Original Article
Prevalence and pattern of psychiatric morbidity and health related quality
of life in patients with ischemic heart disease in a tertiary care hospital
Shiny John
Department of Psychiatry, Amala Insititue of Medical Sciences, Thrissur, Kerala, India
Abstract
Background: Psychiatric morbidity and Health Related Quality of Life(HrQoL) in Ischemic Heart Disease(IHD) are
relatively less studied in our country.
Aims: This crosssectional observational study was undertaken to assess the common psychiatric disorders and HrQoL
in IHD.
Materials and Methods: Onehundred and thirty patients with IHD were evaluated for psychiatric morbidity and
HrQoL. Tools used were SCID1, Euro QoL5D, and Sociodemographic data sheet. The data were analyzed using
SPSS v 10.0 software, Chisquare test, Ttest, ANOVA were used as needed.
Results: Psychiatric morbidity was assessed using psychiatric assessment schedule SCIDI for generating diagnosis
as per DSMIV criteria. Major depressive disorder was found in 34.6%(n=45) patients. 23.8%(n=31) patients had
a diagnosis of depression due to general medical condition. Anxiety disorder due to general medical condition was
present in 36.9%(n=48) patients. Around 95.4% of patients reported psychiatric symptoms, either depression or anxiety.
Though widely disputed, low educational status was reported as significantly associated with psychiatric morbidity in
IHD. Female sex of the patient and the presence of diabetes mellitus were associated with psychiatric morbidity in a
significant manner. Majority of patients with poor quality of life were in the domain of anxiety/depression.
Conclusion: The findings of our study reveal a high rate of psychiatric morbidity and impaired quality of life in IHD Patients.
Key words: Anxiety, cardiovascular, depression, ischemic heart disease, IHD India
Introduction
Ischemic heart disease (IHD) is no longer confined by
geographical area or by age, sex, or socioeconomic
boundaries. Heart disease has already reached epidemic
proportions in poorer countries. Of the 45.0 million
adult deaths reported worldwide in 2002, threequarters
(32million) were due to noncommunicable diseases.
Globally, IHD was the leading killer in the age group
60 years, and, with 1 332 000 deaths in adults aged
15-59years.[1] Asian Indians residing in different countries
have higher rates of incidence, hospitalization, prevalence,
Address for correspondence: [Link] John,
Department of Psychiatry, Amala Insititue of Medical Sciences,
Thrissur, Kerala, India.
Email:shinyskd@[Link]
morbidity, mortality, and case fatality from IHD than people
of other ethnicity.[2,3] Psychological problems associated with
IHD have been studied including the prevalence of psychiatric
disorders, their predictors, and quality of life. Complex
multidimensional relationships exist among depression
and IHD. Depression is recognized as an independent risk
factor for the development of IHD as well as a significant
predictor of higher morbidity and mortality in patients with
symptomatic IHD.[4] The etiology of IHD is multifactorial.
Risk factors include modifiable ones like cigarette smoking,
high blood pressure, elevated serum cholesterol, diabetes,
obesity, sedentary habits, and stress.[57] The nonmodifiable
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How to cite this article: John S. Prevalence and pattern
of psychiatric morbidity and health related quality of life
in patients with ischemic heart disease in a tertiary care
hospital. Indian J Psychiatry 2013;55:353-9.
Indian Journal of Psychiatry 55(4), Oct-Dec 2013
DOI:
10.4103/0019-5545.120554
353
John: Psychiatric morbidity and health related quality of life in patients with ischemic heart disease
risk factors include increasing age, male sex, family history,
and genetic disposition.[8,9]
Increased IHD risk associated with depression was
also found in a 6year study of 4493 elderly Americans
(age65years) who were free of IHD at baseline.[10] In a
Spanish study,[11] authors analyzed the psychiatric morbidity
and IHD in a consecutive series of 194patients with IHD.
