APRIL 2012 DELHI PSYCHIATRY JOURNAL Vol. 15 No.1. Department of Psychology, State Institute of Mental Health, PGI-MS, Rohtak, Haryana 2,7

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1 APRIL 2012 DELHI PSYCHIATRY JOURNAL Vol. 15 No.1 Original Article Comparative Study of Prevalence of Psychological Distress Factors in Coronary Heart Disease Patients Living Under Disturbed Conditions and a normal place of North India Dharmender Kumar Nehra 1, Nov Rattan Sharma 2, Gazanfar Ali 3, Mushtaq Ahmed Margoob 4, Huda Mushtaq 5, Pradeep Kumar 6, Sheetal Nehra 7 1,6 Department of Psychology, State Institute of Mental Health, PGI-MS, Rohtak, Haryana 2,7 Department of Psychology, M.D.U. Rohtak, Haryana 3 Department of Medicine, Government Medical College, Srinagar 4,5, Department of Psychiatry, Government Medical College, Srinagar Abstract Background: The experience of heart disease seems to contribute to risk for numerous psychiatric problems, especially depression, anxiety, and stress. Although, these psychosocial factors appear to be outside the immediate realm of medicine, they have a profound impact on morbidity and mortality in cardiac patients. Aims: Purpose of the present study was to assess psychological distress (depression, anxiety, perceived stress) in Coronary Heart Disease (CHD) patients and compare the levels of these constructs among CHD patients living in disturbed condition (Kashmir) and a normal place (Haryana). Methods: Hospital Anxiety Depression Scale (HADS) and Perceived Stress Scale (PSS-4) were administered to a total of 200 male participants, 100 (50 CHD Patients and 50 healthy controls) from Kashmir and 100 (50 CHD Patients and 50 healthy controls) from Haryana. Statistical analysis was done using SPSS Results: The results revealed a high prevalence of depression, anxiety and stress in our study groups from both the places. Unlike Haryana, the stress levels between the CHD patients and healthy controls in the Kashmiri population did not show any significant difference. Comparison of depression between the study groups of the two states also did not reveal any significant difference. Further comparison of anxiety and stress between the study groups of the two states revealed a highly significant difference. The levels of depression, anxiety and stress in the control groups of the 2 states also differed significantly with alarmingly higher levels of psychological distress in the Kashmiri population. Conclusions: Thus, our study suggests that increased exposure of the Kashmiri population to traumatic events and stressful conditions has increased their levels of emotional distress, adversely affecting the mental connotation of their chronic physical condition (CHD) as well as putting the whole population at a greater risk of developing psychological problems due to extremely high levels of psychological distress. Keywords:Coronary heart disease; perceived stress; depression; anxiety; stressful conditions; risk factors. Delhi Psychiatry Journal 2012; 15:(1) Delhi Psychiatric Society 99

