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.

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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).

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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.

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Purpose

• To examine the relationship between

depression, anxiety, anger, and biomarker (B-

type natriuretic peptide, BNP) in Taiwanese

people with heart failure.

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Methods

7 7

Research Design

• Cross-sectional, descriptive, correlational research design

• Individually interviewed by an experienced nurse

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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

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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)

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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)

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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

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Data Analysis

• Descriptive data

• Inferential analyses

– Bivariate analyses

– Multiple regression with forward method for

identifying predictor of depression

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Results

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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)

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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)

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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)

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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)

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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

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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

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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.

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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).

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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.

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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.

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Jenner, R. C., Strodl, E. S., & Schweitzer, R. D. (2009). Anger and depression predict

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failure. Critical Care Nursing Quarterly, 26(1), 35-39.

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Thanks for your attention!