The results demonstrated a high prevalence of psychiatric
morbidity (44.8%) in patients with cardiological pathology
in contrast to another study using a similar methodology
(prevalence=35%).[12]
During the past three decades, quality of life(QOL) has
emerged as an important attribute of clinical outcome and
patient care. A study has attempted to identify clinical,
demographic, and psychosocial characteristics of patients
at admission that were independent predictors of QOL
6months and 1year after acute myocardial infarction.[13]
They measured physical and mental QOL (Short Form36
Physical and Mental Components Summary Scores) and
overall QOL(Euro QOL health perception scale) in a
prospective cohort of 587patients. The results suggested
that age and psychosocial characteristics at baseline are the
most important predictors of QOL after acute myocardial
infarction. Authors suggested routine measurement of
QOL and the level of depression at the time of admission
for myocardial infarction to target treatment interventions
that can improve QOL for patients with the lowest scores.
Another study evaluated the association between a history
of depression and patient reported angina frequency,
physical limitation, and QOL 7months after discharge
from the hospital for acute coronary syndrome.[14] Out
of 1957patients, 526patients (26.7%) had a history of
depression. Authors found a strong association between
a history of depression, heavier angina burden, and worse
QOL after an acute coronary syndrome. The presence of
depression at entry point as a powerful predictor of QOL
among survivors of myocardial infarction was reported
by other studies also.[15,16] Apart from depression, effect
of anxiety on QOL in patients hospitalized for acute
myocardial infarction was also studied. One such study
reported that symptoms of anxiety and depression did
predict QOL among those who lived to 12months after
acute myocardial infarction.[17] This finding confirmed the
previous similar report.[16]
Psychological and psychosocial factors play important roles
in the etiology course and outcome of IHD. The importance
of psychological factors was even more evident when
attempts were made to rehabilitate IHD patients. Changes
in psychological factors in patients with IHD have been
found to be important determinants for improvement. The
disease can directly affect the mental function and result in
chronic impairment in mental function. By so far, the most
commonly reported emotional consequences associated
354
with IHD are depression, anxiety, certain psychosocial
work characteristics, social networks and social support,
and typeA personality behavior plus hostility.[18] These
psychosocial components are important in the secondary
prevention of IHD apart from their role in primary and
primordial prevention. Understanding the interplay between
psychosocial factors and IHD is crucial in understanding
QOL in IHD.[19]
Aims and Objectives
Aim
The aim of the study is to assess the psychiatric morbidity
and QOL in coronary heart disease(IHD).
Objectives
1. To assess prevalence and patterns of psychiatric
morbidity in patients with IHD
2. To assess health related QOL in patients with IHD
3. To assess the relationship among sociodemographic
and clinical factors, psychiatric morbidity, and health
related QOL in patients with IHD.
Materials and Methods
The sample comprised patients with coronary heart disease.
The following diagnoses are included under the heading
of coronary heart disease: (1) myocardial infarction with
ST segment elevation, (2) myocardial infarction without
ST segment elevation, (3) chronic stable angina, and
(4)unstable angina.
Data were collected from the inpatient cardiology
department at St. Johns Medical college Hospital
Bangalore. Investigator visited the patients admitted to
the coronary care unit on a daily basis. Consultants from
the Cardiology department confirmed the diagnosis of IHD
with the aid of ECG and cardiac enzyme studies. Patients
fulfilling the inclusion criteria were selected and were
explained about the nature of the study, and then informed
consent was taken from all the patients. Selected patients
were interviewed on third or fourth day of the admission
instead of the day itself, in view of possible unstable
medical condition interfering with the interview procedure.
All instruments were administered in a single session
of one and a half to two hours duration approximately.
Patients were first administered the Mini Mental Status
Examination (MMSE) or Hindi Mental Status Examination
(HMSE) wherever applicable. Then the clinical proforma,
Structured Clinical Interview for DSMIV Axis I Diagnosis
(SCIDI), and Health related quality of scale (EQ5D) were
administered. The diagnosis (ICD10 and DSMIV), the
proposed medication and the role of counseling were
discussed with the cardiologists and the clients having a
psychiatric morbidity.
Indian Journal of Psychiatry 55(4), Oct-Dec 2013
John: Psychiatric morbidity and health related quality of life in patients with ischemic heart disease
Results
Sociodemographic distribution
The sample consisted of predominantly males(n=101,
77.7%) compared to females (n=29, 22.3%). Age ranged from
26 to 80years. Seventytwo patients were in the range of
46-60years, 38 below age 45, and 20patients were above
60years. The religious break up found predominance
of Hindus(70.8%), followed by Christians(23.1%) and
Muslims(6.2%). Majority of the patients were married (n=109,
83.8%).4.6% were unmarried and 11.5% lost their spouses.
