Health Psychology 2015, Vol. 34, No. 3, 283–287

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BRIEF REPORT

Psychological Distress and Intensive Care Unit Stay After Cardiac Surgery: The Role of Illness Concern Lydia Poole, Tara Kidd, Elizabeth Leigh, and Amy Ronaldson

Marjan Jahangiri University of London

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University College London

Andrew Steptoe University College London Objective: To examine the association between psychological factors and length of intensive care unit (ICU) stay in patients undergoing elective coronary artery bypass graft (CABG) surgery. Method: We studied 212 adults undergoing CABG surgery preoperatively to assess depression symptoms, anxiety symptoms, and illness perceptions and then followed them up during the in-hospital stay to measure length of ICU stay. Results: Greater preoperative concern about the illness (B ⫽ .200, 95% CI [.094, .305], p ⫽ ⬍ .001), but not depression or anxiety symptoms, was significantly related to longer ICU stays after controlling for demographic, clinical, and behavioral covariates. Conclusions: Illness concern may be particularly relevant for CABG recovery, though more work is needed to delineate the exact mechanisms of this effect. Keywords: depression symptoms, anxiety, illness perceptions, intensive care, coronary artery bypass graft surgery

surgery. Depression and anxiety are both mood disorders, but recent attention has also been paid to cognitive aspects of the experience of illness. Negative illness perceptions have been associated with an array of poor outcomes in myocardial infarction patients (Cherrington, Moser, Lennie, & Kennedy, 2004; Petrie, Weinman, Sharpe, & Buckley, 1996). However, little is known about how preoperative illness perceptions affect physical recovery after CABG. The aim of this study was to assess the relationship between preoperative depression symptoms, anxiety, and illness perceptions, and length of postoperative ICU stay. Because these were exploratory analyses, we made no specific hypotheses regarding which marker of psychological response would best predict length of ICU stay.

It has been estimated that every day spent in an intensive care unit (ICU) costs in the region of $6,000 to $10,000 for the first day, and more than $3,000 per day on subsequent days (Dasta, McLaughlin, Mody, & Piech, 2005). Little attention has been paid to the role of psychological factors in predicting length of ICU stay. Psychological distress is a heterogeneous concept. Much attention has been paid to the predictive utility of depression. Burg and colleagues (Burg, Benedetto, Rosenberg, & Soufer, 2003) found that, compared with nondepressed patients, presurgery depressed patients had higher levels of medical complications during the 6 months following surgery, and were more likely to report poor quality of life and worse recovery. Another psychological response associated with CABG recovery is anxiety. Tully and colleagues (Tully, Baker, & Knight, 2008) found that preoperative anxiety was associated with greater risk of mortality following

Method Participants

This article was published Online First December 22, 2014. Lydia Poole, Tara Kidd, Elizabeth Leigh, and Amy Ronaldson, Department of Epidemiology and Public Health, University College London; Marjan Jahangiri, Department of Cardiac Surgery, St George’s Hospital, University of London; and Andrew Steptoe, Department of Epidemiology and Public Health, University College London. This research was funded by the British Heart Foundation. Correspondence concerning this article should be addressed to Lydia Poole, Department of Epidemiology and Public Health, 1-19 Torrington Place, University College London, London, WC1E 6BT UK. E-mail: [email protected]

The study used data collected in the Adjustment and Recovery after Cardiac Surgery (ARCS) study. Full details of the recruitment and retention of participants has been published elsewhere (Poole et al., 2014). Briefly, 249 candidates for CABG were recruited consecutively from a presurgery assessment clinic at St. George’s Hospital, London. Twenty-six participants had missing data for one or more covariates, and an additional 11 were excluded on the grounds of limited cognitive ability (see below), so analyses were based on the 212 CABG surgery patients with complete data. Those excluded from analyses (n ⫽ 37) were more likely to be 283

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older, (t ⫽ 2.088, p ⫽ .038) have fewer chronic illnesses, (t ⫽ ⫺2.337, p ⫽ .020) and be of non-White ethnic origin (␹2 ⫽ 5.622, p ⫽ .018) compared with those included. Ethical approval was obtained from the South West London Research Ethics Committee.

