL, United States b c
a r t i c l e
i n f o
Article history: Received 15 May 2014 Accepted 16 November 2014 Available online 18 November 2014 Keywords: Sudden cardiac arrest Cardiac anxiety Psychosocial adjustment Quality of life
a b s t r a c t Background: Survival from cardiac arrest is a medical success but simultaneously produces psychological challenges related to perception of safety and threat. The current study evaluated symptoms of cardiac-specific anxiety in sudden cardiac arrest (SCA) survivors and examined predictors of cardiac anxiety secondary to cardiac arrest. Methods: A retrospective, cross-sectional study of 188 SCA survivors from the Sudden Cardiac Arrest Association patient registry completed an online questionnaire that included a measure of cardiac anxiety (CAQ) and sociodemographic, cardiac history, and psychosocial adjustment data. CAQ scores were compared to published means from implantable cardioverter defibrillator (ICD), inherited long QT syndrome (LQTS), and hypertrophic cardiomyopathy (HCM) samples and a hierarchical regression was performed. Results: Clinically relevant cardiac anxiety and cardioprotective behaviors were frequently endorsed and 18% of survivors reported persistent worry about their heart even when presented with normal test results. Compared to all other samples, SCA survivors reported significantly higher levels of heart-focused attention (d = 0.3–1.1) and greater cardiac fear and avoidance behaviors than LQTS patients. SCA patients endorsed less severe fear and avoidance symptoms than the HCM sample. Hierarchical regression analyses revealed that younger age (p = 0.02), heart murmur (p = 0.02), history of ICD shock ≥ 1 (p = 0.01), and generalized anxiety (p = 0.008) significantly predicted cardiac anxiety. The overall model explained 29.2% of the total variance. Conclusions: SCA survivors endorse high levels of cardiac-specific fear, avoidance and preoccupation with cardiac symptoms. Successful management of SCA patients requires attention to anxiety about cardiac functioning and security. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Advances in resuscitation and medical technology have revolutionized care and improved survival outcomes for more than 350,000 adults who experience sudden cardiac arrest (SCA) in the United States each year [1]. Although a majority of studies have focused on medical outcomes, the behavioral and psychosocial sequelae of cardiac arrest are a major cause of long-term morbidity and disability among survivors
☆ Funding sources: This work was supported by a research contract with the Sudden Cardiac Arrest Association. The SCAA received grant funds from the Medtronic Foundation in support of this study. ⁎ Corresponding author at: East Carolina University, Department of Psychology, 104 Rawl Hall, Greenville, NC 27858, United States. E-mail address: [email protected] (S.F. Sears).
http://dx.doi.org/10.1016/j.ijcard.2014.11.115 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
[2–5]. This life-threatening event may also lead some survivors to develop disease-specific anxiety or cardiac anxiety, a condition characterized by cardiac specific-fear, avoidance behaviors, and excessive cardiac symptom monitoring [6]. This cluster of symptoms is clinically relevant to cardiology patients, as it has been associated with higher rates of CVD-related distress, avoidance of physical activity, patient-reported disability, and worse perceived health outcomes [6–10]. Cardiac anxiety is equally problematic for health care providers, as patients are more likely to seek medical reassurance for normal alterations in cardiac function, resulting in medically unnecessary emergency department visits, costly diagnostics and procedures, and provider burden [7]. No prior studies have examined the extent to which symptoms are present and predictors of cardiac anxiety in this particular population. Therefore, the purpose of this report is to provide an initial evaluation of the severity of cardiac anxiety in a large cross-section of SCA survivors and identify factors that predict cardiac anxiety following cardiac arrest.