2 DELHI PSYCHIATRY JOURNAL Vol. 15 No.1 APRIL 2012 Introduction As per World Health Organization s estimations, 30% of the 58 million deaths that occurred globally in 2005 were due to cardiovascular disorder 1. The most common cardiovascular disorder, Coronary Heart Disease (CHD) is responsible for almost 50% of cardiovascular deaths 1,2. Epidemiological studies suggest that there are more than 32 million patients with CHD in India 3, and over 30% of patients are below 40 years of age 4. By 2015, CHD will be the most significant cause of fatality in India 5. The relation between psychosocial factors and Coronary Heart Disease (CHD) has been the subject of research since the past two decades. These two most common public health concerns have been found to be strongly correlated. Bunker et al. 6 concluded in their study that there is a strong and consistent evidence of an independent causal association between depression, social isolation and lack of quality social support and the causes and prognosis of CHD. The increase risk contributed by these psychological factors is of similar order to the more conventional CHD risk factors such as smoking, dyslipidemia and hypertension 6. Research on the relationship between psychological factors and heart disease may be said to have evolved along two parallel paths. One has examined whether psychological constructs are a risk factor for incident coronary disease. The other path has examined whether psychosocial conditions are risk factors for cardiovascular morbidity and mortality in the context of established CHD. Both paths have established positive findings suggesting that depression is indeed linked to adverse cardiac outcomes 7. Both of them cause a significant decrease in quality of life for the patient and impose a significant economic burden on society 8. Furthermore, the CHD risk is directly related to the severity of depression: a 1 2 fold increase in CHD for minor depression and 3 5 fold increase for major depression has been reported 9,10. Kuper et al 11 recently conducted a comprehensive systematic review regarding the role of psychosocial factors in CHD. The study included only prospective cohort studies and focused on psychosocial factors which were measured in at least two different study populations, i.e. on Type A behaviour, hostility, depression, anxiety, psycho-social work characteristics and social support. The authors concluded that, based on prospective epidemiological data, there is indication for an association between depression, low social support and work stress with CHD risk and/or prognosis. The evidence for an association between anxiety and CHD was not clear. Most of the studies investigating Type A behaviour found no association between this personality trait and CHD 12,13. There is an impressive number of prognostic studies for several of these psychosocial factors including socio-economic status, Type A behavior, depression, anxiety or social support. For other psychosocial characteristics such as work stress or anger, studies have been conducted mainly in initially healthy samples, thus their established role in CHD is yet to be ascertained 11. The detrimental effect of chronic traumatic situation on CHD patients, nevertheless very relevant, has not been well researched so far even in the developed countries. Going by the adage absence of evidence is not the evidence of absence our study attempts to examine the psychological concomitants (depression, anxiety and stress) associated with CHD and the difference, if any, in these variables in two states varying in terms of the socio-political background. Methodology Sample The sample consisted of 200 male participants who were selected at random from two different places known to be at extremes of the socio-political continuum in India. Out of these 100 (50 from Kashmir and 50 from Haryana) were patients with a diagnosis of Coronary Heart Disease and the remaining 100 (50 from Kashmir and 50 from Haryana) were non-chd healthy controls. CHD cases were no more than 75 years of age, discharged from the hospital within the past 12 months or stable patients from the general population. The study groups from both the places were matched to the control group by age, sex, and place of living. Tools Perceived Stress Scale (PSS-4) The short version, PSS-4, is an economical and simple psychological instrument to administer, 100 Delhi Psychiatry Journal 2012; 15:(1) Delhi Psychiatric Society

3 APRIL 2012 DELHI PSYCHIATRY JOURNAL Vol. 15 No.1 comprehend, and score. It measures the degree to which situations in one s life over the past month are appraised as stressful. Items are designed to detect how unpredictable, uncontrollable, and overloaded respondents find their lives. Since the questions are of a general nature and are not directed at any particular sub-population group, using this abbreviated version (or any version) with a diverse population is predicted to yield equally reliable results 14. The total score ranges from 0 to 16, with higher scores indicating greater stress. Hospital Anxiety Depression Scale (HADS) HADS was developed by Zigmond & Snaith 15 in 1983 and consists of a series of 14 questions, 7 of which are related to anxiety (HAD-Anxiety subscale) while the other 7 questions are related to depression (HAD-Depression subscale). It is worth noting that items referring to depression symptoms that describe somatic aspects of depression (e.g. insomnia and weight loss) are not included in the scale. The cut-off scores for depression and anxiety were in accordance with those previous studies 16. Data Analysis Data was analyzed using SPSS (version 12.0.) statistical program. Prevalence of depression, anxiety and perceived stress in both the groups was computed by descriptive statistics of percentage analysis. Student s t test was used to obtain the p value. P<0.05 was considered to indicate statistical significance. Result The analysis of the data and the results are tabulated below: Table-1: Percentage analysis of Depression, Anxiety and Perceived Stress in the CHD and control groups of Kashmir and Haryana Condition Categories Groups KASHMIR HARYANA CHD Control CHD Control No. (%) No. (%) No. (%) No. (%) Depression Highly Likely 21 (42%) 5 (10%) 18 (36%) 3 (6%) Probably Present 9 (18%) 16 (32%) 10 (20%) 6 (12%) Lack of Disorder 20 (40%) 29 (58%) 22 (44%) 41 (82%) Anxiety Highly Likely 30 (60%) 27 (54%) 26 (52%) 4 (8%) Probably Present 11 (22%) 14 (28%) 18 (36%) 9 (24%) Lack of Disorder 9 (18%) 9 (18%) 6 (12%) 34 (68%) Perceived Stress Stressed 45 (90%) 33 (66%) 43 (86%) 18 (36) Non-stressed 5 (10%) 17 (34%) 7 (14%) 32 (64%) Table 2-A: Mean and standard deviation of anxiety, perceived stress, depression between CHD and healthy controls in the Kashmiri population Kashmir N Mean Std. Deviation Anxiety Healthy controls CHD Perceived Stress Healthy controls CHD Depression Healthy controls CHD Discussion Prospective studies have implicated emotional distress as a risk factor for the development of CHD Anxiety and depression in CHD patients can adversely affect their mental health and increase their risk of death 20. Despite inconsistencies across studies, recent meta-analysis support the status of depression as a risk factor for cardio vascular morbidity and mortality in patients with CHD 21,22. It has also been reported that up to 60% of patients Delhi Psychiatry Journal 2012; 15:(1) Delhi Psychiatric Society 101

