Correlation among anxiety and depression, fear of disease progression, and social support in coronary heart disease

Abstract

BACKGROUND

The mental well-being of individuals with coronary heart disease (CHD) during the intensive care unit (ICU) transition period is a multifaceted and significant concern. In this phase, the individuals might encounter psychological challenges like anxiety and depression, which can impede their recuperation and potentially have lasting effects on their health.

AIM

To investigate the correlation among psychological factors in CHD patients in the ICU transition period.

METHODS

A questionnaire survey was conducted with 119 patients admitted to the ICU after coronary artery bypass grafting between March and December 2023. Variations in Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD), Fear of Progression Questionnaire-Short Form (Fop-Q-SF), and Social Support Rating Scale (SSRS) were collected and analyzed among diverse populations. We used Pearson’s correlation analysis to examine the correlation. Multiple linear regression analysis was used to explore whether these indicators influenced depression and anxiety in the patients.

RESULTS

The total scores for anxiety, depression, fear of disease progression, and social support were (7.50 ± 1.41) points, (8.38 ± 1.62) points, (35.19 ± 8.14) points, and (36.34 ± 7.08) points, respectively (P < 0.05). Multivariate regression analysis showed that both the level of disease progression and social support affected the level of postoperative depression and anxiety in patients.

CONCLUSION

The anxiety and depression levels were positively related to each dimension of phobia disease progression and negatively related to each dimension of social support among patients with CHD.

Key Words: Intensive care unit transition period; Coronary heart disease; Anxiety and depression; Fear of disease progression; Social support level

Core Tip: Patients with coronary heart disease may experience negative emotions, such as anxiety and depression, which affect disease progression. This study found a correlation between anxiety and depression, fear of disease progression, and social support level and confirmed it through a multiple linear regression model. By probing the factors that affect patients’ negative emotions, this study provides a reference for medical staff to formulate reasonable intervention measures.

INTRODUCTION

Coronary heart disease (CHD) is a common ischemic heart disease caused mainly by coronary artery insufficiency or stenosis. The clinical manifestations include chest pain and tightness and, in severe cases, myocardial infarction can occur[1]. Coronary artery bypass grafting is a common treatment for CHD and can improve myocardial blood supply, angina pectoris, and cardiac function[2]. Fear of progression refers to the fear-in individuals facing diseases-of the biological, psychological, and social consequences of the disease or reactive and conscious disease recurrence[3]. Related studies have confirmed that the functional response caused by moderate fear of disease is beneficial to the patient’s health by, e.g., promoting self-care or healthy behavior; however, excessive fear can lead to strong inhibition, affecting the quality-of-life, social function, and subjective well-being of the anxiety and depression levels were positively related to each dimension of phobia disease progression positively and negatively related to each dimension of social supportatients. Severe cases of excessive fear require treatment[4]. The intensive care unit (ICU) transition period refers to the period before and after the patient is transferred from the general ward after the patient reaches a stable condition in the ICU. During this period, although the patient’s condition stabilizes, special care and monitoring are still needed to ensure that the condition does not deteriorate and to help the patient gradually adapt to the environment and nursing methods of the general ward. Owing to the change in physical health status and the changes to work and life brought about by the disease, ICU transitional patients produce a variety of psychological stress reactions, including anxiety, fear, depression, anger, and other negative emotions[5]. Fear is a common negative emotional reaction that occurs when individuals encounter dangerous situations. Unknown disease progression, surgery, complications, and treatment costs cause varying degrees of fear in patients. Moderate fear helps activate the alertness mobilization pathway and focus attention on risk defense, but an excessive response will impair the treatment of physical diseases and physical immunity. Sufficient social support can help patients alleviate negative emotions. In recent years, researchers have gradually expanded their attention to the negative emotions of inpatients from anxiety and depression to fear and anger. However, the correlations between depression, anxiety, fear of disease progression, and social support levels in ICU patients during the transitional period have received less attention. This study aimed to explore the correlations between depression, anxiety, fear of disease progression, and support from society in the patients’ transitional period, grasp the common negative emotional characteristics of patients, provide a reference for medical staff to formulate reasonable intervention measures, adjust the psychological state of patients to the best state, and promote the treatment and rehabilitation of physical diseases.

