Psychological Response to an Acute Coronary Event and Its Effect on Subsequent Rehabilitation and Lifestyle Change

Clin. Cardiol. 10, 256-260 (1987) Psychological Response to an Acute Coronary Event and Its Effect on Subsequent Rehabilitation and Lifestyle Change E. GUIRY, B.A., Lic. Phil., R. M. CONROY, B.A., Mus. B., N. HICKEY, M.D.. F.R.C.P.I., R. MULCAHY, M.D., F.R.C.P. Cardiac Department and Department of Preventive Cardiology, St. Vincent s Hospital and University College, Dublin, Ireland Summary: We assessed anxiety, depression, body image, motivation, and coping ability in 264 patients admitted with a first myocardial infarction. They were followed over 1 year to determine the relationship between psychological factors and subsequent return to work, smoking cessation, weight reduction, and adoption of a leisure exercise program. Females showed a poorer reaction to illness than did males. The better-educated, and patients in white-collar occupations showed less depression and expressed greater motivation. Anxiety and poor body image, however, tended to be least common in the intermediate educational and occupational group. All psychological factors predicted leisure exercise change, and all but anxiety predicted smoking cessation. Poor body image was linked with failure to reduce weight. Low expressed motivation was the only factor predicting delayed return to work. dition, in-patient psychological characteristics may help to identify individuals whose subsequent compliance or rehabilitation may pose difficulties. In this study we report on 264 patients who were followed over one year in order to study the relationship between psychological reaction to an acute coronary admission and subsequent return to work, smoking cessation, weight reduction, and adoption of a leisure exercise program. Patients and Methods Between February 1978 and February 1982, 264 subjects were assessed by psychological interview on the fourth day following hospital admission. Key words: coronary disease, psychology, anxiety, depression, body image, rehabilitation Introduction During hospital admission with a first episode of acute coronary heart disease (CHD), patients are faced with two psychological tasks: coping with the immediate traumatic situation, and dealing with the long-term threat to their health and sense of well-being. Although average coronary patients spend less than a fortnight in hospital, they may suffer from considerable distress during this time which may be alleviable. In ad- Address for reprints: Ronan M. Conroy Cardiac Department St. Vincent s Hospital Elm Park Dublin 4, Ireland Received: June 30, 1986 Accepted: September 20, 1986 Entry Criteria (1) Admission to coronary care with a proven attack of unstable angina or myocardial infarction. (2) Age less than 60 years on admission. (3) Attendance at follow-up clinic three weeks and one year after discharge. We have previously described our diagnostic criteria for myocardial infarction and unstable angina. Detailed interview criteria are available from the authors. A semistructured interview, administered by EG, was used to rate psychological state. Ratings were made as follows: Anxiety: Painful, unpleasant thoughts which are unproductive and resist the patient s attempts to think of other things, carry on conversations, etc. They are of sufficient intensity to impair the patient s ability to think clearly. Depression: Depression persisting for significant periods of the patient s waking hours. The patient feels like crying, becomes tearful on interview, or expresses extreme hopelessness. Motivation: This is the level of motivation expressed by the patient concerning rehabilitation, return to work,

E. Guiry et al.: Psychological response to MI 257 and lifestyle change, regardless of whether the interviewer suspects exaggeration. Body Image: This rating reflects the degree of preoccupation with damage to the body, impairment of function, or vulnerability resulting from the heart attack. A conviction of being seriously, possibly permanently, damaged is required for a positive rating. Coping Ability: This rating is made by the interviewer, based on the patient s history of coping with situations requiring some adaptation to new circumstances. Symptoms were rated on a 4-point scale, and these scores are used in calculating correlations. For clarity, however, symptom rates are presented on dichotomized ratings which combine the absent and mild categories as absent, and the moderate and severe categories as present. Education was divided into primary, secondary, or tertiary, according to the patient s highest level of education completed. Tertiary education included both university and higher technical education. Occupation was graded in accordance with the classification of the British Registmr General. This uses a five-point scale with higher professionals rated as one and unskilled manual workers as five. We have described these criteria in detail elsewhere.