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2. Methods 2.1. Study population SCA survivors were recruited from the Sudden Cardiac Arrest Association's (SCAA, Washington, DC) SCA survivor registry. SCA survivors who were aged 18 years or older and able to read and complete study questionnaires were contacted to participate in this retrospective cross-sectional online study. 2.2. Data collection procedures This study is part of a larger project, Cardiovascular Outcomes and Psychosocial Education 2012 (COPE 2012), whose purpose was to determine the acute and chronic needs of SCA survivors affiliated with the SCAA survivor registry. Information about the study was distributed to SCA survivors registered with the SCAA online database between October 2012 and January 2013 and included a link to an online survey. Interested participants completed study questionnaires regarding sociodemographic information, cardiac history, psychosocial adjustment, and cardiac-specific anxiety after SCA. The study protocol was approved by the Internal Review Board at East Carolina University. 2.3. Measurement instruments 2.3.1. Cardiac anxiety questionnaire The CAQ is a previously validated, 18-item self-report measure with three subscales (cardiac fear, avoidance, and heart-focused attention), designed to assess cardiacspecific anxiety [6]. For each item, participants indicated how often they have felt in the described manner or performed the described behavior on a 5-point Likert scale bounded by 0 (never) and 4 (always). Individual items were summed and divided by 18 to obtain a CAQ scale score. Means were also used to calculate subscale scores. Prior research supports the measure's internal consistency (αs = 0.83) and convergent validity with other established measures of psychological distress [6,8]. Cronbach's alpha in the current study was 0.89. 2.3.2. Psychosocial adjustment Two single-item dichotomous measures were used to assess current symptoms of depression and generalized anxiety. Symptoms were rated as present or absent and used as measures of general psychological adjustment in the regression analysis. 2.4. Statistical analysis Descriptive statistics were calculated for sociodemographic data and cardiac history. Dichotomous medical variables were coded as present or absent and coded according to participant response. Cohen's d effect sizes were also calculated to compare participants' scores on the CAQ to published means from implantable cardioverter defibrillator (ICD), inherited long QT syndrome (LQTS), and hypertrophic cardiomyopathy (HCM) samples [9,10]. Total scale scores for the CAQ were not consistently provided in studies of these samples, so only mean subscale scores were analyzed to compare our sample to the ICD, LQTS, and HCM data in this particular analysis. In addition, chi-square tests and t-tests were used to compare differences between SCA survivors with severe and mild cardiac anxiety. As there are no established and validated clinical cutoff scores for the CAQ, total scores were divided into quartiles to examine differences between high and low levels of cardiac anxiety. Severe cardiac anxiety was defined as total scores in the upper quartile (CAQ ≥ 1.81), and scores in the lowest quartile (CAQ ≤ 0.73) were considered mild cardiac anxiety. Finally, a hierarchical multiple regression was performed to identify predictors of cardiac anxiety after SCA. In this model, CAQ total scores for all participants were entered as a continuous dependent variable, and eight independent variables were included as predictors (i.e., female gender, age, history of heart disease, history of heart murmur, having an ICD, history of ICD shock, depression and generalized anxiety). Demographic (gender, age), cardiac (history of heart disease, history of heart murmur, ICD status, history of ICD shock ≥ 1), and psychosocial (depression, generalized anxiety) variables were added to the model in three progressive steps to determine the relative contribution of these domains and whether adding additional predictors increased the amount of variance in CAQ scores that was explained. Differences with a p-value of b0.05 were considered significant. All analyses were performed with SPSS version 20.0 (SPSS Inc., Chicago, Illinois).
Table 1 Sociodemographic and cardiac history for SCA survivors with high and low cardiac anxiety. Characteristic
Entire sample (n = 188)
Mild cardiac anxiety (n = 43)
Age in years Men White/Caucasian Education High school Some college/college grad Graduate school Income Low: $0–49,999 Medium: $50,000–149,999 High: $150,000+ Time since SCA (years) Cardiac characteristics Heart disease prior to SCA ICD History of ICD shock
55.43 ± 12.07 58.02 ± 11.13 50.00 ± 11.27 b0.01⁎ 104 (55.0%) 32 (74.4%) 19 (44.2%) b0.01⁎ 177 (93.7%) 40 (93.0%) 38 (88.4%) 0.71
Severe cardiac anxiety (n = 43)
p
4 (2.1%) 127 (67.5%)
0 (0.0%) 21 (48.8%)
2 (4.7%) 33 (76.7%)
0.49 b0.01⁎
58 (30.7%)
22 (51.2%)
8 (18.6%)
0.01⁎
29 (15.3%) 94 (49.7%)
4 (9.3%) 22 (51.2%)
13 (30.2%) 16 (37.2%)
0.03⁎ 0.28
51 (27.0%) 4.7 ± 3.9
16 (37.2%)
9 (20.9%)
0.15
45 (23.8%)
9 (20.9%)
8 (18.6%)
0.79
148 (78.3%) 68 (36.0%)
32 (74.4%) 10 (23.3%)
38 (88.4%) 20 (46.5%)
0.24 0.15
⁎ p b 0.05.
