Psychological factors and outcomes of coronary surgery

Zinchenko, Yu. P. Lomonosov Moscow State University, Moscow, Russia Federal Scientific Center of Psychological and Multidisciplinary Research, Moscow, Russia

Bokeria, L.A. Bakoulev Center for Cardiovascular Surgery of the Russian Academy of Medical Science, Moscow, Russia

Kiseleva, M.G. I.M. Sechenov First Moscow State Medical University, Moscow, Russia

Introduction

Recent studies provide clear andconvincing evidence that such psychological factors as depression, anxiety,personality factors, social isolation, and chronic life stress contribute greatlyto the pathogenesis and expression of coronary artery disease (CAD) (Rosancki,Blumenthal, Kaplan, 1999, Sokolova, Nikolaeva, 1995). The pathophysiologicalmechanism by which these factors promote CAD includes 1) behavioral and 2)direct pathophysiological effects (Rosancki, Blumenthal, Kaplan, 1999). Sincethere is plenty of information on this part of the problem, we will turn ourattention straight to the situation of open heart surgery.

By and large, there are severaltreatment choices to consider in a patient with significant CAD disease:medication, bypass surgery, angioplasty, or combination of these (Laurence,2002). If the treatment were simple and without potentially adverse effects,the decision on treatment would be simple. But the reality is more complicated.Bypass surgery is by far the most traumatic, as it involves surgery andanesthesia, a long recovery period, and potential complications (Bokeria, 2010,Laurence, 2002). It can fail, prove ineffective, or even result in death. Uncertaintyis the hardest part of experiencing illness.

Although the cardiologist decides onthe best treatment in every situation, the patient takes his share ofresponsibility in agreeing to the surgery. Even when the best treatment choiceis obvious for the physician, it can be unacceptable to the patient, who fearshospitalization, pain, or has a friend whose outcome from similar treatment waspoor. In such a situation, the biopsychosocial view of illness and the role ofthe psychologist who can help identify the problem is very important.

The situation of open heart surgeryconsists of a patient’s subjective perception of what medics do and say, aprognosis of the surgery outcome, and many other factors which take on asecondary psychosemantic meaning. Inadequate implicit concepts of forthcomingsurgery can produce respective somatic sensations and, on the contrary, realsomatic sensations can be wrongly identified by the patient (Thostov, 2002).Models of negative surgery outcomes can cause a negative placebo affect (noceboeffect). A nocebo effect is an ill effect caused by the suggestion or beliefthat something is harmful.

When a patient faces the necessity ofopen heart surgery (coronary artery by- pass for CAD patients) he finds himselfin a terrifying situation with an unknown outcome. The threat for his bodyimage, life risk, pain, and helplessness stir up many feelings.

Recent studies show that depressionand anxiety symptoms common for CAD patients worsen the outcomes of cardiacsurgery (Allen, Becker, 1990; Appels, Mulder, 1988; Atrinian, 1991; Berron,1986; Blumental, 1988, 2003; Connerney, 2010; Contrada, 2008; Cserep, 2010,Gallagher, 2007; Hoyer, 2008; Pigney-Demaria, 2003; Rozancki, 1999;Rymaszewska, 2003; Viars, 2009, Zaitsev, 1997). In such a situation,psychological support is very necessary.

Patients stay in hospital for only afew days before the surgery, so there is not much time for deep psychologicalintervention. This means that identifying the main targets for psychologicalhelp is very important.

We suggest that the negative attitudeof patients towards forthcoming open heart surgery is associated with theadverse postsurgical period. The type of attitude towards forthcoming openheart surgery determines illness behavior, compliance, and coping strategies.Assistance in modeling adequate expectations from surgical treatment should beone of the targets of psychological maintenance in the perioperative period.

Method

120 patients (44% female) with CAD,scheduled for open heart surgery, volunteered for the study (the study group).The mean age was 48±13. NYHA class — II-III.

The control group consisted of 35people (45% females) without somatic and mental disorders.

Patients from the study group wereinterviewed and asked to fill in questionnaires the day before heart surgery,and one week afterwards.

The Center for Epidemiologic StudiesDepression Scale (CES-D) was used to measure depression rate; State-TraitAnxiety Inventory (STAI) was used for anxiety rate.

The attitude towards forthcoming heartsurgery was picked up after the analysis of data received from a speciallydesigned clinical interview, the Semantic differential scale, theDembo-Rubinshtein self-rating method (scales: health, happiness, lifesatisfaction, emotional comfort, self confidence, treatment satisfaction), andthe Etkind Color Test of attitudes (50 words describing the situation of openheart surgery and different fillings).

The study of the patient’s history wasused to estimate the outcome (number of postoperative complications (2), andcalculate number of days spent in the hospital.

Weused standard statistics methods (t-test, Mann-Whitney U, Spearman’s rho,Pearson Chi-square) for data analysis.

The research took place in theDepartment of Surgical Treatment for Interactive Pathology at the BakoulevCenter for Cardiovascular Surgery of the Russian Academy of Medical Science,Moscow, Russia.

Results

The level of depression, state, andtrait anxiety was significantly higher in the study group than in the controlgroup (p<0,05). The level of self-rated emotional comfort was significantlylower in the study group.