* Because so few females were in employment, occupation is reported only for males. Response to advice was assessed on three variables: smoking cessation, adoption of an exercise program, and reduction of weight. Smokers were coded as (1) having made no attempt to quit, (2) having quit at three-week follow-up visit but reverted at one year or, (3) having quit successfully. Minimal exercise was defined as activity confined to leisurely walking, at most three times per week, with or without occasional golf or other physical activities rated as having a metabolic cost of less than 3 METs (< 7 ml O2 mi~~/kg)~ (1 MET is the metabolic cost of the body at rest). Patients admitted with minimal leisure exercise were likewise coded as having made no change in their exercise habits, having failed to sustain early improvement, or having maintained an improvement over the first year after discharge. Patients were identified as being overweight using the body mass index (BMI) of Quetelet. This is the ratio of the patient s weight, in kilos, to the square of his height, measured in meters. A BMI of over 25 was taken as defining ove~weight.~ Response to weight reduction advice was defined as attainment of a BMI of less than 25 by one year from discharge. Results A total of 305 patients met the entry criteria. Psychological assessments were missing or incomplete in seven of these. A further 16 patients died before completion of 1 year follow-up and 18 cases were missing either 3 week or 1 year follow-up information. The results presented refer to the remaining cohort of 264 cases. Table I shows the relation of psychological assessment results to sex, education, occupation, and age group. Although anxiety and depression were present in approximately a third of patients, severe anxiety was more common (8.4%) than severe depression (1.5%). Females showed higher levels of symptoms and a poorer reaction to illness than did males. Level of education was related to all symptoms except anxiety. Depression, low expressed motivation, and poor coping style were more common in those with only a primary education, but poor body image and anxiety showed a U-shaped relation to education, with higher levels in patients with either primary or tertiary education. Such a relationship is not appropriately tested by a correlation coefficient. A chi-square test confirmed the relation between body image and education (p<o.ool), but the relationship between anxiety and education failed to reach significance. Occupation, recorded only in males, showed the same relationship as education to psychological assessment results. Table 11 shows compliance over the first year after discharge in patients who were given lifestyle modification advice on discharge. A total of 169 current smokers were advised to stop; 177 patients who took minimal leisure exercise were given specific recommendations about an exercise program suited to their circumstances, and 132 patients who were overweight were advised on reducing. Compliance was best in those asked to give up smoking; two thirds gave up and remained off at one year followup. A third of patients with minimal leisure exercise maintained an improved exercise pattern over the follow-up period, and a third of overweight patients reduced successfully to a BMI of less than 25. Table 111 shows the correlations between impatient psychological assessments and compliance with risk factor modification advice. All factors except anxiety correlated with smoking cessation, with poorer cessation rates in more symptomatic patients. Likewise, all factors correlated with leisure exercise improvement but only poor body image correlated significantly with failure to reduce weight. Table IV records the return to work of the 205 males who were in paid employment prior to admission to the study. Overall 1 year return to work was 90.5 %. Patients who became depressed during admission showed a marginally poorer return to work (p=0.081). Poor body image appeared to slow return to work, and anxiety appeared to hasten it, but neither effect was statistically significant. Poor coping style was associated with a lower 1 year return rate which was likewise not significant, but low expressed motivation was significantly associated with poorer return to work (p=0.045).

258 Clin. Cardiol. Vol. 10, April 1987 TABLE I Prevalance of psychological symptoms among the patients studied Poor Poor Low Number of Anxiety Depression motivation body image coping style cases (%) All cases 35.2% 36.5% 23.1 % 11.7% 10.6% 264 (100%) Sex Male 32.2% 33.8% 21.2% 9.6% 7.7% 208 (78.8%) Female 46.4% 46.4% 30.4% 19.6% 21.4% 56 (21.2%) P= 0.003 0.015 0.023 0.003 0.001 Education Primary 36.8% 46.4% 33.6% 14.4% 16.8% I25 (47.3%) Secondary 28.2% 26.9% 12.8% 6.4% 6.4% 78 (29.5%) Tertiary 41.O% 28.3% 14.8% 13.1 % 3.3% 61 (23.1%) P= 0.232 0.002 0.001 0.001 0.001 Occupation:" Professional 40.0% 25.0% 0.0% 10.0% 0.0% 20 (9.6%) Intermediate 37.5% 25.4% 15.6% 7.8% 1.6% 64 (30.8%) Skilled 17.2% 25.9% 20.7% 5.2% 8.6% 58 (27.9%) Semiskilled 39.6% 45.8% 20.8% 10.4% 10.4% 48 (23.1%) Unskilled 33.3% 66.7% 66.7% 27.8% 27.8% 18 (8.7%) P= 0.253 0.001 0.001 0.001 0.001 Age group: Under 55 34.3% 36.8% 20.3% 9.9% 10.5% 172 (65.2%) Over 55 37.0% 35.9% 28.3% 15.2% 10.9% 92 (34.8%) b P= 0.475 0.417 0.064 0.206 0.414 Significance levels are based on Kendall's Rank-order correlation using a 4-point scale for symptom severity. "Males only, n=208. bexact age used in correlations. TABLE I1 Response to lifestyle modification advice among the study group Smoking Exercise Weight Given advice 169 177 132 No compliance 14.3% 49.7% 66.7% Early compliance only" 19.0% 13.0% - Maintained complianceb 66.7% 37.3% 33.3% "Compliance at 3 week follow-up. 