3.1. Cardiac anxiety secondary to SCA Scores on the CAQ ranged from 0 to 3.2 (1.29 ± 0.7). Means and standard deviations for CAQ subscales (cardiac fear, avoidance, and heart-focused attention) are presented in Table 2. Frequently endorsed symptoms of cardiac anxiety and cardioprotective behaviors (i.e., rated as “often” or “always” on the CAQ) are summarized in Table 3. Among the items most salient on the CAQ were: persistent worry about their heart even when presented with normal test results (18%), routinely seeking medical attention for any perceived increase in heart rate or chest discomfort (16.2%), and believing that providers do not believe their symptoms are real (10%). Additional comparisons of SCA survivors with mild and severe levels of cardiac anxiety are shown in Table 1. Significant differences in baseline characteristics were found, such that younger age, female gender, higher education and lower income were associated with more severe cardiac anxiety. 3.2. Cardiac anxiety in SCA survivors compared to other cardiac patients Means and standard deviations for CAQ subscale scores for SCA survivors and comparison groups are summarized in Table 2. Compared to mean scores from other cardiac samples, SCA survivors in this sample reported significantly greater cardiac fear than patients with ICDs (d = 0.2) and long QT syndrome (LQTS, d = 0.1) but less severe fear than patients with hypertrophic cardiomyopathy (HCM, d = 0.4). Statistically significant differences in avoidance were also found, indicating that SCA survivors report more severe avoidance than patients with LQTS (d = 0.5) but less avoidance symptoms than patients with ICDs (d = 0.3), and HCM (d = 0.6). In addition, significant differences in heart-focused attention were found between SCA survivors and patients with ICDs (d = 0.8), LQTS (d = 1.1), and HCM (d = 0.3).
3. Results
3.3. Predictors of cardiac anxiety after SCA
Among 591 SCA survivors from the SCAA registry database who were contacted about the study, 188 (31%) consented to participate and completed study questionnaires. Notably, 76 survivors (13%) initially contacted for this study were unable to be reached due to invalid or expired email addresses associated with their SCAA registry account. Sociodemographic data and cardiac history for respondents are presented in Table 1.
A hierarchical regression (Table 4) revealed that demographic data (age and female gender) entered at Step 1 was significant, F(2,136) = 5.84, p = 0.004, ΔR2 = 0.08. Cardiac variables (history of CVD, heart murmur, ICD, ICD shock) entered at Step 2 were also significant, F(4, 132) = 4.58, p b 0.001, ΔR2 = 0.09. Psychosocial variables (generalized anxiety, depression) added in Step 3 were significant and explained an additional 11.9% of the variance in cardiac anxiety scores, F(2,130) =
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75
Table 2 Comparison of CAQ subscale scores from SCA survivors to other cardiac samples. SCA
Cardiac fear Avoidance HF attentiona a
ICD
LQTS
HCM
n
M (SD)
n
M (SD)
d
n
M (SD)
d
n
M (SD)
d
182 180 185
1.4 (0.8) 1.1 (1.0) 1.4 (0.8)
205 205 205
1.2 (0.9) 1.4 (1.1) 0.7 (0.8)
0.2 0.3 0.8
12 12 12
1.3 (1.0) 0.6 (0.4) 0.8 (0.8)
0.1 0.5 0.7
20 20 20
1.7 (0.8) 1.7 (1.0) 1.3 (0.8)
0.4 0.6 0.1
HF attention = heart focused attention.
