Luo YT, Ou AZ, Lin DS, Li H, Zhou F, Liu YM, Ye XP, Deng X. Status of anxiety and depression among chronic heart failure patients: Factors influencing poor fluid restriction adherence. World J Psychiatry 2025; 15(6): 103765 [DOI: 10.5498/wjp.v15.i6.103765]
Corresponding Author of This Article
Xu Deng, MD, Preventive Treatment Center, The First Hospital of Hunan University of Traditional Chinese Medicine, No. 95 Shaoshan Middle Road, Changsha 410007, Hunan Province, China. dengxu399@163.com
Research Domain of This Article
Psychiatry
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Yun-Tao Luo, Ai-Zhi Ou, Di-Sha Lin, Hong Li, Fang Zhou, Xin-Ping Ye, Department of Health Management, The First Hospital of Hunan University of Traditional Chinese Medicine, Changsha 410007, Hunan Province, China
Yue-Mei Liu, Department of Cardiology, The First Hospital of Hunan University of Traditional Chinese Medicine, Changsha 410007, Hunan Province, China
Xu Deng, Preventive Treatment Center, The First Hospital of Hunan University of Traditional Chinese Medicine, Changsha 410007, Hunan Province, China
Author contributions: Luo YT designed the study; Luo YT, Ou AZ, Lin DS, Li H, Zhou F, Liu YM, Ye XP and Deng X collected the data; Luo YT and Deng X analyzed the data; Luo YT prepared the manuscript; all authors read and approved the final manuscript.
Supported by Huxiang TCM Physique Intervention Clinical Research Center, No. 2023SK4061; Traditional Chinese Medicine Research Project of Hunan Province, No. B2023065; Hunan Province "14th Five-Year Plan" key specialty of TCM, No. [2023] 4; Hunan University of Chinese Medicine and Hospital Joint Foundation, No. 2023XYLH019 and 2024XYLH365; R & D Plan for Key Areas of Hunan Provincial Department of Science and Technology, No. 2019SK2321; Excellent Youth Program of Hunan Education Department, No. 24B0346; Hunan Provincial Natural Science Foundation for Young Scientists, No. 2025JJ60626.
Institutional review board statement: This study was approved by the Ethic Committee of The First Hospital of Hunan University of Traditional Chinese Medicine.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: There is no conflict of interest.
Data sharing statement: No additional data are available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Xu Deng, MD, Preventive Treatment Center, The First Hospital of Hunan University of Traditional Chinese Medicine, No. 95 Shaoshan Middle Road, Changsha 410007, Hunan Province, China. dengxu399@163.com
Received: February 26, 2025 Revised: March 27, 2025 Accepted: April 15, 2025 Published online: June 19, 2025 Processing time: 92 Days and 2.2 Hours
Abstract
BACKGROUND
Anxiety and depression are prevalent among patients with chronic heart failure (CHF) and can adversely contribute to treatment adherence and clinical outcomes. Poor fluid restriction adherence is a widespread challenge in the management of CHF. To effectively manage disease progression and alleviate symptoms, it is crucial to identify key influencing factors to facilitate the implementation of targeted interventions.
AIM
To investigate the status of anxiety and depression among patients with CHF and determine the factors contributing to poor fluid restriction adherence.
METHODS
Three hundred CHF patients seeking medical treatment at The First Hospital of Hunan University of Traditional Chinese Medicine between June 2021 and June 2023 were included in the study. Questionnaires, including the Psychosomatic Symptom Scale, Self-Rating Anxiety Scale, Self-Rating Depression Scale, and Fluid Restriction Adherence Questionnaire were administered to patients. Based on their anxiety and depression scores, patients were categorized into anxiety/depression and non-anxiety/depression groups, as well as fluid restriction adherence and fluid restriction non-adherence groups. General patient data were collected, and univariate and logistic regression analyses were conducted to determine the occurrence of depression and anxiety. Logistic regression analysis was used to identify independent factors influencing fluid restriction adherence.
