Abstract
Little is known about the role of stress on the psychological well-being of patients after cardiac hospitalization or about factors that protect against or exacerbate the effects of stress. We use prospective data from 1542 patients to investigate the relationship between post-discharge stress and changes in depressive symptoms, and whether the level of prior depressive symptoms, health competence, and perceived social support moderate this relationship. Net of depressive symptoms in the 2 weeks prior to hospitalization, higher levels of post-discharge stress significantly increase depressive symptoms 30 days after discharge. The level of prior depressive symptoms moderates the effect of stress. On the other hand, perceived health competence and social support buffer the negative effects of post-discharge stress. Knowing which patients are particularly vulnerable to experiencing stress and a subsequent increase in depressive symptoms can help trigger interventions prior to discharge and possibly ameliorate the prevalence of depression.
Similar content being viewed by others
Notes
Perceived social support was also measured at the 30-day interview. This is the only variable used in the analysis, other than depressive symptoms, that was measured at another time point.
We excluded marital status (item 7 in the ESSI) because we wanted to assess the independent effects of being married or living with a partner.
We had data for a total of 1576 participants who had completed all three interviews between October 2011 and January 2015. We excluded observations with missing data in any of the variables used in the analysis (N = 35).
References
Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. Newbury Park, CA: Sage.
Aneshensel, C. S. (1992). Social stress: Theory and research. Annual Review of Sociology, 18, 15–38.
Arnold, R., Ranchor, A. V., Koëter, G. H., de Jongste, M. J. L., & Sanderman, R. (2005). Consequences of chronic obstructive pulmonary disease and chronic heart failure: The relationship between objective and subjective health. Social Science and Medicine, 61, 2144–2154.
Arora, N. K., Johnson, P., Gustafson, D. H., McTavish, F., Hawkins, R. P., & Pingree, S. (2002). Barriers to information access, perceived health competence, and psychosocial health outcomes: Test of a mediation model in a breast cancer sample. Patient Education and Counseling, 47, 37–46.
Bane, C., Hughes, C. M., & McElnay, J. C. (2006). The impact of depressive symptoms and psychosocial factors on medication adherence in cardiovascular disease. Patient Education and Counseling, 60, 187–193.
Barker, C., Pistrang, N., & Elliott, R. (2002). Research methods in clinical psychology: An introduction for students and practitioners (2nd ed.). Chichester, UK: Wiley.
Bekke-Hansen, S., Pedersen, C., Thygesen, K., Christensen, S., Waelde, L., & Zachariae, R. (2014). The role of religious faith, spirituality and existential considerations among heart patients in a secular society: Relation to depressive symptoms 6 months past acute coronary syndrome. British Journal of Health Psychology, 19, 740–753.
Bellizzi, K. M., Rowland, J. H., Arora, N. K., Hamilton, A. S., Miller, M. F., & Aziz, N. M. (2009). Physical activity and quality of life in adult survivors of non-Hodgkin’s lymphoma. Journal of Clinical Oncology, 27, 960–966.
Boyle, M. (2011). Identifying core behavioral and psychosocial data elements for the electronic health record: Executive summary. Retrieved from http://www.sbm.org/UserFiles/file/EHR_Meeting_May_2-3-2011–Executive_Summary.pdf
Bremmer, M. A., Hoogendijk, W. J., Deeg, D. J., Schoevers, R. A., Schalk, B. W., & Beekman, A. T. (2006). Depression in older age is a risk factor for first ischemic cardiac events. American Journal of Geriatric Psychiatry, 14, 523–530.
Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., Craig, I. W., Harrington, H., & Poulton, R. (2003). Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene. Science, 301, 386–389.
Cassel, J. (1976). The contribution of the social environment to host resistance. American Journal of Epidemiology, 104, 107–123.
Chung, M. L., Moser, D. K., Lennie, T., & Frazier, S. K. (2013). Perceived social support predicted quality of life in patients with heart failure, but the effect is mediated by depressive symptoms. Quality of Life Research, 22, 1555–1563.
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385–396.
Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310–357.