93(71.6%) patients were from urban background whereas
28.4% represented rural areas. The family structure revealed
clients belonging to nuclear family represented 73.8% while
26.2% were from non nuclear family. Most of the patients
had formal education(49.2% were with school education
and 43.8% had college education). 6.9% were illiterate.
Twentynine(22.3%) were unemployed. Employment break
up revealed professionals (11.5%), business (16.2%), farmers
(13.1%), skilled workers (13.1%), and clerks (6.9%). Retired
ones and house wives comprised 16.9%. Majority of the
patients (n=87, 66.9%) reported financial problems and
almost a similar number of patients (n=84, 64.6%) reported
decreased efficiency in work capacity in the previous 1year.
Clinical details and illness related information
Mean age at onset of IHD was 50.96 with a range of 49
(min=26, max75) and SD was 10.03. Mean age of the patient
in this study was 56.81, range 54(26-80) SD was 10.72.
Number of episodes of MI
Fortyone(31.5%) patients reported history of previous
episodes in the past. In these 41patients, the majority
(n=24, 58.5%) reported a single episode of MI in the past,
11(26.8%) reported two episodes and 6patients(14.6%)
reported more than two episodes.
Presence of diabetes, hypertension, dyslipidemia
Majority of the patients(n=72, 55.4%) had hypertension
along with IHD, almost a similar number of patients (n=68,
52.3%) were with Diabetes Mellitus. Number of patients
with comorbid dyslipidemia was even higher than diabetes
and hypertension (n=85, 65.4%).
Other clinical details
Ten patients(7.7%) had invasive procedures like CABG and
angioplasty in the past.
The diagnostic categories included ST elevated MI (STEMI)
(53.8%), non ST elevated MI(NSTEMI)(19.2%), unstable angina
(UA)(26.2%), and chronic stable angina (CSA) (one patient).
Physical status
On general examination, 55(42.3%) patients had some
form of abnormal physical signs like pallor, edema, raised
JVP etc., and on systemic examination 59(45.4%) patients
Indian Journal of Psychiatry 55(4), Oct-Dec 2013
had abnormal cardio vascular signs like S3, S4, murmur,
crepitations etc., Majority of patients(n=84, 64.6%) had an
ejection fraction more than 41%.
Alcohol and smoking
About 45.4% reported past or present alcohol use of which
19(32.2%) were current users, 14(23.7%) were exusers
and 20(33.8%) patients fulfilled a diagnosis of alcohol
dependence syndrome(ADS). 54.6% reported no alcohol use.
Sixty(46.9%) patients had history of smoking. Among these,
43(70.5%) were current smokers and 18(29.5%) patients
had past smoking history.
Psychiatric morbidity
Psychiatric symptoms, either depressive or anxiety were
present in most of the patients(n=124, 95.4%). Depressive
symptoms were noticed in 111(85.4%) patients whereas
anxiety symptoms were present in 66(50.8%). With regard
to psychiatric diagnosis major depressive disorder was
present in 45(34.6%) patients. 31(23.8%) patients were
qualified for a diagnosis of depressive disorder due to
a general medical condition(IHD). Anxiety disorder was
diagnosed in 48(36.9%). Sixteen patients reported both
anxiety disorder and depressive disorder. None of patients
reported psychotic disorder. Thirtynine(30.0%) patients
had the presence of dysthymia, of which 26patients had
double depression. Comorbid psychiatric disorders included
panic disorder(3.1%), generalized anxiety disorder(3.8%),
and adjustment disorder(7.7%)[Figure1].
For the purpose of further analysis, patients were classified
into four groups:(1) Major Depressive disorder(MDD)(2)
anxiety disorder due to medical condition,(3) those having
both anxiety disorder and MDD,(4) those without any
psychiatric diagnosis. Further analysis using tests like t
test and Pearson ChiSquare, significant association was
observed in the following variables such as(i) sex of the
patient(ii) educational status,(iii) the presence of diabetes
mellitus,(iv) and the presence of abnormal physical signs.