'At 1 year follow-up. Discussion There is a well-described pattern of psychological adjustment in patients admitted with myocardial infarcti~n.~lo The anxiety provoked by the onset of symptoms and subsequent hospital admission is initially damped by denial, a purposeful narrowing of consciousness which probably serves to protect patients from the full significance of their situation. As denial recedes, anxiety is unmasked again, but the salient characteristic of this later phase is depression. The importance of the work of depression in TABLE 111 The correlation' between inpatient psychological symptoms and I year compliance with risk-factor modification Poor Poor Low Anxiety Depression motivation body image coping style Smoking cessation 0.064-0.1 19-0.286-0.144-0.252 P= 0.184 0.051 < 0.00 1 0.023 <0.001 Exercise compliance -0.196-0.230-0.182-0.292-0.292 P= 0.002 <0.001 0.004 <0.001 <0.001 Weight reduction 0. I10-0.106-0.1 10-0.168-0.087 P= 0.092 0.109 0.092 0.024 0. I54 'Kendall's Rank-order correlation

~~ E. Guiry et al.: Psychological response to MI 259 TABLE IV The relation of inpatient psychological assessment to one-year return to work among 205 males employed prior to admission At 3 months Return to work At 1 year Anxiety Anxious 77.3% 94.2% Not anxious 71.4% 88.6% p=0.294 Depression Depressed 70.0% 84.5% Not depressed 74.8% 93.3% p=o.o81 Body Image Poor body image 65.0% 90.0% Good body image 74.2% 90.4% p=0.590 Coping style Poor coping style 56.2% 81.3% Good coping style 74.7% 91.1% p=0.133 Expressed motivation Low motivation 59.5% 83.3% Good motivation 76.8% 92.1 % p=0.045 Significance levels based on logrank test. restructuring the patient s psychological investments has been recognized since Freud s seminal paper of 1917. It is only more recently that the adaptive function of denial has come to be recognized12-14 as a defense which gives the patient a breathing space to come to terms gradually with the traumatic situation. Depression is usually an indicator that the patient is beginning to deal realistically with the situation. A recent study by Lloyd and Cawley identified two distinct groups of patients who showed high levels of postinfarction psychological symptoms. Patients whose psychological symptoms had preceded their infarction tended to have above-average neuroticism scores, and their symptoms tended to persist. Those whose symptoms had been precipitated by the infarction were not distinguishable psychometrically or demographically from the remainder of postinfarction patients; their symptoms tended to disappear over the course of the year following infarction without any specific treatment. Our results confirm that considerable levels of stress are involved in the early postinfarction period. Of greater importance, however, are the differences between patient groups. Females showed more overt distress than males, and the less well-educated than the better-educated. Both of these groups may benefit from selective intervention. Although some of the differences between patient subgroups may be explained by preinfarction characteristics which are not amenable to intervention during a hospital admission, some of the differences may be due to features of the hospital care system itself, such as poor staff-patient communication. The high prevalences of symptoms reflecting worry and anxiety in both upper and lower social groups may be partly explicable in terms of current research on stressful environments. Three factors appear to influence the stressfulness of an environment: its novelty, predictability, and controllability. For the less well-educated, the element of unpredictability may be the predominant anxiety-provoking factor, while the loss of habitual control over their environment and body may be the source of anxiety in the higher occupational groups. The association between psychological response to acute MI and subsequent success or failure in making beneficial changes in lifestyle may be contaminated by a number of variables, notably the environment of the patient. There have been few studies to date relating compliance and rehabilitation to in-hospital psychological assessment. Nagle16 reported that adverse psychological reaction and poor cardiac function independently and additively predicted poor return to work rates in postcardiac patients. Mayou and co-workets,17 on the other hand, reported no relationship between in-patient psychological reactions and subsequent compliance, with the exception that patients with a low level of expressed motivation complied less well with both smoking cessation and medication. We can confirm this observation from our own data. Friedmanla considers depression developing during the course of recovery after infarction to be the greatest barrier to rehabilitation. Our results do not support the singling out of depression in particular but they do support the thesis that patients whose subsequent rehabilitation will present problems may be identified by their psychological state during hospital admission. The interpretational difficulties in the data presented are typical of investigations into psychological response to stressful situations, such as hospital admission. The investigator is usually faced with a choice between questionnaire and interview measurement. The approach which we have adopted was aimed primarily at providing clini-