6.70, p b 0.001. The overall model explained 29.2% of the total variance in cardiac anxiety scores. Younger age (p = 0.02), heart murmur (p = 0.02), history of ICD shock ≥ 1 (p = 0.01), and generalized anxiety (p = 0.008) significantly predicted cardiac anxiety. 4. Discussion The current study demonstrated that SCA patients report high levels of cardiac-specific fear, avoidance and excessive preoccupation with cardiac symptoms. Further, predictors of cardiac anxiety secondary to SCA were identified and include younger age, history of heart murmur, history of at least one ICD shock, and generalized anxiety. Collectively, these data highlight that many survivors of cardiac arrest experience mild to severe levels of cardiac-specific anxiety, which for some, may increase their risk for adverse functional outcomes. Prior investigations have not directly examined cardiac anxiety secondary to SCA, but have focused on other clinically relevant behavioral and psychological symptoms that contribute to long-term morbidity and disability among SCA survivors [2–5]. The current data extend these findings by examining a maladaptive pattern of intrusive thoughts, avoidance behaviors and excessive cardiac symptom monitoring known to exacerbate CVD-related distress and worsen medical outcomes. Compared to other cardiac samples, our data revealed that SCA survivors reported greater attention to cardiac symptoms than patients with LQTS, HCM, and ICDs. Symptoms of cardiac-specific avoidance, fear and heartTable 3 Frequently endorsed symptoms of cardiac anxiety. CAQ items
Fear If tests come out normal, I still worry about my heart I feel safe being around a hospital, physician or other medical facility I worry that doctors do not believe my symptoms are real When I have chest discomfort or when my heart is beating fast: … I worry that I may have a heart attack … I have difficulty concentrating on anything else … I get frightened … I like to be checked out by a doctor … I tell my family or friends Avoidance I avoid physical exertion I take it easy as much as possible I avoid exercise or other physical work I avoid activities that make my heart beat faster I avoid activities that make me sweat Heart focused attention I pay attention to my heart beat My racing heart wakes me up at night Chest pain/discomfort wakes me up at night I check my pulse I can feel my heart in my chest
Total n Mean SD
% Sx rated as “often” or “always”
focused attention were also more severe in this population than LQTS patients. In contrast, our sample reported less severe avoidance and fear than HCM patients. Findings with regard to data from the ICD sample are particularly interesting, as over 78% of SCA survivors in this study had an ICD. It is important to note that 100% of SCA survivors with ICDs in this sample received a device for secondary prevention compared to only 49% of ICD patients from the comparison group [10]. Although it cannot be concluded with certainty due to the cross-sectional nature our data, it appears unlikely that having an ICD alone conveys risk for cardiac anxiety. Rather, our findings suggest that the acute severity and high lethality of SCA may independently increase risk for persistent cardiac fear and excessive preoccupation with cardiac symptoms. In addition, our results suggest that providers should consider SCA survivors who are younger in age, with comorbidities or significant cardiac history (heart murmur and ICD shock), and/or with pre-existing or current symptoms of generalized anxiety, to be at risk for experiencing significant cardiac-specific anxiety. These findings are consistent with previous research which has found younger age, comorbid anxiety, and shock to be associated with worse long-term psychological adjustment among ICD recipients [11]. Further, the association between benign heart palpitations and a broad spectrum of anxiety disorders is well documented in the literature [12]. A novel contribution of this study was the examination of heart murmur as a cardiac symptom prone to excessive self-monitoring in anxious patients and assessing its predictive value for the development of cardiac anxiety after SCA. Finally, our data does not allow us to determine to what degree cardiacspecific anxiety may be problematic for patient outcomes above and beyond generalized anxiety. However, the association between generalized anxiety and cardiac anxiety for our sample was only weak to moderate in strength, suggesting that the two constructs are distinct. 4.1. Limitations
188
1.37
1.19 17.6
188
2.22
1.47 47.9
187
0.66
1.09
185 185
1.24 1.28
1.07 14.1 1.17 14.6
While results from the current study are compelling, several limitations should be noted. First, the cross-sectional nature of this study limits the extent to which causal inferences can be drawn. Second, the current study evaluated cardiac anxiety in relationship to single-item measures of psychological distress (depression and generalized anxiety). Although prior research has demonstrated the reliability and validity of single-item symptom measures [13], future studies should include comprehensive measures of depression and anxiety in order to provide
185 185 186
1.48 1.40 1.34
1.22 18.4 1.19 16.2 1.17 14.5
Table 4 Predictors of cardiac anxiety secondary to SCA.