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Measures Predictors: Depression symptoms, anxiety, and illness perceptions. The Beck Depression Inventory (BDI; Beck, Steer, & Carbin, 1988) was used to measure depression symptoms at baseline. Ratings on the 21 items were summed, with higher scores indicating greater emotional disturbance, with a range of 0 to 63 (Cronbach’s alpha ⫽ .85). The Hospital Anxiety and Depression Scale (HADS) is a selfreport measure of anxiety and depression for use in outpatient clinical settings (Zigmond & Snaith, 1983). We administered the 7-item anxiety scale at baseline. Items were summed to generate an overall score, with higher scores indicating greater anxiety (Cronbach’s alpha ⫽ .88). The Brief Illness Perceptions Questionnaire (BIPQ; Broadbent, Petrie, Main, & Weinman, 2006) provides rapid assessment of emotional and cognitive representations of illness. An example item includes: “How concerned are you about your illness?” Responses to the first eight items were scored on a scale of 0 to 10. Each item represents a different illness perception (consequences, timeline, personal control, treatment control, identity, concern, coherence, and emotional representation), and each item has been validated for use as a separate construct (Broadbent et al., 2006). Items 3, 4, and 7 were reverse coded, so a higher score on all items reflects a more negative perception. Outcome: Length of stay. Length of ICU stay was collected from clinical records. Length of ICU stay is a marker of clinical recovery, with those participants experiencing the poorest recovery expected to have the longest ICU stays after CABG. Covariates: Clinical and sociodemographic measures. Clinical risk was assessed using the European System for Cardiac Operative Risk Evaluation (EuroSCORE) (Roques, Michel, Goldstone, & Nashef, 2003). Items were scored using the “logistic EuroSCORE” method to generate a percentage mortality risk estimate. Using clinical notes, data were collected in line with definitions provided by the Adult Cardiac Surgery database Version 3.8, Society for Cardiothoracic Surgery (UK; http://www.sts .org/national-database). Using this information, we recorded the participant’s preoperative heart rhythm (sinus, atrial fibrillation, complete heart block) and counted the number of in-hospital complications experienced (e.g., postoperative dialysis, cerebrovascular accident). History of diabetes, whether they had any valve replacements, and whether they underwent cardiopulmonary bypass (yes/no) were also recorded. Participants were asked to report any longstanding illnesses prior to surgery other than their heart disease (e.g., cancer, endocrine disorders, rheumatoid arthritis), and these were added to capture chronic illness burden. Preoperative smoking was assessed, and body–mass index (BMI; kg/m2) was measured at the preoperative clinic appointment. Cognitive screening. The Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005) was administered at baseline. This is a brief measure of mild cognitive impairment covering eight domains. A maximum of 31 points was awarded. Participants

who scored ⬍19 on the MoCA were excluded from this study (n ⫽ 11), because this might have affected the reliability of participants’ questionnaire responses.

Statistical Analysis Hierarchical linear regression was used to examine the relationship between preoperative psychological measures and postoperative ICU stay. Psychological measures were entered simultaneously into models. Secondary analyses were also performed with each distress indicator entered into separate models. Covariates were BMI, smoking status, preoperative heart rhythm, valve replacement, cardiopulmonary bypass use, diabetes, complications, chronic illness burden, and EuroSCORE. Age and sex are included in EuroSCORE so were not entered separately to avoid double adjustment. Step 1 of the regression model controlled for covariates and psychological measures were added in Step 2. Given the number of predictors, we used a Bonferroni correction of p ⬍ .005 to indicate statistical significance. Variance inflation factor values were generated for all regression models to assess multicollinearity; all were within the acceptable range. All analyses were conducted using SPSS Version 21.