RESULTS
Statistically significant differences in age, New York Heart Association (NYHA) grading, marital status, educational attainment, and family support were observed between depressed and non-depressed CHF patients (P < 0.05). Age, NYHA grading, marital status, educational attainment, and family support were identified as factors influencing the development of depression. The anxiety and non-anxiety groups differed statistically in terms of gender, age, NYHA grading, smoking history, alcohol consumption history, monthly income, educational attainment, and family support (P < 0.05). Gender, smoking, alcohol consumption, monthly income, and educational attainment affected anxiety in these patients. The fluid restriction adherence rate was 28.0%, and thirst sensation, anxiety, and depression were identified as independent influencing factors.
CONCLUSION
CHF patients are susceptible to anxiety and depression, with multiple associated influencing factors. Moreover, anxiety and depression are independent factors that can influence fluid restriction adherence in these patients.
Core Tip: In this study, the prevalence of depression and anxiety among 300 patients with chronic heart failure was 30.0% and 43.3%, respectively. Depression was independently influenced by several factors, including age, New York Heart Association classification, marital status, educational attainment, and family support. Alternatively, anxiety was independently affected by gender, smoking status, alcohol consumption, monthly income level, and educational level. Only 28.0% of the patients demonstrated fluid restriction adherence, which was independently determined by thirst sensation, anxiety, and depression. These findings may enhance the identification and management of patients at high risk for depression, anxiety, and non-adherence to fluid restrictions. Implementing targeted interventions, including thirst management, psychological support, and health education, for these high-risk patients can improve their psychological well-being and treatment compliance, ultimately enhancing therapeutic efficacy and prognosis.
Citation: Luo YT, Ou AZ, Lin DS, Li H, Zhou F, Liu YM, Ye XP, Deng X. Status of anxiety and depression among chronic heart failure patients: Factors influencing poor fluid restriction adherence. World J Psychiatry 2025; 15(6): 103765
Heart failure (HF) is a heterogeneous syndrome, primarily distinguished by high morbidity and mortality rates, diminished functional capacity, impaired quality of life, and substantial treatment costs. Notably, its prevalence is increasing in younger patients[1,2]. The lifetime risk of HF in developed countries is 4.2% and 11.8% in people aged 65 years and older[3]. Patients with HF may present with typical clinical symptoms such as fatigue, dyspnea, and ankle swelling. Additionally, they may be accompanied by adverse signs such as pulmonary rales, peripheral edema, and elevated jugular venous pressure, all of which are induced by structural and/or functional cardiac anomalies[4].
Chronic HF (CHF) is a subtype of HF characterized by insidious onset, progressive aggravation, and continuous and recurrent manifestation of signs and symptoms[5,6]. CHF involves the perpetual compensatory activation of the neurohumoral system, which consequently leads to volume overload (manifested as hepatic congestion, ascites, and ankle and pretibial edema), peripheral vasoconstriction (resulting in acrocyanosis), elevated heart rate during both rest and exercise, and exacerbation of cardiorenal system deterioration[7]. Furthermore, previous investigations have revealed that more than 50% of patients afflicted with CHF may experience depression and anxiety symptoms. The hospitalization rates and mortality risks are frequently significantly elevated in patients harboring these negative emotions[8,9]. A study by Easton et al[10] demonstrated that over 30% of individuals with long-term somatic illnesses could simultaneously exhibit mental health problems such as anxiety and depression, increasing the risk of complications and escalating healthcare costs.
There are shared pathological mechanisms underlying both depression and HF. Both are associated with high-risk behaviors (such as smoking and a sedentary lifestyle), excessive activation of the hypothalamus-pituitary-adrenal axis, diminished heart rate variability, and abnormally elevated levels of inflammatory markers[11,12]. Moreover, evidence suggests that anxiety may be related to hypothalamus-pituitary-adrenal axis dysfunction, and the resultant panic, chest pain, and adverse effects on respiratory function can exacerbate CHF progression[13]. Fluid restriction is highly beneficial for controlling CHF progression and alleviating clinical manifestations such as dyspnea, fatigue, congestion, and limb swelling; therefore, it constitutes a critical aspect of the clinical management of CHF patients[14]. Nevertheless, poor fluid restriction adherence is a relatively common phenomenon[15].
Given these findings, this study aimed to conduct an in-depth exploration of the factors influencing anxiety, depression, and poor fluid restriction adherence in CHF patients. Our objective was to contribute to ameliorating the mental health status and fluid restriction adherence of these patients and provide practical and reliable clinical guidance.