186 188 185 187
1.25 1.31 1.03 1.12
1.14 1.14 1.09 1.20
186
0.83
1.11 10.2
187 186 188
2.50 0.60 0.42
1.18 52.9 0.91 4.8 0.75 2.7
188 188
1.52 1.66
1.18 19.7 1.26 27.7
9.6
13.4 14.9 11.4 15.0
Demographic variables Age Female Cardiac history History of heart disease Heart murmur ICD ICD shock ≥ 1 Psychosocial adjustment Depression Generalized anxiety ⁎ p b .05.
β (SE)
Standardized β
p
−0.01 (0.01) 0.21 (0.12)
−0.20 0.15
0.02⁎ 0.08
−0.13 (0.13) 0.30 (0.12) 0.08 (0.14) 0.28 (0.11)
−0.08 0.20 0.05 0.21
0.31 0.02⁎ 0.55 0.01⁎
0.22 (0.12) 0.35 (0.13)
0.17 0.25
0.06 0.008⁎
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a more robust evaluation of cardiac anxiety in relationship to other biobehavioral variables. Third, differences in baseline sample characteristics between survivors with mild and severe cardiac anxiety were determined by data-driven quartiles. Although quartile comparisons are frequently used in cardiovascular disease research, this approach often assumes homogeneity of risk within groups and can make comparisons across studies difficult. Selection bias is another important limitation, as it is possible that SCA survivors who chose to participate in an online patient registry and were willing to participate in quality of life research may have had a special interest in survivor outcomes. This may limit the generalizability of study findings to the broader SCA survivor population. Nonetheless, we felt that the strengths of our sampling strategy outweighed the potential limitations, as it allowed us to recruit a large, nationally-representative sample of SCA survivors from diverse age groups, educational and socioeconomic backgrounds. Finally, other medical and psychosocial variables that were not examined in the current study may predict cardiac anxiety after SCA, including the frequency of appropriate and inappropriate shocks in SCA survivors with an implantable cardioverter defibrillator. These and other important variables should be considered in future investigations. 5. Conclusions Researchers and healthcare providers have called for a more comprehensive study of the psychological experience of cardiac arrest survivors, including examination of disease-specific factors that affect clinically meaningful outcomes. The current study takes a significant step toward this goal by documenting cardiac anxiety in this population, while also contributing to our understanding of factors related to the development of cardiac anxiety following SCA. Findings from this preliminary study and extant research suggest that providers may consider the role of cardiac anxiety in interpreting behavior of SCA survivors. For example, patients with severe levels of cardiac anxiety may remain concerned about their heart despite medical tests that are within normal limits. Awareness of cardiac anxiety symptoms could provide clarification on these types of issues and facilitate patient referrals for further psychological assessment or treatment. Identifying and addressing this maladaptive cycle of fear-induced avoidance and cardiac hypervigilance are important targets for psychosocial intervention to improve quality of life outcomes in SCA survivors. Disclosures Lindsey Rosman: None. Amanda Whited: None. Rachel Lampert: Dr. Lampert has received research grants from the Medtronic, Boston Scientific, and St. Jude Medical in the past two years. Vincent Mosesso: Research grant from the Zoll LifeCor; medical director of SCAA.