In the study group, 7.1% of patientshad a high level (more then 25 points by CES-D) and 27% a heightened level(more then 19 points by CES-D) of depression symptomatology.

In the study group, 54.8% of patientshad high level (more then 46 points by STAI) and 27% a heightened level (morethen 31 points by STAI) of state anxiety.

Correlation analysis of therelationship between depression, state anxiety levels, and the number ofpostsurgical complications determined a significant positive correlation(p=0,000). The higher level of depression correlated with more complications,and the same correlation was true for the relationship between the stateanxiety level and the number of postsurgical complications.

Correlation analysis of therelationship between depression, state anxiety levels and the number of daysspent in the hospital determined a significant positive correlation (p=0,000).The higher level of depression correlated with more days spent in the hospital,and the same correlation was true for the relationship between the stateanxiety level and the number of days spent in the hospital.

A significant negative correlation wasdetected between the level of self-rated emotional comfort and the number ofpostsurgical complications. A significant negative correlation was detectedbetween the level of self-rated emotional comfort and the number of days spentin the hospital after surgery. The lower mark the patients gave to theiremotional comfort before surgery, the more complications they had aftersurgery, and the more days they spent in the hospital after surgery.

Analysis of social and demographicdata determined the following. Age and educational level did not significantlyinfluence the levels of depression, state and trait anxiety, self-rated lifesatisfaction, happiness, or emotional comfort (p<0,05).

On the contrary, the absence of a constantjob has a significant influence on the levels of depression, trait anxiety,self-rated life satisfaction, happiness, and emotional comfort. Thus,non-working patients had significantly higher levels of depression, traitanxiety, and significantly lower levels of self-rated life satisfaction,happiness, and emotional comfort (р<0,05) than working patients.

Following the analysis of datareceived from the Semantic differential scale, Dembo-Rubinshtein self-ratingmethod, and the Et-kind Color Test of attitudes, we have picked out four typesof attitude towards forthcoming open heart surgery: 1) pessimistic (no beliefin recovery, surgery is threatening, damaging), 2) indifferent (no belief inrecovery, surgery will not change anything),3) optimistic, but not realistic (exaggerated expectations, belief infull recovery), 4) optimistic — realistic (adequate expectations, belief inimprovement).

In the study group 15% hadpessimistic, 20% had indifferent, 35 % had optimistic but not realistic, and30% had optimistic-realistic attitudes towards forthcoming open heart surgery.

Sex distribution does notsignificantly differ in the dedicated groups, except that the group withindifferent patients where 96% were male.

The educational level does notsignificantly differ in the dedicated groups, except the group with indifferentpatients, where 78,6 % of patients did not have a higher education.

20.8% of pessimistic patients hadconstant jobs, 25% of indifferent patients had constant jobs, 65.7% ofoptimistic but not realistic patients had constant jobs, and 52,9% ofoptimistic-realistic patients had constant jobs.

Age, marriage status, and length ofillness do not significantly differ in the dedicated groups.

Patients with a pessimistic attitudeconcentrate on the negative aspects of forthcoming open heart surgery. Theyhave a high level of fear before the surgery, especially a fear of death. Theiremotions vary from fright and despair to anger and hostility. They are prone tospeaking about the forthcoming treatment in a binary manner. They feel a totalloss of control over the situation. Such patients have many somatic complaints,and problems in coping with pain.

Patients with pessimistic attitudeshave the highest rates of depression (Table 1), and state and trait anxiety.They have high emotional discomfort during the perioperative period. Theprevailing associations with “surgery” are: despair, misfortune, and death (TheEtkind Color Test of attitudes).

Patients with indifferent attitudesthink there is no sense in the forthcoming open heart surgery. They demonstratethat they do not control their lives, and that nothing depends on them. Theyusually say that their illness controls their life.

Such patients do not speak much, havea poor variety of emotions, and are not motivated for the treatment. They feelcomfortable in hospital, and prefer to stay there as long as possible.

Indifferent patients are very close intheir rates of depression to pessimistic patients, but do not feel as muchemotional discomfort as pessimistic patients do. The prevailing associationswith “surgery” are guilt and sorrow (The Et-kind Color Test of attitudes).

Patients with optimistic but notrealistic attitudes endow the situation of the forthcoming open heart surgerywith unrealistic characteristics. Surgeons seem to them omnipotent and able tosolve all the patient’s problems. They expect total recovery and do not focustheir attention on probable complications. They deny any fear or anxiety beforethe surgery.

During the first days after surgerythey appear depressed and confused because their expectations were provedwrong. Nevertheless, most of them return to their good mood very soon.

Table 1. Emotional status (ES) and different types of attitude towardsforthcoming heart surgery (ATHS).