4 DELHI PSYCHIATRY JOURNAL Vol. 15 No.1 APRIL 2012 Table 2-B: Summary of the t-test for CHD and healthy controls on anxiety, perceived stress, depression in the Kashmiri population Z Df Sig. (2-tailed) Mean Difference 95% Confidence Interval of the Difference Lower Upper Anxiety Perceived Stress Depression Table 3-A: Mean and standard deviation of anxiety, perceived stress, depression between CHD and healthy controls in the Haryanavi population Haryana N Mean Std. Deviation Anxiety Healthy controls CHD Perceived Stress Healthy controls CHD Depression Healthy controls CHD Table 3-B: Summary of the t-test for CHD and Healthy controls on anxiety, perceived stress, depression in the Haryanavi population Z Df Sig. (2-tailed) Mean Difference 95% Confidence Interval of the Difference Lower Upper Anxiety Perceived Stress Depression Table 4-A: Mean and standard deviation of anxiety, perceived stress, depression in CHD population of Haryana and Kashmir Groups N Mean Std. Deviation Anxiety CHD (Haryana) CHD (Kashmir) Perceived Stress CHD (Haryana) CHD (Kashmir) Depression CHD (Haryana) CHD (Kashmir) Table 4-B: Summary of the t-test for comparing anxiety, perceived stress, depression between the CHD groups of Haryana and Kashmir Z df Sig. (2-tailed) Mean Difference 95% Confidence Interval of the Difference Lower Upper Anxiety Perceived Stress Depression Delhi Psychiatry Journal 2012; 15:(1) Delhi Psychiatric Society

5 APRIL 2012 DELHI PSYCHIATRY JOURNAL Vol. 15 No.1 Table 5-A: Mean and standard deviation of anxiety, perceived stress, depression in Healthy controls of Haryana & Kashmir Groups N Mean Std. Deviation Anxiety Healthy controls (Haryana) Healthy controls (Kashmir) Perceived Stress Healthy controls (Haryana) Healthy controls (Kashmir) Depression Healthy controls (Haryana) Healthy controls (Kashmir) Table 5-B: Summary of the t-test for comparing anxiety, perceived stress, depression between the Healthy control groups of Haryana and Kashmir Z Df Sig. (2-tailed) Mean Difference 95% Confidence Interval of the Difference Lower Upper Anxiety Perceived Stress Depression with an acute coronary event experience symptoms of depression within the 12 months of attack 23. The findings of our study also revealed a high prevalence of depression (36% in Haryana and 42% in Kashmir) in the study groups, which is in line with previous research which quoted the prevalence rate between 20 and 45% in CHD population 24,25. The difference in depression between the study group and the control group was found to be highly significant in both the states. Depressed affect and hopelessness increase the risk of non-fatal CHD 26. Social dysfunction is reported twice as high in patients with advanced CHD and depression as in patients with either condition alone Abrupt detection or advance of heart disease is a startling psychological experience, and anxiety is a common early response. In CHD patients, fear of occupational, social, sexual and physical dysfunction is added to the fear of death 30. Further, tension and anxiety are commonly the consequences of CHD but have also been noticed to be the predisposing factors to it 31. The prevalence of anxiety disorders in CHD has not been conclusive, but anxiety symptoms are clearly elevated in patients with acute coronary disease and in 5%-10% of patients with chronic heart disease 32. Our study revealed a high prevalence of anxiety in the study group in both the states with 52% of CHD patients in Haryana and 60% of the CHD patients in Kashmir being anxious. Comparison of anxiety in the study groups with the control groups in both the states was found to be highly significant. With regard to stress our finding revealed a very high prevalence of stress in the study groups (86% in Haryana and 90% in Kashmir). Whereas, the difference in the stress between the CHD and the control groups was found to be highly significant in Haryana (p = 0.000), no significant difference in the levels of stress was found between the CHD and control group in Kashmir (p = 0.264). Further, comparison of each anxiety and stress between the CHD population of Haryana and Kashmir revealed a significant difference in the anxiety and stress levels of the CHD patients in Kashmir and Haryana, with anxiety and stress both being high in the study group of Kashmir. These differences can be explained on account of the present prevailing turbulent conditions in Kashmir Delhi Psychiatry Journal 2012; 15:(1) Delhi Psychiatric Society 103

