Jos Widdershoven

Failure to Consult for Symptoms of Heart Failure in Patients with a Type-D Personality

Background: Self-management and adequate consultation behaviour are essential for the successful treatment of chronic heart failure (CHF). Patients with a type-D personality, characterised by high social inhibition and negative affectivity, may delay medical consultation despite increased symptom levels and may be at an increased risk for adverse clinical outcomes. Aim: To examine whether type-D personality predicts poor self-management and failure to consult for evident cardiac symptoms in patients with CHF. Design/methods/patients: 178 outpatients with CHF (aged ⩽80 years) completed the type-D Personality Scale at baseline, and the Health Complaints Scale (symptoms) and European Heart Failure Self-care Behaviour Scale (self-management) at 2 months of follow-up. Medical information was obtained from the patients’ medical records. Results: At follow-up, patients with a type-D personality experienced more cardiac symptoms (OR 6.4; 95% CI 2.5 to 16.3, p<0.001) and more often appraised these symptoms as worrisome (OR 2.9; 95% CI 1.3 to 6.6, p<0.01) compared with patients with a non-type-D personality. Paradoxically, patients with a type-D personality were less likely to report these symptoms to their cardiologist/nurse, as indicated by an increased risk for inadequate consultation behaviour (OR 2.7; 95% CI 1.2 to 6.0, p<0.05), adjusting for demographics, CHF severity/aetiology, time since diagnosis and medication. Accordingly, of 61 patients with CHF who failed to consult for evident cardiac symptoms, 43% had a type-D personality (n = 26). Of the remaining 108 patients with CHF, only 14% (n = 16) had a type-D personality. Conclusion: Patients with CHF with a type-D personality display inadequate self-management. Failure to consult for increased symptom levels may partially explain the adverse effect of type-D personality on cardiac prognosis.

The distressed (type D) personality is independently associated with impaired health status and increased depressive symptoms in chronic heart failure

Background Chronic heart failure (CHF) is a serious condition that is associated with impaired health status and a high prevalence of depressive symptoms. To date, little is known about the determinants of health status and depressive symptoms in CHF. Therefore, the aim of this study was to assess whether Type D personality is associated with impaired health status and increased depressive symptoms in heart failure patients, independent of disease characteristics. Methods Eighty-four patients (63 men and 21 women, mean age=65.9±12.1 years) with systolic CHF completed four questionnaires to assess Type D personality (14-item Type D Personality Scale [DS14]), health status (Minnesota Living with Heart Failure Questionnaire [MLWHFQ]), depressive symptoms (Center for Epidemiological Studies Depression Scale [CES-D]) and mood status (Global Mood Scale [GMS]) when visiting an outpatient heart failure clinic. Information on clinical variables was obtained from patients’ medical records. Results Type D patients were more likely to experience impairment in health status (18/38=47%) as compared to non-Type Ds (11/46=24%), P=0.027. They also more often reported symptoms of depression; namely 18 of 38=47% versus 6 of 46=13%, P=0.001. When controlling for severity and etiology of CHF, age and gender, Type D remained a significant associate of impaired health status [odds ratio (OR) 3.0, 95% confidence interval (CI) 1.12–7.78] and depressive symptoms (OR 6.3, 95% CI 2.08–19.12). Conclusions Type D was associated with impaired health status and increased depressive symptoms in CHF patients. These preliminary findings demonstrate the value of including personality factors in CHF research.