ES	Types of ATHS	Pessimistic (р1)	Optimistic not realistic (р2)	Indifferent (р3)	Optimistic Realistic (р4)	T-test Syg.
Depression rate before surgery		19.4±8.9	7.4±3.1	16.8±5.3	9.3±3.6	р1-р2=0.000  р1-р4=0.000 p2-p3=0.000 p2-p4=0.021
Depression rate after surgery		22.3±8.4	10.3±4.9	21.0±5.8	9.9±3.4	р1-р2=0.000 p2-p3=0.000 p1-p4=0.000 р3-р4=0.000
Trait anxiety rate		52.7±4.9	41.8±7.6	47.0±4.2	44.9±6.3	p1-2=0.000 p1-3=0.000 p1-4=0.000 p2-3=0.002
State anxiety rait		50.9±5.1	42.5±7.8	45.6±5.7	43.9±6.3	p1-2=0.000 p1-3=0.001 p1-4=0.000
Self-rated emotional comfort before surgery		34.8±21.3	74.2±18.3	43.2±22.1	56.2±11.8	p1-2=0.000 р1-4=0.000 p2-3=0.000 p2-4=0.000 p3-4=0.008
Self-rated emotional comfort after surgery		48.9±21.0	70.9±17.3	43.6±13.8	78.7±13.4	р1-2=0.000 р1-4=0.012 р2-3=0.000 p3-4=0.000

The prevailing associations with“surgery” are: care, happiness, love (The Et-kind Color Test of attitudes).

Optimistic but not realistic patientshave the lowest rates of depression (Table 1), and state and trait anxiety.They have the lowest emotional discomfort during the perioperative period. Theydeclare that they are really happy to be in hospital. After surgery they havethe biggest rise in depression rates, though it is still low.

Patients with optimistic-realisticattitudes towards forthcoming heart surgery admit their worries, and can bearreasonable fear before open heart surgery.

They understand that the surgery is anecessity, they share responsibility for choosing this form of treatment, andunderstand what they can do to help the situation.

They plan their lives according to thestate of their health. They have a variety of interests and hobbies in theirlives.

Optimistic-realistic patients have lowrates of depression (Table 1), and state and trait anxiety. They have emotionaldiscomfort coincidental with the situation.

The prevailing associations with“surgery” are: chance, worry, pride (The Et- kind Color Test of attitudes).

So patients with pessimistic and indifferentattitudes towards forthcoming heart surgery have much more emotional discomfortduring the perioperative period. They also have an adverse postoperative period(complicated and long), and are not satisfied with the treatment (Table 2).

Patients with pessimistic attitudestowards forthcoming heart surgery had 1.68 ±0.79 complications, and stayed inhospital for 23.71±10.0 days after surgery. They were only 58.72±24.11%satisfied with the treatment.

Patients with indifferent attitudestowards forthcoming heart surgery had 1.77±0.81 complications, and stayed inhospital for 18.53±5.3 days after surgery. They were only 62.11±22.28%satisfied with the treatment.

Тable 2. The attitude towards forthcoming heart surgery (ATHS) and the surgeryoutcomes.

ATHS	Number of postsurgical Complications	Number of days stayed in hospital after surgery	Satisfaction with the treatment
Pessimistic	1.68±0.79	23.71±10.0	58.72±24.11
Indifferent	1.77±0.81	18.53±5.3	62.11±22.28
Optimistic not Realistic	0.91±0.58	16.01±6.9	84.82±17.71
Optimistic Realistic	0.2±0.5	10.0±0.1	75.3±14.0

Patients with pessimistic attitudestowards forthcoming heart surgery had 0.91±0.58 complications and stayed inhospital for 16.01±6.9 days after surgery. They were 84.82±17.71% satisfiedwith the treatment.

Patients with pessimistic attitudestowards forthcoming heart surgery had 0.2 ±0.5 complications and stayed inhospital for 10.0±0.1 days after surgery. They were only 75.3±14.0% satisfiedwith the treatment.

So patients with optimistic notrealistic attitudes towards forthcoming heart surgery have few complications,but stay for a long period in hospital after surgery.

Patients with optimistic-realisticattitudes towards forthcoming heart surgery have almost no complications, andthe shortest stay in hospital.

Discussion

The situation of open heart surgery isvery stressful for both body and mind. Patients experience uncertainty, loss ofcontrol, life risk, and great pain. In this situation each patient forms aunique attitude towards the forthcoming heart surgery. We have ascertained thatthe type of attitude is associated with the outcomes of surgery.

Patients with pessimistic andindifferent attitudes do not believe that surgery can help them. They fixate oncomplications and negative aspects of the surgery. Such patients have a longand complicated postoperative period.

Optimistic-realistic patients,although their physical conditions do not differ from those of pessimistic andindifferent patients, have less complications and a shorter stay in hospital.This phenomenon can be explained by the placebo (nocebo) effect.

Optimistic but not realistic patientsstay in hospital longer then optimistic-realistic patients and need more timeto rehabilitate. This probably occurs because they waste energy keeping theirworries and fears out of conscious reach and appearing to be carefree.

This study shows that psychologicalsupport of open heart surgery patients should include help in forming anappropriate, optimistic attitude towards forthcoming open heart surgery.Knowing the type of the attitude towards forthcoming heart surgery can help apsychologist to identify a clear target.

We encourage further studies todetermine whether interventions that target inadequate attitudes towards forthcomingopen heart surgery can help to reduce the risk of postsurgical complicationsand long stays in hospital.

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