MATERIALS AND METHODS

Patient characteristics

In this observational study, a questionnaire survey was conducted with 119 patients admitted to the Cardiovascular Surgery Intensive Care Unit after coronary artery bypass grafting between March 2023 and December 2023. Inclusion criteria were as follows: (1) Age 18 years and above; (2) In line with the World Health Organization or the International Society of Cardiology to develop diagnostic criteria for CHD; and (3) Patients who underwent coronary artery bypass grafting in our hospital and were admitted to the ICU for cardiac and vascular surgery after the operation. The exclusion criteria were as follows: (1) Incomplete clinical data; and (2) Patient experiencing other serious chronic or organic diseases. This study was reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Anhui Medical University (Figure 1).

Figure 1 Research process of this paper. ICU: Intensive care unit; HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Scale; SSRS: Social Support Rating Scale; Fop-Q-SF: Fear of Progression Questionnaire-Short Form.

Clinical data collection

Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD) scores. We used the HAMA[6] and HAMD scores[7] to assess the patients’ degree of anxiety and depression. The HAMA score includes 14 items. If the total score was less than 7 points, it indicated that there was no anxiety state; the more serious the anxiety state, the higher the HAMA score. The HAMD score comprises 17 items. If the total score was less than 8 points, it indicated that there was no depression. Similar to the HAMA score, the severity of depression was positively correlated with the HAMD score; that is, the more severe the depression, the higher the HAMD score. Fear of Progression Questionnaire-Short Form (Fop-Q-SF)[8]. The scale involves two aspects: Physical health and social family with 12 items, “never” scoring 1 point, “always” scoring 5 points, with a scoring range of 12-60 points. The score was positively correlated with the patient’s fear, of which 40 points and below indicated that the fear was low and 41 points and above indicated a high level of fear. Social Support Rating Scale (SSRS)[9]. We used the SSRS to appraise the social support of individuals, including three aspects - objective, subjective, and utilization-for all 10 items. The score range is 12-66 points, with a high score indicating better support. A score of 22 was low support, 23-44 was medium, and 45-66 was high.

Quality control

Two participants entered all the data. The logical errors in the data included in the study were further verified to enhance the dependability of the data.

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics for Windows, version 23.0. Quantitative data conforming to a normal distribution were described by mean ± SD, and the t-test was used for difference analysis. Qualitative data were described as frequency or percentage (%), and the rate between the two groups was compared using two tests. The correlations between the HAMA, HAMD, FoP-Q-SF, and SSRS scores were analyzed using Pearson’s correlation analysis. All statistical tests were two-sided, and the test level was α = 0.05.

RESULTS

Clinical characteristics

This study included 119 participants (92 males and 27 females). The age distribution spanned 44 to 79 years, with 43 individuals aged 60 years or younger and 76 individuals aged over 60 years. Regarding the duration of the condition, 47 patients had a course of 5 years or less, while 72 patients had a course exceeding 5 years. Detailed demographic and clinical characteristics are summarized in Table 1.

Table 1 General information.

	Cases (n = 119)	Percentage
Gender
Male	92	77.31%
Female	27	22.69%
Age (year)
≤ 60	43	36.13%
> 60	76	63.87%
Course (year)
≤ 5	47	39.50%
> 5	72	60.50%
Residential location
City	45	37.82%
Villages or towns	74	62.18%
Marital status
Married	96	80.67%
Unmatched	23	19.33%
Educational background
Primary and below	52	43.70%
Junior high school	29	24.37%
High school or technical secondary school	21	17.64%
Junior college or above	17	14.29%
Occupation
Be on the job	27	22.69%
Self-employed people or farmer	58	48.73%
Take leave or retire	17	14.29%
Unemployed	17	14.29%
Type of medical insurance
Worker with medical insurance	45	37.82%
Medical insurance for residents	74	62.18%
Smoking
Yes	37	31.09%
No	82	68.91%
Drinking
Yes	34	28.57%
No	85	71.43%
Monthly household income (RMB)
< 6000	74	62.19%
6000-9000	34	28.57%
> 9000	11	9.24%