Inadequate consultation behavior modulates the relationship between Type D personality and impaired health status in chronic heart failure

BACKGROUND Psychological risk factors for impaired health outcomes have been acknowledged in chronic heart failure (CHF), with Type D personality being such a risk factor. Inadequate consultation behavior, a specific aspect of self-management, might be one mechanism in explaining the adverse effect of Type D on health outcomes. In this study we examined the relationship between Type D personality, impaired disease-specific health status, and inadequate consultation behavior. METHODS AND RESULTS CHF outpatients (n=313) completed the Type D Scale (DS14) at baseline, and the European Heart Failure Self-care Behaviour Scale (EHFScBS) and the Minnesota Living with Heart Failure Questionnaire (MLWHFQ) at 6-month follow-up. Type D personality independently predicted inadequate consultation behavior (OR=1.80, 95%CI [1.03-3.16], p=.04) and impaired health status (OR=3.61, 95%CI [1.93-6.74], p<.001) at 6-month follow-up, adjusting for demographic and clinical variables. Inadequate consultation behavior (OR=1.80, 95%CI [1.11-2.94], p=.02) and NYHA-class (OR=2.83, 95%CI [1.17-4.71], p<.001) were associated with impaired health status, after controlling for demographics, clinical variables, and Type D personality. Post-hoc multivariable analysis pointed out that Type D patients who displayed inadequate consultation behavior were at a 6-fold increased risk of reporting impaired health status, compared to the reference group of non-Type D patients who displayed adequate consultation behavior (OR=6.06, 95%CI [2.53-14.52], p<.001). CONCLUSIONS These findings provide evidence for inadequate behavior as a mechanism that may explain the link between Type D personality and impaired health status. Future studies are warranted to elaborate on these findings.

Somatic versus cognitive symptoms of depression as predictors of all-cause mortality and health status in chronic heart failure.

OBJECTIVE Depression is a predictor of adverse health outcomes in chronic heart failure (CHF), but it is not known whether specific symptoms drive this relationship. We examined the impact of somatic/affective, cognitive/affective, and total depressive symptoms on all-cause mortality and health status in CHF. METHOD Consecutive CHF outpatients (n = 366) completed the Beck Depression Inventory. The primary endpoint was all-cause mortality; the secondary endpoint was disease-specific health status, as measured by the Minnesota Living with Heart Failure Questionnaire (n = 285) at inclusion and 1-year follow-up. The study was conducted between October 2003 and March 2007. RESULTS There were 68 (18.6%) deaths (mean +/- SD follow-up, 37.2 +/- 10.6 months). Patients high on somatic/affective depressive symptoms had a greater incidence of mortality compared to patients low on somatic/affective depressive symptoms (31% vs 15%; hazard ratio [HR] = 2.3; 95% CI, 1.38-3.69; P = .001). There was no significant difference in the incidence of mortality between patients high versus low on cognitive/affective depressive symptoms (23% vs 18%; HR = 1.4; 95% CI, 0.80-2.40; P = .25), but there was a significant difference between patients high versus low on total depressive symptoms (24% vs 16%; HR = 1.6; 95% CI, 1.01-2.63; P < .05). After adjusting for demographic and clinical characteristics, we found that somatic/affective depressive symptoms predicted all-cause mortality (HR = 1.8; 95% CI, 1.03-3.07; P = .04), while cognitive/affective and total depressive symptoms did not. Both dimensions of depressive symptoms predicted disease-specific health status at 1 year. CONCLUSIONS Only somatic/affective depressive symptoms significantly predicted all-cause mortality in CHF. In the context of diagnosing and intervening, awareness of subtypes of depressive symptoms is important.

