Abstract

P

P

, A

Z

, J

R

, A

S

Depression and Anxiety Symptoms and Cardiovascular

Disease in an Over−Fifty Rural Population

Objawy depresyjne i lękowe a choroby układu krążenia

w populacji wiejskiej 50+

1_{Department of Psychiatry, Silesian Piasts University of Medicine in Wrocław, Poland} 2_{Department of Internal Medicine, Silesian Piasts University of Medicine in Wrocław, Poland}

Adv Clin Exp Med 2007, 16, 4, 513–518 ISSN 1230−025X

ORIGINAL PAPERS

© Copyright by Silesian Piasts University of Medicine in Wrocław

Abstract

Background. This study was part of a research project in psychiatry at the Center of Epidemiology entitled ”Occurrence of psychotic disorders in the rural area of Boguszyce with regard to somatic diseases and the socio− economic situation of the residents.”

Objectives.The aim was to assess symptoms of depression and anxiety and the occurrence of cardiovascular dis− ease among the rural sample over 50 years of age.

Material and Methods. Residents of the village of Boguszyce 50 years of age or over were examined. To assess the occurrence and intensity of symptoms of depression and anxiety, the HADS (Hospital Anxiety and Depression Scale), consisting of two subscales, one assessing symptoms of anxiety (HADS−A) and the other of depression (HADS−D), each with seven statements, was used. The occurrence of hypertension, stroke, angina pectoris, myocardial infarction, and heart failure were also analyzed.

Results.In this sample, similarly to the general population, the intensity of symptoms of anxiety and depression was higher in women; moreover, the intensity of symptoms of depression increased with age. Interestingly, in this study population the individuals who did not suffer from hypertension had severe symptoms of anxiety more fre− quently. No relationship was found between the occurrence and number of cardiovascular diseases and the inten− sity of symptoms of depression and anxiety.

Conclusions. There is a need for diagnosing and directed treatment of emotional disturbances in the group of psy− chosomatically ill individuals, particularly in the group over 50 years of age; however, the connection requires fur− ther studies (Adv Clin Exp Med 2007, 16, 4, 513–518).

Key words: cardiovascular diseases, depressive and anxiety symptoms, age.

Streszczenie

Wprowadzenie.Zbadano związek występowania objawów depresyjnych i lękowych z chorobami układu krążenia wśród starszych osób populacji wiejskiej. Badanie było częścią zrealizowanego projektu badawczego Akademic− kiego Centrum Epidemiologicznego pt.: „Występowanie zaburzeń psychicznych w populacji wiejskiej Boguszyce z uwzględnieniem schorzeń somatycznych oraz sytuacji socjoekonomicznej mieszkańców”.

Cel pracy. Ocena związku występowania objawów depresyjnych i lękowych z chorobami układu krążenia u osób w wieku powyżej 50 lat z populacji wiejskiej.

Materiał i metody. Badaniem objęto osoby w wieku od 50 r.ż., zamieszkałe we wsi Boguszyce. Do oceny wystę− powania i nasilenia objawów depresji oraz lęku zastosowano skalę HADS (Hospital Anxiety and Depression Sca− le), składającą się z 2 niezależnych, zawierających po siedem stwierdzeń podskal, z których jedna ocenia objawy lękowe (HADS−A), a druga objawy depresyjne (HADS−D). W badaniu brano pod uwagę obciążenie następujący− mi chorobami: nadciśnienie tętnicze, udar, choroba wieńcowa stabilna, choroba wieńcowa niestabilna, zawał, nie− wydolność krążenia.

A holistic approach to the human being, in health and disease, has been gaining ground dur− ing recent years as an alternative to depersonalized modern medicine. Patients with psychosomatic diseases merit special interest. Modern concepts of the etiopathogenesis of psychosomatic disorders assume the existence of either biological or psy− chosocial factors. The high efficacy of antidepres− sive and anxiolytic medications in these disorders supports the argument that they are actually the result of restrained aggression and/or anxiety or that they mask depression [1]. Proper appreciation of the actual cause of a disease and the patient’s current emotional state imply a definite diagnostic and therapeutic pathway, this being essential for correct treatment.