Christine Lawless: None. Samuel Sears: Dr. Sears serves as a consultant to Medtronic and has had research grants from the Medtronic in the past 2 years. Dr. Sears also has received speaker honoraria from Medtronic, Boston Scientific, St. Jude Medical, Spectranetics, and Biotronik. Conflict of interests The authors report no relationships that could be construed as a conflict of interest. References [1] V.L. Roger, A.S. Go, D.M. Lloyd-Jones, E.J. Benjamin, J.D. Berry, W.B. Borden, D.M. Bravata, S. Dai, E.S. Ford, C.S. Fox, H.J. Fullerton, C. Gillespie, S.M. Hailpern, J.A. Heit, V.J. Howard, B.M. Kissela, S.J. Kittner, D.T. Lackland, J.H. Lichtman, L.D. Lisabeth, D.M. Makuc, G.M. Marcus, A. Marelli, D.B. Matchar, C.S. Moy, D. Mozaffarian, M.E. Mussolino, G. Nichol, N.P. Paynter, E.Z. Soliman, P.D. Sorlie, N. Sotoodehnia, T.N. Turan, S.S. Virani, N.D. Wong, D. Woo, M.B. Turner, American Heart Association Statistics Committee and Stroke Statistics Subcommittee, Circulation 125 (2012) 188–197. [2] E.M. Wachelder, V.R. Moulaert, C. Van heugten, J.A. Verbunt, S.C. Bekkers, D.T. Wade, Life after survival: long-term daily functioning and quality of life after an out-ofhospital cardiac arrest, Resuscitation 80 (2009) 517–522. [3] K.P. Wilder Schaaf, L.K. Artman, M.A. Peberdy, W.C. Walker, J.P. Ornato, M.R. Gossip, J.S. Kreutzer, Anxiety, depression, and PTSD following cardiac arrest: a systematic review of the literature, Resuscitation 84 (2013) 873–877. [4] M.J. Sauve, Long-term physical functioning and psychological adjustment in survivors of sudden cardiac death, Heart Lung 24 (1995) 133–144. [5] T.J. Bunch, R.D. White, B.J. Gersh, R.A. Meverden, D.O. Hodge, K.V. Ballman, S.C. Hammill, W.K. Shen, D.L. Packer, Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation, N. Engl. J. Med. 348 (2003) 2626–2633. [6] G.H. Eifert, R.N. Thompson, M.J. Zvolensky, K. Edwards, N.L. Frazer, J.W. Haddad, J. Davig, The Cardiac Anxiety Questionnaire: development and preliminary validity, Behav. Res. Ther. 38 (2000) 1039–1053. [7] C.D. Marker, C.N. Carmin, R.L. Ownby, Cardiac anxiety in people with and without coronary atherosclerosis, Depress. Anxiety 25 (2008) 824–831. [8] J. Hoyer, G.H. Eifert, F. Einsle, K. Zimmerman, S. Krauss, M. Knaut, et al., Heartfocused anxiety before and after cardiac surgery, J. Psychosom. Res. 64 (2008) 291–297. [9] A. Hamang, G.E. Eide, B. Rokne, K. Nordin, N. Oyen, General anxiety, depression, and physical health in relation to symptoms of heart-focused anxiety — a cross sectional study among patients living with the risk of serious arrhythmias and sudden cardiac death, Health Qual. Life Outcomes 9 (2011) 100–110. [10] K. Broek, I. Nyklícek, J. Denollet, Anxiety predicts poor perceived health in patients with an implantable defibrillator, Psychosomatics 50 (2009) 483–492. [11] S.B. Dunbar, C.M. Dougherty, S.F. Sears, D.L. Carroll, N.E. Goldstein, D.B. Mark, G. McDaniel, S.J. Pressler, E. Schron, P. Wang, V.L. Zeigler, on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Cardiovascular Disease in the Young, Educational and psychological interventions to improve outcomes for recipients of implantable cardioverter defibrillators and their families: a scientific statement from the American Heart Association, Circulation 126 (17) (2012) 2146–2172. [12] A.J. Barsky, P.D. Cleary, M.K. Sarnie, J.N. Ruskin, Panic disorder, palpitations, and the awareness of cardiac activity, J. Nerv. Ment. Dis. 182 (2) (1994) 63–71. [13] M. Zimmerman, C.J. Ruggero, I. Chelminski, D. Young, M.A. Posternak, M. Friedman, Developing brief scales for use in clinical practice: the reliability and validity of single-item self-report measures of depression symptom severity, psychosocial impairment due to depression, and quality of life, J. Clin. Psychiatry 67 (2006) 1536–1541.