Anxiety scores among patients

The mean anxiety score of the patients was 7.50 ± 1.41. A total of 88 patients exhibited symptoms of anxiety, as indicated by a HAMD score of 7 or higher. Statistically significant variations in anxiety scores were not observed across different demographic and clinical factors (P > 0.05). These findings are detailed in Figure 2A.

Figure 2 Anxiety, depression, Fear of Disease Progression Scores, and Social Support Scores of different dimensionality. A: Anxiety of different dimensionality; B: Depression of different dimensionality; C: Fear of Disease Progression Scores of different dimensionality. ^cP < 0.001; D: Social Support Scores of different dimensionalities. ^bP < 0.01. a₁ is male, a₂ is female; b₁ is 60 years old, b₂ is > 60 years old; c₁ is a disease course of ≤ 5 years, c₂ is a disease course of > 5 years; d₁ is residence in a city, d₂ is residence in villages or towns; e₁ is with spouse, e₂ is without spouse; f₁ is the degree of primary school and below, f₂ is the degree of junior high school, f₃ is the degree of high school or secondary school, f₄ is the degree of college and above; g₁ is employed, g₂ is self-employed people or farmers, g₃ is retired, g₄ is unemployed; h₁ is employee medical insurance, h₂ is resident medical insurance; i₁ is a history of smoking, i₂ is no history of smoking; j₁ is a history of drinking, j₂ is no history of drinking; k₁ is a family income of 6000 RMB, k₂ is a family income of 6000-9000 RMB, k₃ is a family income of 9000 RMB. RMB: Renminbi; HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Scale; Fop-Q-SF: Fear of Progression Questionnaire-Short Form; SSRS: Social Support Rating Scale.

Depression scores among patients

In this analysis, the mean depression score for the patients was 8.38, with a standard deviation of 1.62. A total of 87 patients were identified as suffering from depression, defined by a HAMD score greater than or equal to 8 points. Significant differences in depression scores were not observed among the patients (P > 0.05). These findings are shown in Figure 2B.

Fear of disease progression scores

In this study, the mean fear of disease progression score for patients was 35.19 ± 8.14 points. This score was derived from the FoP-Q-SF, with 83 patients exhibiting a low fear of disease progression (scores ≤ 40 points) and 36 patients showing a high fear of disease progression (scores > 40 points). Notably, significant variations in the fear of disease progression scores were identified across patients of different educational backgrounds (P < 0.05). A visual representation of these findings is shown in Figure 2C.

Social support scores

In this investigation, the mean social support score for patients was 36.34 ± 7.08. The result was categorized into low, moderate, and high levels of social support, with 5 patients identifying with low support (SSRS ≤ 22), 98 with moderate support (23 ≤ SSRS ≤ 45), and 16 with high support (SSRS > 45). Significant differences in social support levels were observed among patients with varying educational backgrounds (P < 0.05). These findings are graphically depicted in Figure 2D.

The correlation of anxiety and depression level with fear of disease progression and social support level

With regard to the correlation between anxiety and depression, fear, and support, the results showed that high anxiety and depression can lead to high fear, demonstrating a positive correlation. High social support stabilizes the patient’s negative emotions, demonstrating a negative correlation, as shown in Table 2. Additionally, considering the gender disparity in the incidence of CHD, we investigated how anxiety and depression levels relate to the fear of disease progression and the levels of social support among genders. Our findings indicated that, in males, higher levels of anxiety and depression were associated with increased fear of disease worsening (P < 0.05) and decreased levels of perceived social support (P < 0.05). Conversely, in females, there was no significant link between anxiety and depression and the fear of disease progression, but there was a negative association with social support scores (P < 0.05) (Table 3).