MATERIALS AND METHODS
General information
A total of 300 CHF patients seeking medical services in The First Hospital of Hunan University of Traditional Chinese Medicine between June 2021 and June 2023 were selected. Based on their anxiety and depression scores, patients were categorized into anxiety/depression and non-anxiety/depression groups, as well as fluid restriction adherence and fluid restriction non-adherence groups. The inclusion criteria were as follows: confirmed diagnosis of CHF in accordance with the relevant diagnostic criteria for CHF[16]; adherence to the New York Heart Association (NYHA) classification standards[17]; normal expressive and communicative abilities, allowing for completion of the questionnaire independently or with assistance; the ability to actively cooperate in all types of examinations; and possession of complete medical records. The exclusion criteria were: acute infections, endocrine system disorders other than diabetes, hematologic disorders, and immune system disorders; chronic conditions such as connective tissue diseases and malignant tumors; a history of seeking medical attention or currently under treatment for severe mental illnesses; severe diseases in vital organs, including the lungs, liver, and kidneys; congenital heart diseases and neurological dysfunctions; and psychological disorders and cognitive impairments.
Outcome measures
Depression: The Self-Rating Depression Scale was utilized to assess the depressive mood of the patients. The scale consists of 20 items that reflect the subjective perception of depression. Each item is graded on a 4-point scale based on the frequency of symptom manifestation. A score ranging from 53 to 62 points corresponds to mild depression, 63-72 indicates moderate depression, and > 73 indicates severe depression. Patients scoring ≥ 53 were categorized in the depression group, and those scoring below 53 were placed in the non-depression group.
Anxiety: The degree of anxiety was assessed using the Self-Rating Anxiety Scale, which adopts a 4-point scoring system. The raw score is multiplied by 1.25 to derive the standard score. A score within the range of 50-59 indicates mild anxiety, 60-69 suggests moderate anxiety, and > 69 indicates severe anxiety. Patients with a score reaching 50 points or above were categorized into the anxiety group, while those with a score lower than 50 were assigned to the non-anxiety group.
Cardiac function grading: All patients were stratified according to the cardiac function classification scheme of the NYHA, which is predicated on the severity of symptomatology and the degree of physical exertion. Grade I indicates patients with cardiac disorders who manifest no restriction in their daily activity capacity. Routine physical exertion does not elicit symptoms such as excessive fatigue, cardiac palpitations, dyspnea, or angina pectoris. Grade II indicates the presence of cardiac pathologies with a mild limitation in physical activity. The patients are asymptomatic during the resting state; however, routine physical exertion can precipitate excessive fatigue, cardiac palpitations, dyspnea, or angina pectoris. Grade III indicates those with cardiac disorders who exhibit significant physical activity constraints. In the resting state, there are no conspicuous symptoms; nevertheless, even mild physical exertion can induce excessive fatigue, cardiac palpitations, dyspnea, or angina pectoris. Grade IV consists of cardiac patients incapacitated from engaging in physical activity. Symptoms of HF are present even during the resting condition and are substantially aggravated following physical exertion.
Intensity of thirst: The thirst intensity among patients was assessed using the Visual Analog Scale. The specific assessment methodology involved using a 10-cm-long measuring ruler with a cursor. Values ranging from 0 to 10 on the ruler corresponded to the spectrum from the absence of thirst sensation to severe thirst. Based on the subjective perception of thirst, patients positioned the freely sliding cursor on the ruler at the point that most accurately represented their level of thirst. Subsequently, the patients’ thirst scores were documented according to the cursor’s position. A score within the range of 0-2 signified an absence of thirst, a score of 3-5 indicated mild thirst, and a score of 6-10 indicated moderate-to-severe thirst. A higher score was indicative of a more intense degree of thirst.
Fluid restriction adherence: The questionnaire was designed by the research personnel and included two elements: Controlling daily water intake to below 19 mL/kg and adhering to daily weighing and recording of body mass. During the treatment course, complete adherence was defined as patients fully complying with medical prescriptions in both aspects. Partial adherence was indicated when patients only adhered to the doctor’s orders in one of these aspects. Non-adherence was defined as patients failing to follow the medical instructions in either of these aspects during treatment. The fluid restriction adherence rate was computed as the percentage of patients with complete or partial adherence. In the pre-survey, the Cronbach’α coefficient of the questionnaire was 0.863, demonstrating favorable reliability and validity.