For the last several years, all the developed European countries have been faced with a pro− gressive increase in the number of persons treated for depressive disorders and diseases of the circu− latory system. There is a higher risk for these dis− eases in patients aged 50 years or more. It has been shown that the presence of depression wors− ens prognosis in some somatic illnesses, e.g. coro− nary heart disease, heart failure, and convales− cence after heart attack or stroke. The links between depressive emotional disturbances and somatic disease are very complex. However, some correlations (partly hypothetical) can be dis− tinguished [2]:

– depression may stimulate different psycho− somatic (including psycho−immunological) mech− anisms, these being a primordial cause of some somatic disorders and diseases, the presence of which becomes an element of the pathogenesis of depression,

– depression is reactive to some somatic dis− orders,

– some somatic disorders result from the patient’s lifestyle, e.g. addictions, habits, and chronic medication,

– the coexistence of certain forms of affective disturbances and some somatic diseases rests upon the common genetic background.

The over−50 population is often affected by numerous somatic diseases, and polymedication, a cause of further problems, both diagnostic and therapeutic, is common. A neglect of careful anamnesis and laboratory testing may easily result in diagnostic failures, usually by underestimating emotional disturbances and considering them to be

unavoidable elements of the aging process, which leads to improper treatment.

The next emotional disorder of great impor− tance in the etiology and symptomatology of psy− chosomatic diseases is anxiety. Anxiety and depression not only coexist, but may also support the development of somatic disturbances, espe− cially of the circulatory system. Recent studies point out that a high level of anxiety may be a sig− nificant predictive factor of acute cardiac events (including arrhythmias) in cardiological outpa− tients, increasing mortality in this group [3]. Some experts have shown that symptoms of anxiety occur in as many as 95% of depressive patients, while secondary depression occurs in about 65% of anxietic patients [5]. All forms of anxiety disor− ders are suggested to give a higher risk of diag− nosing depression in the elderly [6].

Material and Methods

The study of the rural population of Bogu− szyce, with special interest on circulatory diseases and psychiatric disorders, was conducted in coop− eration between the University Center of Epide− miology, Silesian Piasts University of Medicine in Wrocław, and the County of Oleśnica as part of the project “Epidemiological status of the risk and prevalence of hypertension in the residents of Boguszyce, County of Oleśnica”. This study was part of that project, completed within the specific studies of the university. According to the method− ology accepted for the whole study, every second homestead was interviewed. The population study covered 403 persons, including 31 children.

This paper presents the results of the study of 64 individuals, residents of the village of Boguszyce in the voivodship of Lower Silesia aged 50 years or over. The group comprised 33 females (51.6%) and 31 males (48.4%). The mean age was 61.48 years (SD: 8.33), the mean age of the males was 60.61 years and of the females 62.30 years. There were no significant differences between these mean values (p = 0.396, Mann− −Whitney’s test).

The Hospital Anxiety and Depression Scale (HADS), constructed in 1983 by R. P. Snaith and A. S. Zigmond, was used in the study [7]. The scale consists of two independent subscales for measuring anxiety and depression. Each subscale

Wnioski.Istnieje potrzeba diagnozowania i ukierunkowanego leczenia zaburzeń emocjonalnych chorych psycho− somatycznie, zwłaszcza w grupie 50+; chociaż związek ten wymaga dalszych badań (Adv Clin Exp Med 2007, 16, 4, 513–518).

comprises seven statements concerning the pa− tient’s current state. The intensities of different features are assessed by the patient with the use of a four−grade scale. In order to exclude transient emotional fluctuations, the week prior to the examination was analyzed. The subscale of anxi− ety is based upon the Present State Examination (PSE) and Snaith’s own research [7]. The selec− tion of questions for the subscale of depression resulted from the authors’ hypothesis that anhedo− nia is an axis of the endogenic subtype of depres− sion, being a predictive factor of good response to antidepressive medication [8, 9]. This subscale has one point to define depressive mood and one point to define psychomotoric inhibition. It is compatible with the ICD−X classification of somatic symptoms of depression [10]. A result of 0–7 points in each scale is considered normal, 8–10 points indicates mild disturbances, 11–14 points moderate disturbances, and 15–21 points severe disturbances. HADS has been translated into all the main European languages as well as into Arabian, Chinese, Japanese, Urdu, and Hebrew [11–14].

Analysis of the obtained results focused on correlating the sociodemographic (age, sex) and clinical variables (a history of somatic disease or not) with the general result of HADS and its sub− scales. When at least five individuals presented a disorder, the Mann−Whitney test was used to estimate whether the mean anxiety (or depression) level depended on this disorder. When at least 10 individuals presented the disorder, the exact Fisher test was used to verify whether the catego− rization of anxiety (depression) depended on the cardiovascular disorder. The Spearman correlation test was used to verify the correlation between the number of cardiovascular disorders and the level of anxiety and depressive.