260 Clin. Cardiol. Vol. 10, April 1987 cally useful infortnation. The ability of an interviewer to cross-question patients to clarify their responses provides a more sensitive assessment, and being interviewed by a health professional rather than filling in a questionnaire gives patients the sense of being in effective and immediate communication with those responsible for their health and rehabilitation. As part of a multidisciplinary rehabilitation program, therefore, interview assessment is preferable. Our use of semistructured interview, based on standard definitions and carried out by a single interviewer, defines the limits of the interpretability of the results presented. The absolute rates quoted are, to some extent, a product of our definitions. Other definitions would yield other rates. The relative rates, however, are more reliable, as are the associations between psychological ratings and subsequent rehabilitation. Whatever the true rates of psychological symptoms after MI, some patient subgroups show evidence of greater levels of distress than others, and some patterns of psychological response appear to be associated with poorer rehabilitational outcome. These associations point the way to patient subgroups who may need specific intervention. They lead to two important questions for future research: why some groups of patients experience higher levels of distress, and what the causal connection is between psychological response and subsequent rehabilitation. Acknowledgments We are grateful to Dr. Elizabeth Kay and Dr. Alistair Philip of the Royal Edinburgh Hospital, Scotland, and to Dr. Ian Graham of the Meath and Adelaide Hospitals, Dublin, for their invaluable advice in the early stages of this project. We would also like to thank the Computer Centre of University College Dublin for their support and advice. References 1. Conroy RM, Mulcahy R, Hickey N, Daly L: Is a family history of coronary heart disease an independent risk factor? Br Hean J 53, 378 (1985) 2. Conroy RM, Cahill S, Mulcahy R, Johnson H, Graham I, Hickey N: The relation of social class to risk factors, rehabilitation, compliance and mortality in survivors of acute coronary heart disease. Scand J Soc Med 14, 51 (1986) 3. Koenig K, Denolin H, Dorossiev D (Eds): Myocardial Infarction: How to Prevent, How to Rehabilitate, 2nd edition. International Society and Federation of Cardiology (1983) 188 4. Gamw JS: Treat Obesity Seriously. Church and Livingstone, Edinburgh (1981) 5. Hackett TP, Cassem NH: Coronary Care: Patient Psychology. American Heart Association, Inc., New York (1975) 6. Cassem NH, Hackett TP: Psychiatric consultation in a coronary care unit. Ann Intern Med 95, 9 (1971) 7. Gentry WD, Foster S, Hanley T: Denial as a determinant of anxiety and perceived health status in the coronary care unit. Psychosom Med 34, 39 (1972) 8. Miller WB, Rosenfeld RA: Psychophysiological study of denial following acute myocardial infarction. J Psychosom Res 19, 43 (1975) 9. Billings CK: Management of psychologic responses to myocardial infarction. South Med J 10, 1367 (1980) 10. Froese A, Hackett TP, Cassem NH, Silverberg EL: Trajectories of anxiety and depression in denying and non-denying acute myocardial infarction patients during hospitalisation. J Psychosom Res 18, 413 (1974) 11. Freud S: Mourning and melancholia. Standard Edition clfthe Complete Psychological Works of Sigmund Freud (24 Vols). London, Vol. XIV, 255 (1953-73) 12. Hackett TP, Cassem NH: Psychological adaptation to convalescence in myocardial infarction patients. In Exercise Testing and Exercise Training in Coronary Heart Disease. (Naughton J, Hellerstein HK, Eds). Academic Press, New York (1973) 253 13. Hackett TP, Cassem NH: Development of a quantitative rating scale to assess denial. J Psychosom Res 18, 93 (1974) 14. Lindrop CR, Gibson S: The concept of coping. Psychol Med 12, 385 (1982) 15. Lloyd GG, Cawley RH: Distress or illness? A study of psychological symptoms after myocardial infarction. Br J Psychiatr 142, 120 (1983) 16. Nagle R. Morgan D, Bird J: Interaction between physical and psychological abnormalities after myocardial infarction. In Psychological Approach to the Rehabilitation of Coromty Patients. (Stocksmeier U, Ed). Springer Verlag, Heidelberg, 84 (1976) 17. Mayou R, Foster A, Williamson B: Medical care after myocardial infarction. J Psychosom Res 23, 23 (1979) 18. Friedman EH: Psychosocial factors in coronary risk and rehabilitation. In Psychological Approach to the Rehabilitation of Coronary Patients. (Stocksmeier U, Ed). Springer Verlag, Heidelberg (1976) 35