Orginal ArticleIllness perceptions among cardiac patients: Relation to depressive symptomatology and sex☆
Introduction
Depression has been implicated in both the onset and outcome of acute coronary syndromes (ACS; [1], [2], [3]). A recent review suggests that depression in patients with existing cardiovascular disease (CVD) confers a relative risk between 1.5 and 2.5 for cardiac morbidity and mortality [2]. Regrettably, depressive symptomatology and major depressive disorders are common in patients with ACS [4]. The prevalence of major depression ranges from 15% to 23% [5], which is approximately threefold higher than age-matched, community-based prevalence studies [5], [6]. Recovery from depression associated with ACS is extremely poor, with many patients remaining depressed months later [7], [8].
Moreover, women generally experience greater depressive symptomatology following ACS than men do [8], [9], [10], and this symptomatology may more detrimentally affect their prognosis and quality of life [11], [12]. Moreover, results from the M-HART trial of a psychosocial home nursing intervention [13] and recent post hoc subgroup analyses from the ENRICHD trial of cognitive behavioral therapy [14] both revealed that interventions to address depression may be more effective in male cardiac patients than in female patients. Much recent research attention has focused on the correlates of depression in ACS, how they may differ between the sexes, and how to mitigate its effect on cardiac outcome [7], [15], [16], [17], [18].
Previous research has highlighted the importance of personal models of illness to ACS recovery [19], [20], [21]. Patients' illness perceptions have been shown to relate not only to adherence behaviors and functional status [19], [20], [22], [23], [24], [25], but also to emotional distress [26], [27], [28], including depressive symptomatology [26], [29] across numerous health conditions. The construct of illness perceptions stems from Leventhal's Self-Regulation Model [30], [31]. This theory proposes that patients make sense of their health experience through personal cognitions, termed illness perceptions, which form the basis for their coping responses. Illness perceptions influence people's views about the causes of health conditions, perceptions of (a) an acute, chronic, or episodic course, (b) personal control, (c) consequences (e.g., financial, relational), and (d) the extent to which the condition is amenable to treatment control or cure.
While previous work has explored the effect of these illness perceptions on health behaviors in cardiac populations [19], [20], [23], [25], [27], [32], [33], the relationship between illness perceptions and depressive symptomatology has yet to be explored [25]. Such an examination may shed light on possible gender differences in depression and the gender differential in psychosocial treatment outcomes as outlined above. The objectives of this study were to [1] describe sex differences in ACS illness perceptions and [2] to examine the differential illness perceptions that are related to depressive symptomatology among women versus men with ACS, after controlling for other known correlates of depression, including age [34], marital status [35], socioeconomic status [36], [37], ethnocultural background [38], and physical activity and functional status [39].
Section snippets
Procedure and design
Ethics approval was obtained from participating institutions. This study constitutes a cross-sectional component of a larger prospective study on cardiac rehabilitation referral models. Participants were recruited by a research assistant on relevant cardiology floors from two hospitals, namely, the Trillium Health Center (THC) and University Health Network (UHN), both large, urban tertiary care facilities in the Greater Toronto Area, Ontario, Canada. Inclusion criteria were diagnosis of a
Respondent characteristics
The characteristics of participants are shown by sex inTable 2. Among the participants, women were significantly older, were more likely to be white, to have comorbid arthritis, and lower income than men do. Men were significantly more likely to have higher activity status, NYHA functional class, and diastolic blood pressure, to work full time, be more educated, married, a smoker, and to exercise regularly than women do.
There were no significant sex differences in depressive symptomatology,
Discussion
This study examined differences in illness perceptions between women and men in a large sample of ACS patients hospitalized for a coronary event or procedure. Illness perceptions among patients with the same condition and disease severity are shown to vary widely, conferring important ramifications for adherence behavior and functional recovery [21]. Our results suggest that illness perceptions also account for significant variation in emotional distress, specifically depressive symptomatology,
Acknowledgments
We gratefully acknowledge the efforts of Laura Ewart in patient recruitment. We also acknowledge funding for this project from the Canadian Health Services Research Foundation, the Ontario Ministry of Health and Long-term Care, and Canadian Institutes of Health Research.
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Department where work was conducted: Women's Health Program, Behavioral Sciences and Health Division, Toronto General Research Institute, University Health Network.