Health related quality of life
EURO QOL5D measures the quality of life across five
dimensions. They are mobility, selfcare, usual activities,
pain/discomfort, and anxiety/depression. Usual activities
include house work, study, family, or leisure time activities
and work. Patients who reported some problems form
the majority group in all domains except for anxiety or
depression domain[Table1].
Thirtyone(23.8%) patients reported that they were unable
to perform usual activities and 19(14.6%) patients reported
no problem in activity. Majority(n=80, 61.5%) reported
some difficulties. Only 8(10%) patients reported impairment
in mobility and 29(22.3%) reported no impairment in
mobility [Table2].
355
John: Psychiatric morbidity and health related quality of life in patients with ischemic heart disease
Figure1: Prevalence of psychiatric morbidity
Table1: Comparison of psychiatric morbidity with QOL domains
Problem
EQ5D activity
No
Some
Severe
Total
EQ5D mobility
No
Some
Severe
Total
EQ5D anxiety/depression
No
Some
Severe
Total
EQ5D pain/discomfort
No
Some
Severe
Total
EQ5D self care
No
Some
Severe
Total
Psychiatric morbidity
MDD
Anxiety due to IHD
Both
None
Total
3(10.3)
11(37.9)
15(51.7)
29(100)
3(9.4)
23(71.9)
6(18.8)
32(100)
10(62.5)
6(37.5)
16(100)
13(24.5)
36(67.9)
4(7.5)
53(100)
19(14.6)
80(61.5)
31(23.8)
130(100)
ChiSquare=27.356 df=6, P=0.001
4(13.8)
17(58.6)
8(27.6)
29(100)
6(18.8)
25(78.1)
1(3.1)
32(100)
1(6.3)
13(81.3)
2(12.5)
16(100)
18(34.0)
33(62.3)
2(3.8)
53(100)
29(100)
32(100)
16(100)
130(100)
ChiSquare=20.369 df=6, P=0.002
12(41.4)
17(58.6)
29(100)
5(15.6)
10(31.3)
17(53.1)
32(100)
1(6.3)
15(93.8)
16(100)
12(22.6)
25(47.2)
16(30.2)
53(100)
17(13.1)
48(36.9)
65(50.0)
130(100)
ChiSquare=26.549 df=6, P=0.000
12(41.4)
16(55.2)
1(3.4)
29(100)
15(46.9)
17(53.1)
4(25.0)
12(75.0)
16(100)
62(47.7)
66(50.8)
2(1.5)
130(100)
ChiSquare=8.031 df=6, P=0.236
32(100)
31(58.5)
21(39.6)
1(1.9)
53(100)
6(20.7)
15(51.7)
8(27.6)
29(100)
10(31.3)
19(59.4)
3(9.4)
32(100)
2(12.5)
8(50.0)
6(37.5)
16(100)
27(50.9)
22(41.5)
4(7.5)
53(100)
45(34.6)
64(49.2)
21(16.2)
130(100)
ChiSquare=19.622 df=6, P=0.003
MDD Major depressive disorder, IHD Ischemic heart disease; QOL Quality of life
Number of patients with good QOL were more(n=45,
34.6%) in self care domain. 21(16.2%) patients reported
poor QOL in the same.
Higher rate of poor QOL was noted in the anxiety/depression
domain(n=65, 50%). Pain and discomfort domain revealed
high percentage of good quality of life(n=62, 47.7%).
