1 1
Depression, Anxiety, Anger, and
Biomarker in Taiwanese People
with Heart Failure
Hsing-Mei Chen, PhD, RN, Shyh-Jnog Wu, PhD
Chee-Siong Lee, MD, Hsueh-Wei Yen, MD
Wen-Hsien Lee, MD, Hui- Chin Chien, MSN, RN
Acknowledgement
• The study was supported by grants from the
Kaohsiung Medical University Research
Foundation and the Kaohsiung Medical
University Hospital.
2
3 3
Introduction-1
• Patients with anxiety and depression have more
negative perceptions about heart failure (HF),
resulting in poor coping behaviors and reduced
quality of life (n=146) (Hallas, Wray, Andreou, & Banner, 2011).
• Anger significantly predicted length of stay in
hospital, whereas depression predicted the number of
readmissions to hospital after controlling for illness
severity (n=163) (Jenner, Strodl, & Schweitzer, 2009).
4
Introduction-2
• B-type natriuretic peptide (BNP) is released from
cardiac ventricles with left ventricular dysfunction
and elevated filling pressure (Saul & Shatzer, 2003).
• BNP promotes natriuresis, diuresis, and vasodilitation
and therefore neutralizes some of the harmful
consequences of the neuroendocrine effect in HF (Saul
& Shatzer, 2003).
• It is not known if BNP levels are correlated with
depression, anxiety, and anger in people with HF.
5 5
Purpose
• To examine the relationship between
depression, anxiety, anger, and biomarker (B-
type natriuretic peptide, BNP) in Taiwanese
people with heart failure.
6 6
Methods
7 7
Research Design
• Cross-sectional, descriptive, correlational research design
• Individually interviewed by an experienced nurse
8 8
Sample and Setting
• Nnonprobability sampling
• Outpatient department of a medical center located in
southern Taiwan.
• Inclusion Criteria
– A diagnosis of HF by physicians
– Age 20 or older
– Able to communicate either by speaking or writing
Mandarin
– Willing to participate in this study
9 9
Instruments-1
• Patient Outcome Questionnaire-9 (PHQ-9)
– depression
– Likert scale 0-3, total score 0-27, higher score
indicating higher depression
– Cronbach’s α0.73
• Beck Anxiety Inventory (BAI)
– 21 items, Likert scale 0-3, total score 0-63, higher
score indicating higher anxiety
– Cronbach’s α0.71
(Kroenke, Sptizer, Williams, 2001)
(Beck, Epstein, Brown, and Steer, 1988)
10 10
Instruments-2 • State-Trait Anger Expression Inventory-2 (STAXI-2)
– Trait Anger Scale
• Angry temperament (T-Ang/T) 4 items, angry
reaction (T-Ang/R) 6 items, Likert scale 1-4,
higher score indicating higher angry
temperament and reaction.
• Cronbach’s α0.71 for angry temperament, 0.80
for angry reaction, and 0.83 for the total subscale
(Spielberger, 2008)
11 11
Instruments-3
• Plasma BNP
– Examined by the Department of Laboratory of
KMUH
– Beckman Coulter UniCel® DxI 800 Immunoassay
System
– 3 ml of blood
– Normal range <100 pg/ml
12 12
Data Analysis
• Descriptive data
• Inferential analyses
– Bivariate analyses
– Multiple regression with forward method for
identifying predictor of depression
13 13
Results
14 14
Demographics of Participants-1 (n=67)
Variable Categories Frequency (%)
Gender Female
Male
29 (43.3)
38 (56.7)
Spouse Yes
No
48 (71.6)
19 (28.4)
Education Illiterate
Elementary school
High school and above
8 (11.9)
32 (47.7)
24 (40.4)
Employed status Yes
No
11 (16.4)
56 (83.6)
Perceived financial
Status
Poor
Enough
Rich
9 (13.4)
56 (83.6)
2 (3.0)
15 15
Mean SD Range
Age 65.38 12.49 36.65-87.92
Body mass index 27.02 5.11 17.33-41.91
Number of HF
medications 3.11 1.27 0-7
HF history (years) 2.89 3.73 0-20
Comorbidity (number) 3.82 1.91 0-9
Demographics of Participants-2 (n=67)
16 16
Disease Characteristics Variable Categories Frequency (%)
NYHA I
II
III
IV
3 (4.5)
38 (56.7)
24 (35.8)
2 (3.0)
Type of HF Systolic
Diastolic
Valvular
47 (70.1)
18 (26.9)
2 (3.0)
Use of ACEI No
Yes
62 (92.5)
5 (7.5)
Use of ARB No
Yes
33 (49.3)
34 (50.7)
Use of beta-