Donovan, K. A., Grassi, L., McGinty, H. L., & Jacobsen, P. B. (2014). Validation of the distress thermometer worldwide: State of the science. Psycho-Oncology, 23, 241–250.
Folkman, S., Lazarus, R. S., Dunkel-Schetter, C., DeLongis, A., & Gruen, R. J. (1986). Dynamics of stressful encounter: Cognitive appraisal, coping, and encounter outcomes. Journal of Personality and Social Psychology, 50, 992–1003.
Frasure-Smith, N., Lesperance, F., Gravel, G., Masson, A., Juneau, M., Talajic, M., & Bourassa, M. G. (2000). Social support, depression, and mortality during the first year after myocardial infarction. Circulation, 101, 1919–1924.
Friedmann, E., Son, H., Thomas, S. A., Chapa, D. W., & Lee, H. J. (2014). Poor social support is associated with increases in depression but not anxiety over 2 years in heart failure outpatients. Journal of Cardiovascular Nursing, 29, 20–28.
Graven, L. J., & Grant, J. (2013). The impact of social support on depressive symptoms in individuals with heart failure: Update and review. Journal of Cardiovascular Nursing, 28, 429–443.
Hammash, M. H., Hall, L. A., Lennie, T. A., Heo, S., Chung, M. L., Lee, K. S., & Moser, D. K. (2012). Psychometrics of the PHQ-9 as a measure of depressive symptoms in patients with heart failure. European Journal of Cardiovascular Nursing, 12, 446–453.
Hammen, C. (2005). Stress and depression. Annual Review of Clinical Psychology, 1, 293–319.
Haworth, J. E., Moniz-Cook, E., Clark, A. L., Wang, M., Waddington, R., & Cleland, J. G. F. (2005). Prevalence and predictors of anxiety and depression in a sample of chronic heart failure patients with left ventricular systolic dysfunction. The European Journal of Heart Failure, 7, 803–808.
Hemingway, H., & Marmot, M. (1999). Psychosocial factors in the aetiology and prognosis of coronary heart disease: Systematic review of prospective cohort studies. BMJ, 318, 1460–1467.
Heo, S., Lennie, T. A., Moser, D. K., & Kennedy, R. L. (2014). Types of social support and their relationships to physical and depressive symptoms and health-related quality of life in patients with heart failure. Heart and Lung, 43, 299–305.
Hsu, N., Tsao, H., Chen, H., & Chou, P. (2014). Anxiety and depression mediate the health-related quality of life differently in patients with cardiovascular disease and stroke—preliminary report of the Yilan study: A population-based community health survey. PLoS ONE, 9, 1–9.
Kendler, K. S., & Gardner, C. O. (2010). Dependent stressful life events and prior depressive episodes in the prediction of major depression: The problem of causal inference in psychiatric epidemiology. Archives of General Psychiatry, 67, 1120–1127.
Kendler, K. S., Karkowski, L. M., & Prescott, C. A. (1999). Causal relationship between stressful life events and the onset of major depression. American Journal of Psychiatry, 156, 837–841.
Kessler, R. C. (1997). The effects of stressful life events on depression. Annual Review of Psychology, 48, 191–214.
Kessler, R. C., & Magee, W. J. (1994). The disaggregation of vulnerability to depression as a function of the determinants of onset and recurrence. In W. R. Avison & I. H. Gotlib (Eds.), Stress and mental health: Contemporary issues and prospects for the future (pp. 239–258). New York: Plenum.
Kroenke, K., Spitzer, R. L., Williams, J. B. W., & Löwe, B. (2010). The Patient Health Questionnaire somatic, anxiety, and depressive symptom scales: A systematic review. General Hospital Psychiatry, 32, 345–359.
Kuiper, N. A., Olinger, L. J., & Lyons, L. M. (1986). Global perceived stress level as a moderator of the relationship between negative life events and depression. Journal of Human Stress, 12, 149–153.
Lazarus, R. S. (1966). Psychological stress and the coping process. New York: McGraw-Hill.
Lesman-Leegte, I., Jaarsma, T., Sanderman, R., Linssen, G., & van Veldhuisen, D. J. (2006). Depressive symptoms are prominent among elderly hospitalised heart failure patients. European Journal of Heart Failure, 8, 634–640.