Results Table 1 summarizes the characteristics of the participants at baseline prior to CABG surgery. Scores on the BIPQ, HADS, and BDI were significantly positively correlated with each other; the correlation coefficients ranged from r ⫽ .005–.660 indicating limited multicollinearity. Table 2 shows that preoperative concern scores on the BIPQ were significant predictors of length of ICU stay in the fully adjusted model (B ⫽ .200, p ⫽ ⬍ .001) after controlling for demographic, behavioral, and clinical covariates. This is a positive association such that greater preoperative concern was associated with longer ICU stays. The only other significant predictors of longer ICU stays were greater complications (B ⫽ 3.036, p ⬍ .001) and higher EuroSCORE (B ⫽ .128, p ⫽ .001). Fewer chronic illnesses (B ⫽ ⫺.600, p ⫽ .007) approached statistical significance, but this may be a chance association. The final model accounted for 34.7% of the variance in post-CABG ICU stays. Neither depressive symptoms nor anxiety predicted length of ICU stay. The same pattern of results was found when each distress indicator was entered into separate models.

Discussion We found that greater perceptions of concern about the condition were associated with longer ICU stays, remaining significant even after a Bonferroni correction. Other illness perceptions, depression symptoms and anxiety were not related to length of ICU stay. Our results are congruent with those by Juergens and colleagues (Juergens, Seekatz, Moosdorf, Petrie, & Rief, 2010), who reported that greater negative preoperative illness perceptions were associated with greater disability and poorer quality of life 3 months after surgery. Moreover, analogous results have been reported in a correlational study of myocardial infarction patients in which greater negative illness perceptions were shown to be associated with greater in-hospital complications (Cherrington et al., 2004). These previous researchers did not look at each illness

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Table 1 Demographic, Psychological Distress and Clinical Characteristics of the Sample at Baseline (N ⫽ 212) Mean ⫾ SD or N (%)

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Characteristic Age (years) Female Ethnicity: White British/Other White BMI (kg/m2) Smoker Comorbidities Diabetes Hypertension Pulmonary disease Neurological disorder Extracardiac arteriopathy Chronic illness burden Clinical factors Logistic EuroSCORE (%) Preoperative heart rhythm - Sinus Preoperative heart rhythm - Atrial fibrillation/flutter Preoperative heart rhythm - Complete heart block/pacing CABG in isolation Valve replacement Cardiopulmonary bypass Length of ICU stay Complications Psychological distress Depression symptoms (BDI) Anxiety (HADS) Illness perceptions (BIPQ)–consequences Illness perceptions (BIPQ)–timeline Illness perceptions (BIPQ)–personal control Illness perceptions (BIPQ)–treatment control Illness perceptions (BIPQ)–identity Illness perceptions (BIPQ)–concern Illness perceptions (BIPQ)–coherence Illness perceptions (BIPQ)–emotional representation

67.32 ⫾ 8.88 25 (11.8) 190 (89.6) 28.83 ⫾ 4.16 18 (8.5) 52 (24.1) 168 (79.2) 12 (5.7) 17 (7.9) 21 (9.9) 0.49 ⫾ 0.68 4.38 ⫾ 3.22 194 (94.5) 16 (7.5) 2 (0.9) 167 (78.8) 39 (18.4) 164 (77.4) 1.31 ⫾ 1.81 0.08 ⫾ 0.30 8.53 5.81 5.62 4.51 6.00 1.08 4.70 7.22 4.68 4.66

⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾

6.52 4.26 2.85 3.01 2.89 1.41 2.66 2.64 2.02 3.03

Note. BMI ⫽ body-mass index; EuroSCORE ⫽ European System for Cardiac Operative Risk Evaluation; ICU ⫽ intensive care unit; BDI ⫽ Beck Depression Inventory; HADS ⫽ Hospital Anxiety and Depression Scale; BIPQ ⫽ Brief Illness Perceptions Questionnaire.