Results

The prevalence of consecutive cardiovascular diseases in the study group was as follows: hyper− tension occurred in 45.31%, stroke/TIA in 1.56%, coronary heart disease in 12.5%, myocardial infarction in 7.81%, and heart failure in 21.87% of the examined individuals. Analysis of the correla− tions between the symptoms of depression/anxiety and the sociodemographic variables (age, sex) showed that:

– symptoms of anxiety (HADS−A subscale) were significantly more severe in females than in males (mean HADS−A: males 6.48, females 9.52, p = 0.014). Depressive symptoms (HADS−D sub− scale), however, occurred in both sexes with sta−

tistically approximate intensity (mean HADS−D: males 4.42, females 6.21, p = 0.155),

– in cases of symptoms of depression (sub− scale HADS−D) as well as in the sum of both sub− scales (HADS−A+D) there was a significant corre− lation between age and the intensity of symptoms (subscale HADS−D: r = 0.264788, p = 0.034; HADS−A+D: r = 0.272, p = 0.03). No correlation between age and the intensity of anxiety symp− toms in HADS−A was found (r = 0.186, p = 0.141). The correlations between symptoms of de− pression and anxiety and the clinical variables (i.e. the presence of circulatory disorders or not) were analyzed. The results showed that individuals without hypertension presented symptoms of severe anxiety significantly more often (Fisher exact test, p < 0.01). No relationship between hypertension and the intensity of depression was found (Table 1).

Moreover, the intensity of symptoms of de− pression did not correlate with the number of car− diovascular diseases (r = 0.026, p = 0.846), and the intensity of symptoms of anxiety had no relation− ship with the number of such diseases (excluding hypertension) (r = 0.173, p = 0.179).

A relationship between the existence of at least one circulatory disease and higher intensity of symptoms of depression is suggested (p < 0.1).

Discussion

The gender−related differences in emotional disturbances are worth emphasizing. A higher intensity of symptoms of anxiety was observed in females. This is in accordance with other authors’ reports, who try to explain this phenomenon in biological, psychological, social, and cultural terms [15].

The older the age at onset of a disease, the greater the role of emotional factors in the devel− opment of psychosomatic disorders [16, 17], which explains the correlation between old age and the higher intensity of symptoms of depres− sion. These symptoms may be caused by recurrent somatic ailments, the patient’s feeling of having no control over the symptoms, discrimination in daily activity, as well as by feelings of isolation, loneliness, and uselessness typical of elderly patients. All these together may lead to feelings of low self−esteem, dejection, and depression [18–20].

fer myocardial infarction have suppressed mood, and 15–22% fulfill the criteria of severe depres− sion [22, 23]. It is also suggested that, on the one hand, depression is a risk factor of coronary heart disease, while on the other hand, patients with diagnosed coronary heart disease show depressive syndrome much more often than the general popu− lation. What is more, the coexistence of both con− ditions is considered to be indicative of poor prog− nosis.

Regulatory disturbances in the circulatory sys− tem are similar in patients with anxiety and those with depression. Anxiety has been found to be

a stressor which, as with depression, causes pro− longed stimulation of the sympathetic nervous sys− tem. This leads to, among other things, a decrease in heart rhythm variability and in the control of heart function through baroreceptor reflexes [24]. In addition, symptoms of anxiety or depression may also be linked to risk factors preceding circu− latory diseases, e.g. hypertension or improper lifestyle, which means poor dietary habits, smok− ing, excessive alcohol use, and benzodiazepine intake.