Psychological Distress and Mortality in Systolic Heart Failure

Background—Depression, anxiety, and type D (“distressed”) personality (tendency to experience negative emotions paired with social inhibition) have been associated with poor prognosis in coronary heart disease, but little is known about their role in chronic heart failure. Therefore, we investigated whether these indicators of psychological distress are associated with mortality in chronic heart failure. Method and Results—Consecutive outpatients with chronic heart failure (n=641; 74.3% men; mean age, 66.6±10.0 years) filled out a 4-item questionnaire to assess mixed symptoms of anxiety and depression and the 14-item type D scale. End points were defined as all-cause and cardiac mortality. After a mean follow-up of 37.6±15.6 months, 123 deaths (76 due to cardiac cause) were recorded. Cumulative hazard functions for elevated anxiety/depression symptoms differed marginally for all-cause (P=0.06), but not cardiac, mortality (P=0.43); type D personality was associated with neither all-cause mortality (P=0.63) nor cardiac mortality (P=0.87). In multivariable analyses, neither elevated anxiety/depression symptoms nor type D personality was associated with all-cause mortality (hazard ratio [HR]=1.18; 95% CI, 0.76 to 1.84; P=0.45 and HR=1.09; 95% CI, 0.67 to 1.77; P=0.73, respectively) or cardiac mortality (HR=1.13; 95% CI, 0.63 to 2.04; P=0.65 and HR=1.16; 95% CI, 0.62 to 2.18; P=0.67). In secondary analyses, a 1-point increase in anxiety/depression (range, 0 to 16) was associated with an 8% increase in risk for all-cause mortality (HR=1.08; 95% CI, 1.01 to 1.15; P=0.02). Conclusions—Neither elevated anxiety/depression symptoms nor type D personality was associated with an increased risk for all-cause or cardiac mortality. Future studies with adequate power and a longer follow-up duration are needed to further elucidate the role of psychological distress in chronic heart failure.

Type D personality and cardiac mortality in patients with chronic heart failure

BACKGROUND Clinical predictors of cardiac mortality in chronic heart failure (CHF) are established, but less is known about chronic psychological predictors. Therefore, we examined the prognostic value of Type D personality (tendency to experience negative feelings and inhibit self-expression) in CHF patients. METHODS AND RESULTS Consecutive systolic CHF outpatients (n=232) filled in the Type D Scale (DS14) at baseline. Socio-demographic and clinical data were obtained from the medical record/cardiologist. The primary endpoint was total cardiac mortality (follow-up=30.7+/-11.1 months). Late (>6 months) cardiac mortality was the secondary endpoint. Type D patients had a higher incidence of total cardiac mortality (15/48=31.3%) as compared to non Type D patients (32/184=17.4%), OR=2.16;95%CI:1.05-4.43, p=.04. Type D personality was a near significant independent predictor of total cardiac mortality (OR=1.40;95%CI:0.93-4.29, p=.08), and a significant independent predictor of late cardiac mortality, adjusting for sex, age and left ventricular ejection fraction (OR=2.34;95%CI:1.05-5.26, p=.04). CONCLUSIONS Type D personality was a near-significant independent predictor of total cardiac mortality, and a significant independent predictor of late cardiac mortality, adjusting for socio-demographics and disease-severity. These findings suggest that Type D personality, a chronic psychological risk factor, is of importance in long-term prognosis in CHF.

Type D personality and depressive symptoms are independent predictors of impaired health status in chronic heart failure

To examine whether Type D personality exerts a stable, independent effect on health status in CHF over time, adjusted for depressive symptoms.

Usefulness of Type D Personality and Kidney Dysfunction as Predictors of Interpatient Variability in Inflammatory Activation in Chronic Heart Failure

Tumor necrosis factor-alpha (TNF-alpha), soluble TNF-alpha receptors 1 and 2 (sTNFR1/2), and interleukin (IL)-6 are powerful predictors of mortality in chronic heart failure (CHF). Little is known, however, about the origins of proinflammatory cytokine production or the determinants of substantial interpatient variability in inflammatory activation. We prospectively examined kidney dysfunction and Type D personality (tendency to experience and inhibit emotional distress) as predictors of interpatient variability in these markers of inflammatory activation. At baseline, 125 patients with CHF were assessed for kidney dysfunction and Type D. Serum levels of proinflammatory cytokines (TNF-alpha, sTNFR1, sTNFR2, IL-6), the anti-inflammatory cytokines IL-10, and IL-1 receptor antagonist were measured at 1-year follow-up. Type D patients had higher levels of sTNFR1 (p = 0.009) and sTNFR2 (p = 0.001) and lower levels of IL-10 (p = 0.006) than patients without Type D and kidney dysfunction. Patients with kidney dysfunction also had elevated levels of sTNFR1 and sTNFR2 (p <0.0001), but their IL-10 level was not decreased. Type D personality and kidney dysfunction predicted increased sTNFR1/IL-10 and sTNFR2/IL-10 ratios (p < or =0.007); Type D also predicted an increased IL-6/IL-10 ratio (p = 0.013). Other predictors were spironolactone and older age. After adjusting for these variables, the odds for elevated ratios (highest 20%) were still increased in Type D patients (all odd ratios >3.00). In conclusion, Type D personality and kidney dysfunction independently predicted unfavorable cytokine profiles in patients with CHF and may enhance our understanding of interpatient variability in inflammatory activation in these patients.