Table 2 Correlation between anxiety and depression level and fear of disease progression and social support level.

Index	HAMA		HAMD
	r	P value	r	P value
Fear of disease progression
Physical health dimension	0.376	< 0.001	0.384	< 0.001
Social family dimension	0.219	0.017	0.185	0.044
Total score	0.349	< 0.001	0.333	< 0.001
Social support
Objective support	-0.392	< 0.001	-0.425	< 0.001
Subjective support	-0.617	< 0.001	-0.568	< 0.001
Utilization degree of support	-0.605	< 0.001	-0.584	< 0.001
Total score	-0.799	0.001	-0.765	< 0.001

HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Scale.

Table 3 Correlation between anxiety and depression level and fear of disease progression and social support level in different genders.

Index	HAMA		HAMD
	r	P value	r	P value
Male
Fear of disease progression	0.354	0.001	0.350	0.001
Social support	-0.805	< 0.001	0.768	< 0.001
Female
Fear of disease progression	0.336	0.087	0.273	0.169
Social support	-0.776	< 0.001	-0.751	< 0.001

HAMA: Hamilton Anxiety Scale; HAMD: Hamilton Depression Scale.

Multiple linear regression analysis

The sum of the anxiety and depression scores was used as the dependent variable, whereas the FoP-Q-SF total score and its sub-items and the SSRS total score and its sub-items were used as independent variables. Stepwise regression analysis revealed that fear of disease progression and social support could affect depression and anxiety levels in patients with CHD after surgery (P < 0.05) (Table 4).

Table 4 Multiple linear regression analysis.

Index	B	SE	B’	t	P value
Constant term	25.682	1.162	-	22.100	< 0.001
Physical health dimension	0.178	0.037	0.282	4.809	< 0.001
Social family dimension	0.077	0.032	0.127	2.423	0.017
Objective support	-0.651	0.078	-0.491	-8.321	< 0.001
Utilization degree of support	-0.256	0.080	-0.207	-3.186	0.002
Total score of social support	-0.165	0.031	-0.393	-5.332	< 0.001

DISCUSSION

The number of individuals with CHD has increased in the past few years. Studies have shown that CHD is currently recognized as a psychosomatic disease, often accompanied by negative emotions such as anxiety and depression. It is a globally recognized disease affecting human health[10]. Coronary artery bypass grafting is an important procedure in the clinical treatment of CHD. It uses the patient’s own blood vessels or vascular substitutes to connect the aorta and distal end of the coronary artery to improve the blood supply to the ischemic site, which can effectively reduce the patient’s clinical symptoms and prolong survival time[11]. However, patients with heart disease have longer recovery periods after coronary artery bypass grafting. Combined with clinical experience in the case of CHD and based on factors such as social support and patients’ fear of disease progression due to insufficient disease cognition, patients have obvious negative emotions, increasing their body burden and thus affecting clinical efficacy[12]. Therefore, in addition to surgical treatment, it is necessary to focus on the psychological state of patients to improve their prognosis.

Anxiety and depression during the ICU transition period

Relevant research and clinical practice have proven that coronary artery bypass grafting is the main way to treat CHD; given its remarkable effect, it is widely used in clinical practice. However, the surgery is traumatic. After surgery, patients easily fall into emotional traps such as anxiety and depression. The findings of this study revealed that more than 70% of the surveyed patients exhibited symptoms of depression and anxiety. The characteristics of high risk, high trauma, and high cost of coronary artery bypass grafting also cause a series of psychological problems. Negative psychology affects the occurrence, development, treatment, and rehabilitation of heart disease. These two factors are mutually causal and affect disease progression[13]. In the ICU, medical staff generally tend to focus on the short-term treatment effects on patients, sometimes ignoring communication with patients and potentially triggering negative psychological states. The transition period in the ICU indicates that patients with CHD enter the disease rehabilitation stage. The general ward and ICU differ in terms of staffing, working methods, and environment. Patients often experience patient abandonment. If the psychological state of patients is not taken seriously and timely intervention is not carried out, it will negatively affect their prognoses[14,15].