blocker
No
Yes
19 (28.4)
48 (71.6)
17 17
Disease Characteristics Variable Categories Frequency (%)
Use of diuretic No
Yes
30 (44.8)
37 (55.2)
Use of digitalis No
Yes
54 (80.6)
13 (19.4)
Use of vasodilator No
Yes
48 (71.6)
19 (28.4)
Use of alpha
adrenergic
antagonist
No
Yes
65 (97.0)
2 (3.0)
Use of CCB No
Yes
49 (73.1)
18 (26.9)
18 18
Scores for Major Variables
Mean SD Range
Angry trait 7.12 2.92 4-15
Angry reaction 7.88 3.55 5-20
Anger total score 15.00 5.73 9-35
BAI-Neurophysiologic 2.63 2.53 0-10
BAI-Subjective 1.28 1.83 0-10
BAI-Panic 1.30 1.72 0-8
BAI-Autonomic 0.82 1.24 0-5
BAI (anxiety) 6.03 5.02 0-21
PHQ-9 (depression) 5.49 4.58 0-24
BNP pg/ml 370.42 696.82 5-4901
19 19
Relationship Between Variables 2 3 4 5 6 7 8 9 10 BNP
1.NYHA .10 .21 .18 .37** -.12 .21 .30* .29* .18 -.01
2.STAXI-angT .56*** .86*** .31* .02 .27* .30* .33** .40*** .08
3.STAXI-angR .91*** .25* .18 .23 .30* .35** .34** -.08
4.STAXI .31* .12 .28* .34** .38** .42*** -.01
5.BAI-Neuro
physiologic .23 .30* .33** .77*** .56*** -.24
6.BAI-
Subjective .22 .24 .61*** .23 -.18
7.BAI-Panic .37*** .67*** .27* -.07
8.BAI-
Autonomic .63*** .37** -.08
9.BAI (anxiety) .55*** -.23
10.PHQ-9 -.23
20
Predictors of Depression
Model B Beta F R2
change R2
1 Constant 2.84 29.57***
BAI-Neurophysiologic 1.01 .56 31.3 31.3
2 Constant 0.03
19.38*** BAI-Neurophysiologic 0.86 .48
Anger total score 0.21 .27 6.4 37.7
Note. Analyzed by using multiple regression analysis with forward
method.
21 21
Conclusion-1
• Participants suffered from mild depression, anxiety,
and anger.
• BNP did not significantly correlate with any
psychological variables.
• NYHA functional class was significantly correlated
with BAI total (r= .29), neurophysiologic component
(r= .37), and autonomic subscale (r= .30).
22
Conclusion-2
• PHQ-9 was significantly correlated with all subscales
of STAXI (r= .34-.42) and BAI components (r= .27-
.56), except for the subjective subscale.
• STAXI was significantly correlated with all
components of BAI (r=.28-.38), except for the
neurophysiologic domain.
• BAI-neurophysiologic component and anger total
were two important predictors of depression
– dynamic interactions were existed among the
physiological variables.
23
Conclusion-3
• Besides of HF itself, there are other environmental or
genetic factors that determine susceptibility to co-
morbid depression and distress in this population (York, Hassan, & Sheps, 2009).
• Continuous monitoring of the symptoms is needed to
help patients early recognize and manage their
psychological problems.
24
Reference Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring
clinical anxiety: Psychometric properties. Journal of Consulting and Clinical
Psychology, 56(6), 893-897.
Hallas, C. N., Wray, J., Andreou, P., & Banner, N. R. (2011). Depression and perceptions
about heart failure predict quality of life in patients with advanced heart failure. Heart &
Lung, 40(2), 111-121. doi:10.1016/j.hrtlng.2009.12.008.
Jenner, R. C., Strodl, E. S., & Schweitzer, R. D. (2009). Anger and depression predict
hospital use among chronic heart failure patients. Australian Health Review, 33(4), 541-
548. doi:10.1071/AH090541
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9 validity of a brief
depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. doi:
10.1046/j.1525-1497.2001.016009606.x
Saul, L., & Shatzer, M. (2003). B-type natriuretic peptide testing for detection of heart
failure. Critical Care Nursing Quarterly, 26(1), 35-39.
Spielberger, C. D. (1988). Manual for the State-Trait Anger Expression Inventory (STAXI).
Odessa, FL: Psychological Assessment Resources.
York, K. M., Hassan, M., & Sheps, D. S. (2009). Psychobiology of depression/distress in
congestive heart failure. Heart Failure Reviews 14 (1), 35-50. doi:10.1007/s10741-008-
9091-0
25
Thanks for your attention!
Top Related