Lett, H. S., Blumenthal, J. A., Babyak, M. A., Catellier, D. J., Carney, R. M., Berkman, L. F., & Schneiderman, N. (2007). Social support and prognosis in patients at increased psychosocial risk recovering from myocardial infarction. Health Psychology, 26, 418–427.
Lett, H. S., Blumenthal, J. A., Babyak, M. A., Strauman, T. J., Robins, C., & Sherwood, A. (2005). Social support and coronary heart disease: Epidemiologic evidence and implications for treatment. Psychosomatic Medicine, 67, 869–878.
Maciejewski, P. K., Prigerson, H. G., & Mazure, C. M. (2000). Self-efficacy as a mediator between stressful life events and depressive symptoms. British Journal of Psychiatry, 176, 373–378.
Marks, G. R., & Lutgendorf, S. K. (1999). Perceived health competence and personality factors differentially predict health behaviors in older adults. Journal of Aging and Health, 11, 221–239.
Mazure, C. M. (1998). Life stressors as risk factors in depression. Clinical Psychology: Science and Practice, 5, 291–313.
Meyer, T., Hussein, S., Lange, H. W., & Herrmann-Lingen, C. (2014). Transient impact of baseline depression on mortality in patients with stable coronary heart disease during long-term follow-up. Clinical Research in Cardiology, 103, 389–395.
Meyers, A. G., Salanitro, A., Wallston, K. A., Cawthon, C., Vasilevskis, E. E., Goggins, K. M., & Kripalani, S. (2014). Determinants of health after hospital discharge: Rationale and design of the Vanderbilt Inpatient Cohort Study (VICS). BMC Health Services Research, 14, 1–10.
Mitchell, A. J., Morgan, J. P., Petersen, D., Fabbri, S., Fayard, C., Stoletniy, L., & Chiong, J. (2012). Validation of simple visual-analogue thermometer screen for mood complications of cardiovascular disease: The emotion thermometers. Journal of Affective Disorders, 136, 1257–1263.
Mitchell, P. H., Powell, L., Blumenthal, J., Norten, J., Ironson, G., Pitula, C. R., & Berkman, L. F. (2003). A short social support measure for patients recovering from myocardial infarction. Journal of Cardiopulmonary Rehabilitation, 23, 398–403.
Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., & Turner, M. B. (2015). Heart disease and stroke statistics–2015 Update: A report from the American Heart Association. Circulation, 131, e29–e322.
Ransom, S., Jacobsen, P. B., & Booth-Jones, M. (2006). Validation of the distress thermometer with bone marrow transplant patients. Psycho-Oncology, 15, 604–612.
Rao, P., & Miller, R. L. (1971). Applied econometrics. Belmont, CA: Wadsworth.
Riegel, B., Moser, D. K., Anker, S. D., Appel, L. J., Dunbar, S. B., Grady, K. L., & Whellan, D. J. (2009). State of the science: Promoting self-care in oersons with heart failure: A scientific statement from the American Heart Association. Circulation, 120, 1141–1163.
Sanjuán, P., Arranz, H., & Castro, A. (2014). Effect of negative attributions on depressive symptoms of patients with coronary heart disease after controlling for physical functional impairment. British Journal of Health Psychology, 19, 380–392.
Shnek, Z. M., Irvine, J., Stewart, D., & Abbey, S. (2001). Psychological factors and depressive symptoms in ischemic heart disease. Health Psychology, 20, 141–145.
Smith, M. S., Wallston, K. A., & Smith, C. A. (1995). The development and validation of the Perceived Health Competence Scale. Health Education Research, 10, 51–64.
Stafford, L., Berk, M., & Jackson, H. J. (2013). Tobacco smoking predicts depression and poorer quality of life in heart disease. BMC Cardiovascular Disorders, 13, 35.
Surtees, P., Wainwright, N., Luben, R., Wareham, N., Bingham, S., & Khaw, K. (2008). Depression and ischemic heart disease mortality: Evidence from the EPIC-Norfolk United Kingdom Prospective Cohort Study. American Journal of Psychiatry, 165, 515–523.
