528071

research-article2014

CNU0010.1177/1474515114528071European Journal of Cardiovascular NursingFan and Meng

EUROPEAN SOCIETY OF CARDIOLOGY ®

Original Article

The mutual association between depressive symptoms and dyspnea in Chinese patients with chronic heart failure

European Journal of Cardiovascular Nursing 2015, Vol. 14(4) 310­–316 © The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1474515114528071 cnu.sagepub.com

Xiuzhen Fan1 and Zhu Meng1,2

Abstract Background: Depressive symptoms are prevalent in patients with chronic heart failure, but information about the relationship between depressive symptoms and dyspnea in chronic heart failure patients is limited. Aim: To assess the prevalence and mutual association between depressive symptoms and dyspnea in Chinese patients with chronic heart failure. Methods: A cross-sectional design was used in this study. One hundred and fifty-two patients with chronic heart failure (mean age 67 years, 57% female) were recruited from cardiovascular wards of hospitals. Depressive symptoms were measured with the Beck Depression Inventory, whereas dyspnea was evaluated with the Modified Pulmonary Functional Status and Dyspnea Questionnaire. Other data were obtained via patient interview and/or medical record review. Results: Out of 152 patients with chronic heart failure, 136 patients (89.5%) experienced dyspnea, whereas depressive symptoms were observed in 67 patients (44.1%). The transformed Beck Depression Inventory score correlated with dyspnea score positively (r = 0.54, p < 0.01). Multiple regression analysis revealed that gender, monthly income, body mass index, New York Heart Association class and dyspnea score contributed to depressive symptoms in Chinese patients with chronic heart failure. In addition, Beck Depression Inventory score and ejection fraction were identified as independent factors that contributed to dyspnea. Conclusions: In Chinese patients with chronic heart failure, the prevalence for both depressive symptoms and dyspnea is high and depressive symptoms and dyspnea are related to each other. Our results implicate that managing depressive symptoms and dyspnea appropriately is of great importance to patients with chronic heart failure. Keywords Depressive symptoms, dyspnea, heart failure Date received 8 March 2013; revised: 4 February 2014; accepted: 24 February 2014

Introduction Depressive symptoms in patients with chronic heart failure (CHF) are common. According to a meta-analysis of 36 studies, prevalence rates of depressive symptoms in CHF patients were found to range from 11 to 25% in outpatients and 35 to 70% in hospitalized patients.1 A previous study has shown that CHF patients with depressive symptoms report more negative beliefs, which would lead to negative coping behaviours and poor quality of life.2 Depressive symptoms are also predictors of repeated hospitalization in CHF patients. Compared to non-depressed patients, those

with depressive symptoms were hospitalized 1.45 times often.3 In addition, CHF patients with depressive symptoms also have an increased all-cause mortality risk.4 1Shandong 2Shandong

University, PR China Provincial Hospital, PR China

Corresponding author: Xiuzhen Fan, School of Nursing, Shandong University, 44# Wenhua Xi Road, Jinan, Shandong, 250012, PR China. Email: [email protected]

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Fan and Meng Despite the obvious negative effects of comorbid depressive symptoms in CHF patients, patients with depressive symptoms often go unrecognized and undertreated.5 Dyspnea is a prevalent symptom among patients with CHF, over half of whom experience dyspnea daily.6,7 A study found that nearly all CHF patients experienced dyspnea before hospitalization.8 As CHF progresses, dyspnea becomes increasingly troublesome for most patients, worsening the quality of their lives.9,10 A recent integrative literature review found that older patients with CHF usually experienced more severe and frequent symptoms of dyspnea.11 In patients with heart failure-related acute dyspnea, there were increased mortality rate at 6 months (28%) and at 3 years (59%) with a median survival time of 23 months.12 Regarding the relationship between depressive symptoms and dyspnea in CHF patients, a recent systematic review indicates that depressive symptoms are a factor affecting dyspnea.13 Conversely, a previous study found that physical symptoms (including dyspnea) were moderately correlated with depressive symptoms.14 If the mutual association between depressive symptoms and dyspnea exists, both of them should be managed at the same time to improve patient outcomes. However, to our knowledge, the mutual relationship between depressive symptoms and dyspnea has not been examined in Chinese patients with CHF. The purposes of the current study were to assess the prevalence of depressive symptoms and dyspnea and to examine the mutual relationship between depressive symptoms and dyspnea in Chinese patients with CHF.