Statistical analysis
Count data, presented as n (%), were compared using the χ2 test. Binary logistic regression analysis (forward selection) was employed to analyze the risk factors for anxiety, depression, or fluid restriction adherence. The variance inflation factor (VIF) was used to evaluate multicollinearity among the variables. All variables demonstrated VIF values below 5, confirming the absence of significant multicollinearity. SPSS 20.0 or GraphPad Prism software was used for statistical analysis. A P value less than 0.05 indicated a statistically significant difference. The required sample size in this study was calculated using the following formula: n = 2(Za/2+Zβ)2·σ2/d2. Where α (significance level) = 0.05, 1-β (statistical power) = 0.80, d (effect size) = 0.6, and σ (SD) = 1. Based on these parameters, the minimum sample size required was 264. The study enrolled 300 participants, exceeding the calculated minimum requirement to ensure robust statistical power.
RESULTS
Univariate analysis of factors affecting the occurrence of depression
In this study, 90 of the 300 CHF patients (30.0%) were depressed. Univariate analysis demonstrated statistically significant differences in age, NYHA grading, marital status, educational attainment, and family support between depressed and non-depressed patients (P < 0.05; Table 1).
Table 1 Univariate analysis of depression in chronic heart failure patients, n (%).
Variable
n
Depression (n = 90)
Non-depression (n = 210)
χ2
P value
Gender
1.149
0.284
Male
174
48 (53.33)
126 (60.00)
Female
126
42 (46.67)
84 (40.00)
Age (years)
9.790
0.002
< 60
142
55 (61.11)
87 (41.43)
≥ 60
158
35 (38.89)
123 (58.57)
Disease course (years)
0.338
0.561
< 3
139
44 (48.89)
95 (45.24)
≥ 3
161
46 (51.11)
115 (54.76)
NYHA grading
5.794
0.015
I-II
149
35 (38.89)
114 (54.29)
III-IV
151
55 (61.11)
96 (45.71)
Smoking history
3.777
0.052
Without
115
27 (30.00)
88 (41.90)
With
185
63 (70.00)
122 (58.10)
Alcohol consumption history
1.465
0.226
Without
119
31 (34.44)
88 (41.90)
With
181
59 (65.56)
122 (58.10)
Monthly income (CNY)
2.086
0.149
< 5000
118
41 (45.56)
77 (36.67)
≥ 5000
182
49 (54.44)
133 (63.33)
Marital status
10.227
0.001
Single
132
27 (30.00)
105 (50.00)
Married
168
63 (70.00)
105 (50.00)
Educational attainment
8.269
0.004
Below senior high school
129
50 (55.56)
79 (37.62)
Senior high school or above
171
40 (44.44)
131 (62.38)
Family support
9.300
0.002
Without
153
58 (64.44)
95 (45.24)
With
147
32 (35.56)
115 (54.76)
Thirst sensation
1.655
0.198
None or mild
157
42 (46.67)
115 (54.76)
Moderate-severe
143
48 (53.33)
95 (45.24)
Logistic regression analysis of risk factors for depression
Multivariate analysis identified age (P = 0.002), NYHA grading (P = 0.010), marital status (P = 0.001), educational attainment (P = 0.006), and family support (P = 0.013) as independent factors influencing depression onset (Table 2). Additionally, we did not observe any multicollinearity issues among the variables.
Table 2 Logistic regression analysis of risk factors for depression onset in chronic heart failure patients.
Factor
β
SE
Wald
P value
OR
95%CI
Age (years)
-0.871
0.275
10.059
0.002
0.418
0.244-0.717
NYHA grading
0.714
0.277
6.654
0.010
2.043
1.187-3.515
Marital status
0.993
0.287
11.963
0.001
2.698
1.537-4.735
Educational attainment
0.695
0.278
7.532
0.006
0.467
0.271-0.804
Family support
0.695
0.279
6.227
0.013
2.004
1.161-3.461
Univariate analysis of factors influencing anxiety onset
Of the 300 CHF patients, 130 (43.3%) had anxiety. We identified statistically significant differences between anxious and non-anxious patients in terms of gender, age, NYHA grading, smoking history, alcohol consumption history, monthly income, educational attainment, and family support (P < 0.05; Table 3).