perception individually, but rather computed a composite score, which limited the interpretability of the findings. Our results are the first, to our knowledge, to have shown a specific association between concerns about illness and a clinical marker of acute complications following CABG surgery: length of ICU stay. Previous work has shown the independent effects of depression and anxiety for CABG recovery (Burg et al., 2003; Tully et al., 2008). Our data simultaneously assessed the combined contribution of distress indicators, and were unable to support the negative effect of depression and anxiety on length of ICU stay. This finding was also supported in individual models, with concern being the only significant independent predictor of length of ICU stay. Because the illness perception of concern is conceptualized as an emotional representation of illness (Broadbent, Ellis, Thomas, Gamble, & Petrie, 2009) this finding might suggest that illness-specific distress is more relevant for length of ICU stay than feelings of general anxiety and depression. Moreover, our recovery endpoint was a marker of acute clinical complications, while other researchers have looked at more long-term markers. Mechanisms of the association between illness concern and length of ICU stay are likely to involve several pathways. The

construct of concern could be likened to “worry,” which has been associated with changes to heart rate and heart-rate variability (Pieper, Brosschot, van der Leeden, & Thayer, 2007). Therefore, it could be hypothesized that patients who are high in concern may be more susceptible to biological changes that put them at greater risk of acute clinical events in hospital, such as cardiac arrhythmia, which in turn could prolong ICU stay; this has yet to be tested empirically. It is also possible that a noncausal pathway exists: for example, patients who were at high risk of complications may be both more concerned and have longer stays. We tried to address this issue by controlling for clinical covariates. Further work is needed to delineate these pathways in CABG patients. Our study has a number of strengths. The prospective nature of our analyses allows the direction of the effect to be explored. In addition, our analyses controlled for a large range of potential confounders. The ARCS study examined patients undergoing CABG at a single hospital and therefore removed the influence of interhospital variation in patient-care policy. We must also acknowledge some limitations. First is the reliance on questionnaire measures of psychological distress. The BIPQ relies on single-item constructs, and so may not fully capture the cognitive experience

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Table 2 Multiple Regression on Baseline Psychological Distress Measures Predicting Length of ICU Stay

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Model Step 1 Smoking BMI Heart rhythm Valve replacement Cardiopulmonary bypass Diabetes Complications Chronic illness burden EuroSCORE Step 2 Smoking BMI Heart rhythm Valve replacement Cardiopulmonary bypass Diabetes Complications Chronic illness burden EuroSCORE Depression symptoms (BDI) Anxiety (HADS) Consequences (BIPQ) Timeline (BIPQ) Personal control (BIPQ) Treatment control (BIPQ) Identity (BIPQ) Concern (BIPQ) Coherence (BIPQ) Emotional representation (BIPQ)

B

SE

95% CI



p

0.384 0.028 ⫺0.299 ⫺0.161 0.254 0.554 2.849 ⫺0.394 0.126

0.385 0.026 0.324 0.292 0.257 0.330 0.370 0.214 0.037

[⫺0.376, 1.143] [⫺0.023, 0.080] [⫺0.938, 0.340] [⫺0.737, 0.415] [⫺0.254, 0.762] [⫺0.097, 1.204] [2.119, 3.579] [⫺0.817, 0.028] [0.053, 0.199]

0.059 0.065 ⫺0.053 ⫺0.034 0.059 0.132 0.469 ⫺0.149 0.224

.320 .283 .358 .583 .325 .095 ⬍.001 .067 .001

0.259 0.033 ⫺0.364 ⫺0.247 0.297 0.667 3.036 ⫺0.600 0.128 0.010 ⫺0.023 ⫺0.063 ⫺0.040 ⫺0.014 0.140 ⫺0.038 0.200 0.007 0.029