Methods The present study used a cross-sectional design. Permission to conduct this study was obtained from the Medical Ethics Committee of Shandong University. The study conformed to the principles outlined in the Declaration of Helsinki.

Sample All patients enrolled had a diagnosis of CHF that was confirmed by a cardiologist with the following criteria to be met. First, the patient should be in a stable condition. Second, no acute myocardial infarction had occurred within the past 3 months. Third, the patient had not been referred for heart transplantation. Patients were excluded if they had valvular heart disease(s), peripartum heart failure, history of cerebral vascular accident within the past 3 months, any co-existing terminal illness or a major psychiatric disorder other than depression.

Measures Assessment of demographics and clinical characteristics. Demographics including age, gender, marital status, educational

level, monthly income, living status, body mass index (BMI) as well as some clinical characteristics including New York Heart Association (NYHA) class, ejection fraction (EF) and the number of hospitalization per year were selected as covariates of depressive symptoms based on the literature14–18 and the results of bivariate analyses in the current study. These covariates, except NYHA class and the number of hospitalizations per year, were also chosen as covariates of dyspnea based on the literature19,20 and the results of bivariate analyses in the current study. Information on the above covariates was obtained by patient interview or medical chart review. BMI was calculated using patients’ self-reported height and weight and categorized into four different classes: lower BMI, < 18.5; normal BMI, 18.5– 23.9; higher BMI, 24.0–27.9; obesity, ≥ 28.21 The number of hospitalizations per year was measured in the past year from enrolment date. Measure of depressive symptoms.  The Chinese version of the Beck Depression Inventory (BDI)22,23 was used to assess the severity of depressive symptoms. Each item of the BDI (21 items in total) is rated by a patient on a scale of 0– 3; the BDI total score ranges from 0 to 63. A person with a score ≥ 10 was considered to be depressed, with higher scores indicating more severe depressive symptoms. In our study, Cronbach’s alpha was 0.898. Evaluation of dyspnea.  The Chinese version of the Modified Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ-M)24,25 was used to assess the severity of dyspnea. The dyspnea component of PFSDQ-M consists of 15 items: five general questions assess the patients’ experience with shortness of breath, frequency of occurrence and overall intensity of shortness of breath; 10 items relating to intensity of shortness of breath and each of the 10 activities are rated on an 11-point scale from 0, ‘no shortness of breath’ to 10, ‘very severe shortness of breath.’ The dyspnea component ratings were summed for a total score that can range from 0 to 100; higher scores indicate a greater level of dyspnea. Cronbach’s alpha was 0.911 in our study. Statistical analysis of data.  Data are presented as frequencies and percentages, or mean ± SD. Kolmogorov–Smirnov test was used to assess data normality either in arithmetic form or logarithmic form. For dyspnea that showed normal distribution, independent t-test and one-way analysis of variance were used to examine the mean differences in patient characteristics. For depressive symptoms that showed abnormal distribution, data were transformed using logarithmic transformation. After transforming the data, the same statistical methods were used to examine the mean differences in patient characteristics. Pearson’s correlation test was employed to evaluate the relationship between depressive symptoms and dyspnea. Multiple linear regression analysis

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European Journal of Cardiovascular Nursing 14(4)

Table 1.  Characteristics of patients with chronic heart failure (N=152). Characteristics Age Gender Marital status Monthly income Living status

BMI

EF

NYHA class

Number of hospitalizations per year

n (%) c**; b>c a>b*; a>c*; bb*; a>c**; a>d**; b>c; b>d; c>d a>b; a>c; a>d*; b>c; b>d; c>d a

The mutual association between depressive symptoms and dyspnea in Chinese patients with chronic heart failure.

Depressive symptoms are prevalent in patients with chronic heart failure, but information about the relationship between depressive symptoms and dyspn...
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