Table 3 Univariate analysis of anxiety in chronic heart failure patients, n (%).
Variable
n
Anxiety (n = 130)
Non-anxiety (n = 170)
χ2
P value
Gender
10.006
0.002
Male
174
62 (47.69)
112 (65.88)
Female
126
68 (52.31)
58 (34.12)
Age (years)
3.903
0.048
< 60
142
70 (53.85)
72 (42.35)
≥ 60
158
60 (46.15)
98 (57.65)
Disease course (years)
3.293
0.070
< 3
139
68 (52.31)
71 (41.76)
≥ 3
161
62 (47.69)
99 (58.24)
NYHA grading
3.862
0.049
I-II
149
73 (56.15)
76 (44.71)
III-IV
151
57 (43.85)
94 (55.29)
Smoking history
5.553
0.019
Without
115
40 (30.77)
75 (44.12)
With
185
90 (69.23)
95 (55.88)
Alcohol consumption history
8.957
0.003
Without
119
39 (30.00)
80 (47.06)
With
181
91 (70.00)
90 (52.94)
Monthly income (CNY)
10.939
< 0.001
< 5000
118
65 (50.00)
53 (31.18)
≥ 5000
182
65 (50.00)
117 (68.82)
Marital status
2.856
0.091
Single
132
50 (38.46)
82 (48.24)
Married
168
80 (61.54)
88 (51.76)
Educational attainment
6.824
0.009
Below senior high school
129
67 (51.54)
62 (36.47)
Senior high school or above
171
63 (48.46)
108 (63.53)
Family support
4.698
0.030
Without
153
57 (43.85)
96 (56.47)
With
147
73 (56.15)
74 (43.53)
Thirst sensation
0.225
0.635
None or mild
157
66 (50.77)
91 (53.53)
Moderate-severe
143
64 (49.23)
79 (46.47)
Logistic regression analysis of risk factors for anxiety occurrence
Gender (P = 0.001), smoking (P = 0.026), alcohol consumption (P = 0.003), monthly income (P = 0.001), and educational attainment (P = 0.039) were determined to play independent influential roles in the development of anxiety in the CHF patients (Table 4). We did not identify any evidence of multicollinearity across variables.
Table 4 Logistic regression analysis of risk factors affecting anxiety in chronic heart failure patients.
Factor
β
SE
Wald
P value
OR
95%CI
Gender
0.855
0.263
10.530
0.001
2.351
1.403-3.940
Age (years)
-0.446
0.256
3.031
0.082
0.640
0.388-1.058
NYHA grading
-0.356
0.255
1.945
0.163
0.701
0.425-1.155
Smoking history
0.593
0.266
4.989
0.026
1.810
1.075-3.047
Alcohol consumption history
0.792
0.267
8.776
0.003
2.208
1.307-3.730
Monthly income (CNY)
0.849
0.263
10.446
0.001
2.337
1.397-3.910
Educational attainment
0.528
0.256
4.267
0.039
1.696
1.027-2.800
Family support
-0.293
0.257
1.304
0.253
0.746
0.451-1.234
Univariate analysis of factors influencing fluid restriction adherence
Among the 300 CHF patients, 84 (28.0%) exhibited fluid restriction adherence. We identified statistically significant differences (P < 0.05) in age, thirst sensation, anxiety, and depression between those with and without fluid restriction adherence (Table 5).
Table 5 Univariate analysis of factors influencing fluid restriction adherence in chronic heart failure patients, n (%).