Cognitive/affective and somatic/affective symptom dimensions of depression are associated with current and future inflammation in heart failure patients

BACKGROUND Little is known about whether cognitive/affective depressive symptoms or somatic/affective depressive symptoms are associated with inflammation in heart failure (HF), or that the relation is confounded with disease severity. AIM To examine the association between depressive symptom dimensions in HF patients with inflammatory markers cross-sectionally and prospectively, while adjusting for appropriate confounders. RESULTS Consecutive HF patients completed the Beck Depression Inventory at inclusion and at 12 month follow-up. Cytokines were assessed at both occasions. Cross-sectional--multivariate linear regression analysis (n=110) demonstrated that cognitive/affective depressive symptoms were independently associated with increased levels of sTNFR2 (β=0.20, p<0.05) and IL-1ra (β=0.28, p<0.01). Somatic/affective depressive symptoms were independently related to sTNFR2 (β=0.21, p<0.05). Prospective--(n=125) the level of cognitive/affective depressive symptoms at inclusion was prospectively associated with increased levels of sTNFR1 and sTNFR2 (β=0.21 and 0.25 resp. p<0.05), independent of covariates. Change in somatic/affective depressive symptoms over the 12 month period was associated with sTNFR2 (β=0.30, p=0.008). At symptom level, core depressive cognitions such as hopelessness and guilt drove the relation between the sTNF receptors and the cognitive/affective component, while having sleep problems was the most important associate of the somatic/affective dimension. CONCLUSIONS Baseline cognitive/affective depressive symptoms were prospectively associated with sTNFR1 and sTNFR2 in HF patients, while change in somatic/affective depressive symptoms was associated with sTNFR2, independent from clinical and demographic covariates. Further studies are warranted to replicate these findings and to examine the association between depression dimensions, inflammation and prognosis in HF.

Psychological Determinants of Heart Failure Self-Care: Systematic Review and Meta-Analysis.

Objective Psychological distress has been associated with poor outcomes in patients with chronic heart failure (HF), which is assumed to be partly due to poor HF self-care behavior. This systematic review and meta-analysis describes the current evidence concerning psychological determinants of self-care in patients with chronic HF. Methods Eligible studies were systematically identified by searching electronic databases PubMed, PsycINFO, and the Conference Proceedings Citation Index (Web of Science) for relevant literature (1980–October 17, 2014). Study quality was assessed according to the level of risk of bias. Quantitative data were pooled using random-effects models. Results Sixty-five studies were identified for inclusion that varied considerably with respect to sample and study characteristics. Risk of bias was high in the reviewed studies and most problematic with regard to selection bias (67%). Depression (r = −0.19, p < .001), self-efficacy (r = 0.37, p < .001), and mental well-being (r = 0.14, p = .030) were significantly associated with self-reported self-care. Anxiety was not significantly associated with either self-reported (r = −0.18, p = .24) or objective self-care (r = −0.04, p = .79), neither was depression associated with objectively measured medication adherence (r = −0.05, p = .44). Conclusions Psychological factors (depression, self-efficacy, and mental well-being) were associated with specific self-care facets in patients with chronic HF. These associations were predominantly observed with self-reported indices of self-care and not objective indices. Methodological heterogeneity and limitations preclude definite conclusions about the association between psychological factors and self-care and should be addressed in future research.