Feelings of fear and anxiety are considered to be a typical symptom of myocardial infarction

Table 2. Depression and anxiety symptoms and cardiovascular diseases (excluding hypertension)

Tabela 2.Objawy depresyjne i lękowe a choroby układu krążenia (wyłączając nadciśnienie tętnicze)

Intensity of symptoms HADS−A HADS−D

(Stopień nasilenia _{patients with patients without patients with patients without}

objawów) _{cardiovascular cardiovascular cardiovascular cardiovascular}

diseases diseases diseases diseases

(osoby z chorobą (osoby bez choroby (osoby z chorobą (osoby bez choroby układu krążenia) układu krążenia) układu krążenia) układu krążenia)

n (%) n (%) n (%) n (%)

Normal 18 (30) 13 (21.66) 27 (45) 18 (30)

(W normie) 0–7 points

Mild 9 (15) 4 (6.66) 4 (6.66) 4 (6.66)

(Lekkie) 8–10 points

Moderate 7 (11.66) 1 (1.66) 4 (6.66) 2 (3.33)

(Średnie) 11–15 points

Severe 2 (3.33) 6 (10) 1 (1.66) 0 (0)

(Ciężkie) > 15 points

Table 1. Depression and anxiety symptoms and hypertension

Tabela 1. Objawy depresyjne i lękowe a nadciśnienie tętnicze

Intensity of symptoms HADS−A HADS−D

(Stopień nasilenia _{patients with patients without patients with patients without}

objawów) _{hypertension hypertension hypertension hypertension}

(osoby z nadciśnie− (osoby bez nadciś− (osoby z nadciśnie− (osoby bez nad− niem tętniczym) nienia tętniczego) niem tętniczym) ciśnienia tętniczego)

n (%) n (%) n (%) n (%)

Normal 14 (22.58) 17 (27.42) 22 (35.48) 23 (37.09)

(W normie) 0–7 points

Mild 8 (12.8) 6 (9.68) 4 (6.45) 5 (8.06)

(Lekkie) 8–10 points

Moderate 7 (11.29) 2 (3.23) 3 (4.84) 4 (6.45)

(Średnie) 11–15 points

Severe 0 (0) 8 (12.8) 0 (0) 1 (1.61)

[25]. On the other hand, ailments of the circulato− ry system such as tachycardia, chest pain, or stab− bing pain may also be symptoms of anxiety disor− der, e.g. generalized or paroxysmal anxiety. About 25% of patients who are admitted to emergency cardiac units due to chest pain are diagnosed as having chest pain as a symptom of anxiety disor− der. It appears important that such a cause of chest pain is more common in young females who com− plain of feelings of severe anxiety without a histo− ry of coronary heart disease and those with atypi− cal localization of pain [26]. Frasure−Smith et al. showed in their study that in a group of patients after myocardial infarction, a high level of anxiety was found to be a significant predictor of recurrent cardiac incidents, including arrhythmias [3]. Other studies confirmed the relationship between anxiety symptoms and morbidity risk in patients after myocardial infarction, including sudden cardiac death, as well as positive correlation between anx− iety level and mortality in these patients.

Knowledge of the mutual relationships between depressive and anxiety syndromes and circulatory diseases, especially coronary heart dis− ease, turns out to be a very important element of clinical practice, considering that the coexistence of these disturbances is a factor of poor prognosis and may significantly increase the risk of sudden cardiac death in patients with coronary heart dis−

ease. It is worth remembering the holistic, inter− disciplinary approach to the patient, with the focus on both physical examination and emotional status evaluation.

It is difficult to refrain from analyzing the causes of the more severe symptoms of anxiety in patients without hypertension. Anxiety is known to have a triad of symptom groups: psychic (cog− nitive and emotional), behavioral, and somatic. Persons without hypertension do not show sympa− thetic stimulation: their anxiety is determined extrasomatically. Therefore, both simple and com− plex psychic and behavioral symptoms ought to dominate in these patients. This may lead to more intensified anxiety symptoms in this group.

Overall, there is a need for diagnosing emo− tional disturbances in psychosomatic patients as well as for psychotherapeutic actions and proper forms of medication aimed to decrease the level of anxiety and depression, especially in the group over 50 years of age. Regarding atypical symp− toms of these disorders in patients over 50 as “normal for this group” results in improper diag− nostics and treatment of emotional disturbances. The HADS abbreviated scale of anxiety and depression facilitates the diagnostics of general emotional disturbances in psychosomatic patients as well as subsequent, properly directed specialist treatment.

Acknowledgements: The authors would like to thank all the research assistants of the Students’ Research Teams of the Departments of Internal Medicine and Psychiatry who participated in the study. The project was supported by the Center of Epidemiology of Silesian Piasts University of Medicine in Wrocław.

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Address for correspondence:

Paulina Podgórna

Research Unit of Consultation Psychiatry and Behavioral Medicine Department of Psychiatry

Silesian Piasts University of Medicine Pasteura 10

50−367 Wrocław Poland

Conflict of interest: None declared