Variable
n
Fluid restriction adherence (n = 84)
Fluid restriction non-adherence (n = 216)
χ2
P value
Gender
1.243
0.365
Male
174
53 (63.10)
121 (56.02)
Female
126
31 (36.90)
95 (43.98)
Age (years)
6.318
0.012
< 60
142
30 (35.71)
112 (51.85)
≥ 60
158
54 (64.29)
104 (48.15)
Disease course (years)
1.610
0.205
< 3
139
34 (40.48)
105 (48.61)
≥ 3
161
50 (59.52)
111 (51.39)
NYHA grading
0.196
0.658
I-II
149
40 (47.62)
109 (50.46)
III-IV
151
44 (52.38)
107 (49.54)
Smoking history
0.045
0.832
Without
115
33 (39.29)
82 (37.96)
With
185
51 (60.71)
134 (62.04)
Alcohol consumption history
0.195
0.659
Without
119
35 (41.67)
84 (38.89)
With
181
49 (58.33)
132 (61.11)
Monthly income (CNY)
1.087
0.297
< 5000
118
37 (44.05)
81 (37.50)
≥ 5000
182
47 (55.95)
135 (62.50)
Marital status
0.073
0.788
Single
132
38 (45.24)
94 (43.52)
Married
168
46 (54.76)
122 (56.48)
Educational attainment
1.016
0.314
Below senior high school
129
40 (47.62)
89 (41.20)
Senior high school or above
171
44 (52.38)
127 (58.80)
Family support
0.002
0.967
Without
153
43 (51.19)
110 (50.93)
With
147
41 (48.81)
106 (49.07)
Thirst sensation
4.285
0.039
None or mild
157
52 (61.90)
105 (48.61)
Moderate-severe
143
32 (38.10)
111 (51.39)
Anxiety
4.751
0.029
< 50
170
56 (66.67)
114 (52.78)
≥ 50
130
28 (33.33)
102 (47.22)
Depression
8.192
0.004
< 53
210
69 (82.14)
141 (65.28)
≥ 53
90
15 (17.86)
75 (34.72)
Logistic regression analysis of risk factors affecting fluid restriction adherence
The results of the logistic regression analysis demonstrated that thirst sensation (P = 0.020), anxiety (P = 0.045), and depression (P = 0.026) were independent influential factors for fluid restriction adherence in CHF patients (Table 6). There was no multicollinearity.
Table 6 Logistic regression analysis of risk factors affecting fluid restriction adherence in chronic heart failure patients.
Factor
β
SE
Wald
P value
OR
95%CI
Age (years)
0.516
0.277
3.471
0.062
1.675
0.973-2.883
Thirst sensation
0.637
0.275
5.385
0.020
1.891
1.104-3.239
Anxiety
0.556
0.277
4.030
0.045
1.744
1.013-3.001
Depression
0.728
0.327
4.957
0.026
2.071
1.091-3.932
DISCUSSION
Of the 300 CHF patients included in this study, 30.0% had depression, and 43.3% had anxiety. These findings are similar to those reported by Yohannes et al[18], wherein the prevalence of depression and anxiety in CHF patients ranged from 10% to 60% and 11% to 45%, respectively.
Our research confirms that age, NYHA grading, marital status, educational attainment, and family support are closely related to depression and are independent factors influencing depression. NYHA grading III-IV, being married, higher educational attainment, and lack of family support were identified as risk factors, while advanced age was a protective factor for depression in CHF patients. Furthermore, anxiety, gender, age, NYHA grading, smoking history, alcohol consumption history, monthly income, educational attainment, and family support were closely associated with anxiety in CHF patients. Gender, smoking, alcohol consumption, monthly income, and educational attainment were identified as independent factors influencing anxiety. Thus, being female, smoking, alcohol consumption, having a low monthly income, and a higher educational status may be considered risk factors for anxiety in CHF patients.
The adverse clinical symptoms accompanying CHF patients are known to impose a substantial somatic burden and life restrictions, giving rise to significant mental stress and, subsequently, psychological distress, such as depression and anxiety[19,20]. The emergence of such psychiatric issues not only renders it arduous for CHF patients to comply with health behavior recommendations (exercise, diet, and medication adherence) but also predisposes them to adverse medical consequences like frequent hospitalizations, recurrent cardiac events, and mortality[21-23]. Moreover, CHF patients with a high NYHA grade endure long-term physical and mental afflictions from the disease, which can exacerbate their negative emotions to a certain degree, particularly depression levels[24].
The influence of marriage on patients’ depressive mood may stem from domestic trivia, family conflicts, or household economic burdens[25]. CHF patients with higher educational attainment are susceptible to depression and anxiety, which may be due to a deeper understanding of the disease that exacerbates their concerns about disease consequences, as well as their unmet higher expectations for treatment efficacy and prognosis. To some extent, it might also arise from information overload, restrictions on health-promoting behaviors, and excessive focus on medical information[26,27].