The Hr QOL mean score was 9.654 with a range of
nine having a maximum score of 15 and minimum
score of five. Summary statistics for individual items
are shown in Table2. ChiSquare results from cross
tabulation between Hr QOL items with psychiatric
morbidity as well as sociodemographic and illness
356
related variables have shown significant association
for following items(i)activity, (ii) anxiety/depression,
(iii)mobility,(iv)and self care. Oneway ANOVA was
used for comparison of mean EQ 5 total score between
the groups with psychiatric morbidity. In post hoc test
(multiple comparisons) for Hr QOL total ratings across
different groups the following items have shown
significant association (i)group with depression versus
no psychiatric morbidity group,(ii)group with only
anxiety versus group having both anxiety and depression,
(iii) group with both anxiety and depression versus none
group. Post hoc test results for Hr QOL total ratings
for depression due to IHD versus MDD groups revealed
significant association for two groups: MDD versus
Indian Journal of Psychiatry 55(4), Oct-Dec 2013
John: Psychiatric morbidity and health related quality of life in patients with ischemic heart disease
Table2: Frequency distribution-QOL domains
EQ5D mobility
No problem
Some problem
Severe problem
EQ5D activity
No problem
Some problem
Severe problem
EQ5D self care
No problem
Some problem
Severe problem
EQ5D anxiety/dep
No problem
Some problem
Severe problem
EQ5D pain/discomfort
No problem
Some problem
Severe problem
29
88
13
22.3
67.7
10.0
19
80
31
14.6
61.5
23.8
45
64
21
34.6
49.2
16.2
17
48
65
13.1
36.9
50.0
62
66
2
47.7
50.8
1.5
QOL Quality of life
depression due to general medical condition and MDD
versus none group. Comparison of mean Hr QOL EQ five
total score with different variables has shown following
items as significant (i) age, (ii)sex, (iii)marital status,
(iv)family type, (v) psychiatric morbidity (depressive
episode, depression due to general medical condition
and anxiety disorder), (vi) diabetes mellitus, (vii)
abnormal physical, and cardiac signs, (viii) treatment
for IHD.
Discussion
The focus on psychiatric aspects of medical disease has
been on the increase in the past few decades. The concept
of consultation liaison psychiatry is gaining ground as
more research is being done in this area. Psychosocial
management is becoming a part of treatment of chronic
medical illness. More awareness is being created among
physicians, and evidence of effective treatment for
psychiatric disorders is reducing the negative attitudes
toward psychiatric disorders. This study was undertaken
to systematically examine the psychiatric aspects of IHD
focusing on the prevalence of psychiatric symptoms and
disorders and its relation to health related to quality of life.
MMSE is a simple, brief scale with high sensitivity and
reliability[20] also is used for excluding patients with
cognitive impairment.
To assess psychiatric morbidity, Structured Clinical
interview for DSMIV Axis I diagnosis (SCIDI) was used.[21]
It is a semi structured diagnostic interview and all available
information including hospital records, informants, and
patient information was used to rate the SCIDI. The
superior quality of SCID as a tool for research on mental
Indian Journal of Psychiatry 55(4), Oct-Dec 2013
disorders ensured a uniform and standard assessment in all
subjects.
Though there are generic as well as disease specific
instrument available to assess QOL, EQ5D was used
in this study.[22] This is a simple scale, short, and easy to
administer, which basically measures health related QOL
across five dimensions. It has been used in a variety of
medical conditions. This instrument has minimum possible
confounding influence on socio cultural differences.
This instrument has proved as a valid general Hr QOL
measurement postMI.[23] The limitation with disease
specific questionnaires like Mac new Heart Disease Quality
of Life instrument is that many items are not applicable to
Indian population.[24]
Majority of the sample were males(n =101, 77.7%). This
is expected since male gender is an established risk factor
for IHD. One earlier study has reported that peak period
for IHD is: (a) between 51-60years(b) males are affected
more than females(c) hypertension and diabetes account
for about 40% of all cases(d) heavy smoking is responsible
etiologically in a good number of cases.[5] Our findings are
also in conformity with these observations. In our study
more than half of the patients(55.4%) were in the age group
of 45-60years. Diabetes mellitus was present in a similar
proportion of patients(52.3%). Sixtyone(46.9%) patients
were reported nicotine use. Majority of our sample had
the presence of hypertension and dyslipidemia(55.4 and
65.4%, respectively). Though family history is a risk factor
for IHD in our sample only a minority had a family history of
IHD(n=31, 23.8%).[8,9] Patients who had abnormal physical
or cardiac signs were less than half of the sample. This is
expected because of the fact that at the time of interview,
patients were largely stable and received good medical
support. The same fact is reflected in the finding that
majority had normal ejection fraction, >41% (n=84, 64.6%).
Prevalence of psychiatric comorbidity associated with
IHD varies from 17 to 45%. Ahigh proportion of patients
reported psychiatric symptoms in our study either
depression or anxiety (n=124, 95.4%). Two studies on
prevalence of psychiatric morbidity reported rates of 35%,
44.8%.[11,12] Though widely disputed, low educational status
was reported as significantly associated with psychiatric
morbidity in IHD.[25,26] In our study, we found the same
association, thus making a strong point that low educational
status is indeed associated with psychiatric morbidity.