0.394 0.026 0.326 0.290 0.259 0.329 0.380 0.218 0.037 0.023 0.037 0.049 0.038 0.038 0.086 0.049 0.053 0.056 0.050

[⫺0.517, 1.036] [⫺0.018, 0.085] [⫺1.008, 0.279] [⫺0.819, 0.325] [⫺0.215, 0.808] [0.018, 1.316] [2.287, 3.785] [⫺1.031, 0.170] [0.056, 0.201] [⫺0.036, 0.055] [⫺0.097, 0.050] [⫺0.159, 0.034] [⫺0.115, 0.036] [⫺0.088, 0.061] [⫺0.029, 0.309] [⫺0.135, 0.059] [0.094, 0.305] [⫺0.104, 0.119] [⫺0.069, 0.127]

0.040 0.076 ⫺0.065 ⫺0.053 0.069 0.159 0.500 ⫺0.227 0.228 0.035 ⫺0.055 ⫺0.099 ⫺0.066 ⫺0.022 0.109 ⫺0.056 0.290 0.008 0.048

.511 .206 .265 .395 .254 .044 ⬍.001 .007 .001 .674 .530 .201 .300 .722 .104 .440 ⬍.001 .899 .560

Note. ICU ⫽ intensive care unit; BMI ⫽ body–mass index; EuroSCORE ⫽ European System for Cardiac Operative Risk Evaluation; BDI ⫽ Beck Depression Inventory; HADS ⫽ Hospital Anxiety and Depression Scale; BIPQ ⫽ Brief Illness Perceptions Questionnaire. Step 1: adj R2 ⫽ .318; Step 2: adj R2 ⫽ .347; ⌬adj R2 p ⫽ .047.

of illness. In addition, care needs to be taken with the interpretation of length of ICU stay because it is only a proxy marker of physical recovery; other factors such as bed-space constraints may influence transfer times of some patients. We tested several different illness perceptions, which raises the issue of multiple comparisons; however, the association with illness concern would remain significant even after a Bonferroni correction. Finally, because our sample was predominantly White men, our findings may not readily generalize to other populations. In conclusion, we have shown that, among three different markers of psychological response, the illness perception of concern was the only factor related to length of ICU stay in patients undergoing CABG surgery. Further work is needed to understand the processes through which illness perceptions affect cardiac recovery.

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This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

ILLNESS PERCEPTIONS AND CARDIAC SURGERY RECOVERY Petrie, K. J., Weinman, J., Sharpe, N., & Buckley, J. (1996). Role of patients’ view of their illness in predicting return to work and functioning after myocardial infarction: Longitudinal study. British Medical Journal (clinical research ed.), 312, 1191–1194. http://dx.doi.org/ 10.1136/bmj.312.7040.1191 Pieper, S., Brosschot, J. F., van der Leeden, R., & Thayer, J. F. (2007). Cardiac effects of momentary assessed worry episodes and stressful events. Psychosomatic Medicine, 69, 901–909. http://dx.doi.org/ 10.1097/PSY.0b013e31815a9230 Poole, L., Kidd, T., Leigh, E., Ronaldson, A., Jahangiri, M., & Steptoe, A. (2014). Preoperative sleep complaints are associated with poor physical recovery in the months following cardiac surgery. Annals of Behavioral Medicine, 47, 347–357. http://dx.doi.org/10.1007/s12160-013-9557-8 Roques, F., Michel, P., Goldstone, A. R., & Nashef, S. A. M. (2003). The logistic EuroSCORE. European Heart Journal, 24, 882. http://dx.doi .org/10.1016/S0195-668X(02)00799-6

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Received January 15, 2014 Revision received September 23, 2014 Accepted September 26, 2014 䡲

Psychological distress and intensive care unit stay after cardiac surgery: The role of illness concern.

To examine the association between psychological factors and length of intensive care unit (ICU) stay in patients undergoing elective coronary artery ...
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