A combination of factors, including higher NYHA classification, marital status, advanced educational attainment, and lack of family support, may exacerbate depressive symptoms in CHF patients. Specifically, married patients with higher education may face increased stress due to their profound understanding of the disease and a heightened sense of familial responsibility, particularly in the absence of family support and with advancing disease severity. Additionally, Chinese family norms emphasize intergenerational support and family obligations. However, excessive family expectations or intergenerational conflicts (e.g., mother-in-law and daughter-in-law tensions) can lead to emotional distress, further increasing the risk of depression[28].
The greater predisposition of females to anxiety may be associated with their relatively older age when suffering from CHF and their higher susceptibility to diastolic dysfunction compared to men[29]. Smoking is a well-recognized risk factor for cardiovascular disorders and elevates the risk of CHF occurrence; additionally, withdrawal symptoms may induce negative affective states, such as anxiety and dysphoria. The connection between alcohol consumption and anxiety among CHF patients may derive from physical malaise (e.g., adverse cardiac events) caused by excessive alcohol intake[30]. The relatively high life stress and resource constraints due to low monthly income may also contribute to anxiety in CHF patients[31]. Collectively, female gender, smoking, alcohol consumption, low monthly income, and higher educational attainment may contribute to heightened anxiety in CHF patients. For instance, female patients with low incomes, burdened by financial pressures and concerns about their illness, are more prone to anxiety. Smoking and alcohol consumption may serve as coping mechanisms for anxiety, but these behaviors can paradoxically worsen anxiety symptoms. In the study by Polikandrioti et al[32], prolonged CHF duration was identified as an independently significant factor for depression. A disease course exceeding 5 years may enhance the risk of patients developing major depressive disorder by 69%.
The principles of traditional Chinese medicine (TCM) such as emotional regulation hold great potential in alleviating psychological distress in CHF patients[33]. TCM theory emphasizes the integration of body and spirit, asserting a close connection between emotions and the functions of internal organs[34]. For example, liver qi stagnation may lead to depressed mood, while heart-fire hyperactivity may trigger anxiety. A study by Wang et al[35] demonstrated that acupuncture is clinically effective and safe in alleviating anxiety and depression in HF patients.
The fluid restriction adherence rate in the current study was 28.0%. Age, thirst sensation, anxiety, and depression were intimately linked to fluid restriction adherence in CHF patients. Among these, thirst sensation, anxiety, and depression were identified as independent influential factors for fluid restriction adherence in the patients. Thirst sensation, anxiety, and depression may interact to reduce adherence to fluid restrictions in CHF patients. Specifically, patients with anxiety and depression may find it more challenging to tolerate thirst due to emotional distress, making them more likely to exceed fluid restrictions. Furthermore, anxiety and depression may reinforce each other, further impairing self-control.
CONCLUSION
To summarize, there are considerable risks among CHF patients for depression and anxiety. The risk factors for depression include age, NYHA grading, marital status, educational attainment, and family support, whereas those for anxiety involve gender, smoking, alcohol consumption, monthly income, and educational attainment. Furthermore, the fluid restriction adherence of CHF patients also warrants improvement, especially for those with thirst sensation combined with anxiety or depression. For such patients, targeted thirst-alleviating care and active psychological interventions should be implemented to enhance fluid restriction adherence. Thus, the psychological well-being of CHF patients can be significantly improved through a multifaceted approach, which includes implementing regular psychological evaluations, offering robust psychological support, and employing therapeutic interventions such as cognitive-behavioral therapy or mindfulness-based stress reduction. Furthermore, involving the family in support interventions can provide a comprehensive care framework. On the physical management side, fluid restriction adherence can be optimized through effective thirst management strategies—utilizing ice chips, lemon water, sprays, or modifying diuretic therapy—alongside personalized fluid management plans and targeted health education initiatives.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychiatry
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade B, Grade C
Novelty: Grade B, Grade C
Creativity or Innovation: Grade B, Grade B
Scientific Significance: Grade C, Grade C
P-Reviewer: Al Shawan DS; Chen C S-Editor: Lin C L-Editor: Filipodia P-Editor: Zhang L
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