The relationship between anxiety and depression level and fear of disease progression

According to the results of this study, there was a strong positive correlation between anxiety, depression, and fear of disease progression (P < 0.05). Consistent with previous research results[16], anxiety and depression in patients had a strong relationship with fear of disease progression, which was confirmed. As CHD is a psychosomatic disorder, many scholars have called for psychological intervention during the biological treatment of patients with CHD[17,18]. After coronary artery bypass grafting, owing to the lack of understanding of coronary artery bypass grafting and disease knowledge among family members and patients, complex psychological reactions, such as fear and pain, will become more intense. Moreover, most patients remain in bed for a long time after hospitalization. The reduction in activity and comorbid chronic conditions (such as hypertension and diabetes) can lead to a heightened fear of disease progression and may worsen preexisting health conditions[19]. In individuals with anxiety and depression, apprehension can impair the regulatory functions of the immune system, leading to a marked increase in the risk of complications. Consequently, healthcare professionals must implement psychological interventions to mitigate these adverse emotional effects on patients. Nonetheless, correlation analysis among patients of varying genders revealed no connection between female patients’ anxiety and depression and their fear of disease progression. It is hypothesized that this may be attributed to the tendency of female patients with CHD to focus more on immediate physical well-being and psychological comfort rather than the disease’s long-term outcome.

The relationship between anxiety and depression level and social support level

During the ICU transition period, patients with CHD face various challenges such as disease instability, exposure to complex medical equipment and treatment procedures, and separation from their families. These factors may lead to negative emotions such as anxiety and depression. At the same time, due to the uncertainty of postoperative rehabilitation, patients may be concerned about their health status, which increases the psychological burden[20]. According to the results of this study, there was a strong negative correlation between anxiety, depression, and social support (P < 0.05). Social support became particularly important during this period. Support from family members, friends, medical staff, etc., can help patients reduce bad moods and enhance their rehabilitation confidence. According to existing research, CHD is closely associated with psychosocial factors. The mental health of patients has a crucial impact on the prognosis of their condition[21,22]. Good social support can improve patients’ quality of life by alleviating their psychologically bad moods and promoting the rehabilitation process. In contrast, a lower level of social support may increase the psychological burden on patients and affect the rehabilitation effect. Therefore, during the ICU transition period after coronary artery bypass grafting, we should attach importance to social support; strengthen communication and exchanges between patients and family members, friends, and medical staff; and provide patients with comprehensive support and assistance to promote their mental health and rehabilitation[23]. This was a single-center study, and the potential selection biases within the sample size are acknowledged, which may constrain the generalizability of our findings. Moving forward, we intend to embark on a broader, multi-site study with an expanded sample size. We will employ diverse methodologies to assess patient psychological well-being and monitor the evolution of psychological variables and their rehabilitation outcomes longitudinally. The use of such an approach aims to bolster the robustness and reliability of our research outcomes.

CONCLUSION

In summary, the levels of anxiety and depression in patients in the ICU transitional period after CHD surgery were positively correlated with the progression of fear of the disease and negatively correlated with the level of social support. Therefore, during the ICU transition period, one not only needs to keep a watchful eye on the patient’s condition changes but also needs to communicate effectively with patients and their families, explain the condition and treatment plan, improve their social support level, and alleviate the patient’s fear of disease progression to help reduce their anxiety and fear. This study selected only retrospective data from a single hospital, and the sample size may have had some deviations in selection and collection. In the future, we plan to conduct a multicenter study with a large sample size to further confirm the reliability of our findings.