6 DELHI PSYCHIATRY JOURNAL Vol. 15 No.1 APRIL 2012 as compared to a peaceful state in Haryana. Hence, our study indicates that traumas of any nature do not only have physical manifestations 33 but can also effect the mental connotation of chronic physical conditions such as CHD. Another reason for this differ ence of anxiety and stress in the two populations could be explained by the differences in the family structure of the two places. The chronic conflict situation in Kashmir has led to large scale destruction of life and property resulting in the dissolution of family structure and a weakening of family ties. Many continue to be re-traumatized for want of basic physical need like proper shelter and property 34. On the contrary, stronger family support in the Haryanavi community on account of the normalcy prevailing there could explain the lower level of anxiety related to the uncertainty about the future of the family associated with the fear of death in CHD patients. However, the comparison of depression between the study groups of the two states did not reveal any significant difference (p= 0.871). This finding is consistent with the large body of evidence suggesting that depression is a risk factor for morbidity and mortality in patients with existing CHD 35. Hence, our study indicates that depression is an independent concomitant of CHD, with environmental conditions having little effect on this variable in CHD. A strikingly revealing finding of our study is not just the high prevalence of anxiety and stress in our study group from Kashmir but also a highly significant difference in all the three psychological variables of depression, anxiety and stress between the control groups of the two states with the Kashmiri control group having alarmingly higher score on all the three variables. This can be attributed to an increased exposure of this population to traumatic events which are well established to play a key role in the genesis of various psychological problems 36. A study by Margoob et al yielded a lifetime exposure of traumatic events of 58.69% in the Kashmiri community with firing and explosion being the commonest traumatic event encountered (81.37 %) 36. Thus, the high prevalence of anxiety, stress and depression in the Kashmiri population is in agreement with other research findings revealing that the psychological impact of any catastrophe whether in the shape of a natural calamity or human caused disaster gives rise to a number of stress related reactions and psychiatric problems in the affected population 37. The limitation of the study is its small sample size. Also, the study does not provide an insight into the cause and/or effect association of the studied psychological variables and CHD. However, there is considerable evidence suggesting that these factors and co-morbid CHD may lead to an increased risk of death, regardless of which occurred first 7. References 1. Cardiovascular diseases. World Health Organization. Fact sheet N 317. February The World Health Report. World Health Organization. Geneva Gupta, R.. Burden of coronary heart disease in India. Indian Heart J 2005; 57 : (6), Joshi P, Islam S, Pais P et al. Risk Factors for Early Myocardial Infarction in South Asians Compared with Individuals in other countries. JAMA (2007); 297 (3) : Reddy KS. Why is preventive cardiology essential in the Indian context? In: Preventive Cardiology: Introduction. Wasir HS. Ed. New Delhi, Vikas Publishing House 1991; Bunker SJ, Colquhoun DM, Esler M, et al. Stress and coronary heart disease: psychosocial risk factors. Med J Aust 2003; 178 : O Conner CM, Gurbel PA, Serebruany VL. Depression and ischemic heart disease. Am Heart J 2000; 140 : Zellweger MJ, Osterwalder RH, Langewitz W, Pfisterer ME: Coronary artery disease and depression. European Heart J 2004; 25 : Musselman DL, Evans DL, Nemeroff CB. The relationship of depression to cardiovascular disease: epidemiology, biology and treatment. Arch Gen Psychiatry 1998; 55 : Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 1999; 99 : Delhi Psychiatry Journal 2012; 15:(1) Delhi Psychiatric Society

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8 DELHI PSYCHIATRY JOURNAL Vol. 15 No.1 APRIL 2012 lence of adult post traumatic stress disorder in South Asia: Experience from Kashmir. JK Practitioner 2006; 13 (SII) : Margoob MA : Post traumatic stress disorder: Culture syndrome of the West or a hidden diagnosis for the rest. Editorial. JK Practitioner 2006; 13 (Supp II): S7-S Whooley MA. Depression and cardiovascular disease: healing the broken-hearted. JAMA 2006; 295 : Margoob MA, Firdosi MM, Bansal R, et al. Community prevalence of trauma in South Asia Experience from Kashmir. JK Practitioner 2006; 13(SI): Margoob MA: Post disaster recovery: Issues, impressions and interventions. JK Practitioner 2006; 13 (SI) : Delhi Psychiatry Journal 2012; 15:(1) Delhi Psychiatric Society