Thoits, P. A. (2010). Stress and health: Major findings and policy implications. Journal of Health and Social Behavior, 51, S41–S53.
Thomas, S. A., Friedmann, E., Gottlieb, S. S., Liu, F., Morton, P. G., Chapa, D. W., & Nahm, E. S. (2009). Changes in psychosocial distress in outpatients with heart failure with implantable cardioverter defibrillators. Heart and Lung, 38, 109–120.
Thurston, R. C., Kubzansky, L. D., Kawachi, I., & Berkman, L. (2006). Do depression and anxiety mediate the link between educational attainment and CHD? Psychosomatic Medicine, 68, 25–32.
Tully, P. J., Baker, R. A., Turnbull, D., & Winefield, H. (2008). The role of depression and anxiety symptoms in hospital readmissions after cardiac surgery. Journal of Behavioral Medicine, 31, 281–290.
Turner, R. J., & Brown, R. L. (2010). Social Support and Mental Health. In T. L. Scheid & T. N. Brown (Eds.), A handbook for the study of mental health: Social contexts, theories, and systems (2nd ed., pp. 200–212). New York: Cambridge University Press.
Uchino, B. N. (2006). Social support and health: A review of physiological processes potentially underlying links to disease outcomes. Journal of Behavioral Medicine, 29, 377–387.
Umberson, D., Crosnoe, R., & Reczek, C. (2010). Social relationships and health behavior across the life course. Annual Review of Sociology, 36, 139–157.
van Deursen, V. M., Urso, R., Laroche, C., Damman, K., Dahlstrom, U., Tavazzi, L., & Voors, A. A. (2014). Co-morbidities in patients with heart failure and its relation with venous congestion and prognosis: An analysis of the European Heart Failure Pilot Survey. European Journal of Heart Failure, 16, 103–111.
Wulsin, L. R., & Singal, B. M. (2003). Do depressive symptoms increase the risk for the onset of coronary disease? A systematic quantitative review. Psychosomatic Medicine, 65, 201–210.
Zautra, A. J., Parrish, B. P., Van Puymbroeck, C. M., Tennen, H., Davis, M. C., Reich, J. W., & Irwin, M. (2007). Depression history, stress, and pain in rheumatoid arthritis patients. Journal of Behavioral Medicine, 30, 187–197.
Acknowledgments
The authors acknowledge the following additional members of the Vanderbilt Inpatient Cohort Study research team who contributed to design or conduct the study: Susan P. Bell, MD, MSCI; Courtney Cawthon, MPH, NP; Catherine Couey; Katharine M. Donato, PhD; Olivia Dozier; Catherine Evans; Vanessa Fuentes; Frank E. Harrell, PhD; Blake Hendrickson; Cardella Leak, MPH; Daniel Lewis; Abby G. Meyers, MD; Samuel Nwosu, MS; Monika Rizk; Hannah Rosenberg; Russell L. Rothman, MD, MPP; Amanda S. Mixon, MD, MS, MSPH; Jonathan S. Schildcrout, PhD; John F. Schnelle, PhD; Eduard E. Vasilevskis, MD, MPH.
Funding
This study was funded by the National Heart, Lung, and Blood Institute (R01 HL109388) and in part by the National Center for Advancing Translational Sciences (2 UL1 TR000445-6). The content is solely the responsibility of the authors and does not necessarily represent official views of the National Institutes of Health.
Author information
Authors and Affiliations
Consortia
Corresponding author
Ethics declarations
Conflict of interest
Gabriela León-Pérez, Kenneth A. Wallston, Kathryn M. Goggins, Heidi M. Poppendeck, and Sunil Kripalani declare that they have no conflict of interest.
Human and animal rights and informed consent
All procedures performed in the study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all patients for being included in the study.
Rights and permissions
About this article
Cite this article
León-Pérez, G., Wallston, K.A., Goggins, K.M. et al. Effects of stress, health competence, and social support on depressive symptoms after cardiac hospitalization. J Behav Med 39, 441–452 (2016). https://doi.org/10.1007/s10865-015-9702-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10865-015-9702-x