Studies, which looked into the influence of marital status
contributing to the psychosocial morbidity, reported
conflicting results on the association.[27,28] This has been
confirmed in another study.[29] In our study, we also did not
find an association between marital status and psychiatric
morbidity. We found that female sex of the patient and
the presences of diabetes mellitus were associated with
psychiatric morbidity in a significant manner. Diabetes is
357
John: Psychiatric morbidity and health related quality of life in patients with ischemic heart disease
a known medical illness producing marked psychiatric
morbidity, especially affective disorders. So the finding was
in accordance with current research evidence with regard
to diabetes and psychiatric morbidity.
These findings are preliminary and need more studies before
any definite conclusion can be drawn. Lacks of comparable
studies also makes these findings interesting and support
the case for further studies.
Quality of life(QOL) has been defined as the subjective
satisfaction expressed or experienced by an individual
in his physical, mental, and social situations.[30] Various
measures both generic as well as disease specific have been
used to assess QOL. The performance of basic social roles
and activities of daily living is often used as a standard for
the impact of disease on quality of life. The dimensions of
quality of life that were analyzed included the following:
mobility, selfcare, usual activities, pain/discomfort, and
anxiety/depression. Since weighted scores are not available
for Indian population, we have taken the grand total and
subtotal for analysis. When the frequency tabulations were
done, we found that maximum number of patients with
good quality of life were in the domain of pain/discomfort
domain. Reflecting the same finding in Chisquare cross
tabulation with psychiatric morbidity the domain of pain/
discomfort did not show any significant association. Patients
with poor quality of life were seen maximum in the domain
of anxiety/depression. We divided psychiatric morbidity
into four groups, namely major depressive episode, anxiety
due to general medical condition, both depression and
anxiety disorder and a group with none. These groups
were compared with Health related QOL mean total score,
we found that group with major depression, group with
anxiety due to general medical condition, and group with
both comorbidity have shown significant association with
QOL total score compared to group having no psychiatric
morbidity. This finding is comparable to the previous studies
that had shown depression and anxiety at entry point as a
powerful predictor of QOL among survivors of myocardial
infarction.[1315]
Standardized instruments with proven reliability and
validity were used for assessments. To improve the quality
of assessments, we took adequate precautions to avoid any
possible interference due to delirium and other serious
medical complications. All the variables on which data were
collected were truly reflective of the problem and have got
practical implications.
When major depressive episode was compared with
depression due to general medical condition on HrQOL
total mean score, major depression was found to be more
significant. t test results for Hr QOL EQ 5 D total score
with various demographic and clinical variables have shown
results in the expected lines. Age has been reported as a
significant variable in earlier QOL studies.[13] These studies
had reported poor quality of life as age increases. Like the
previous studies, we also found that advanced age is a
predictor of poor quality of life. Male patients were found
to have better quality of life compared to female patients.
People with nuclear family had good quality of life compared
with patients from nonnuclear families. Among psychiatric
morbidity depression had the maximum significance with
regards to poor quality of life compared with depression due
to general medical condition or anxiety. Abnormal physical
signs or other medical illnesses with an established role
in the pathogenesis of psychiatric morbidity like diabetes
were proved as significant with regard to QOL in this study.
References
358
In view of the paucity of studies in our country concerning
psychiatric morbidity in IHD, our attempts to have a
close look at psychiatric morbidity and quality of life in a
reasonable sample of IHD patients may serve a platform for
further research.
Limitations of the study and suggestions
The design was cross sectional but a prospective study would
have given a better idea about development and course of
psychiatric symptoms and disorders. Alarge sample based
prospective study with a control group is needed to overcome
the limitation of cross sectional studies. Axis II problems were
left out from the purview of our assessment, Axis II issues have
important role in quality of life as well as psychiatric morbidity.
Astudy looking at both Axis I and Axis II comorbidity patterns
would be helpful to understand the problem comprehensively.
Acontrol group would have enabled us to compare the rates
with age and sex matched populations.
Acknowledgment
Thank to [Link] Appaya and Dr.E. Mohandas for their
valuable contributions to this work.
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