|Year : 2022 | Volume
| Issue : 4 | Page : 201-207
Psychological distress in patients with coronary artery disease during the COVID-19 pandemic and its association with coping mechanisms
Prerna Maheshwari1, KP Lakshmi1, Bindu Menon1, Rajesh Thachathodiyl2, Renjitha Bhaskaran3, Subhash Chandra4
1 Department of Psychiatry, Amrita Institute of Medical Sciences, Kochi, Kerala, India
2 Department of Cardiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
3 Department of Biostatistics, Amrita Institute of Medical Sciences, Kochi, Kerala, India
4 Department of General Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
|Date of Submission||21-Jun-2022|
|Date of Acceptance||02-Oct-2022|
|Date of Web Publication||17-Nov-2022|
Dr. K P Lakshmi
Department of Psychiatry, Amrita Institute of Medical Sciences, Kochi - 682 041, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background and Objectives: Coronary artery disease (CAD) has been associated with increased stress both etiologically and as a consequence. The current pandemic of COVID-19 infection has impacted the personal, social, and occupational spheres of people's lives and has negatively affected mental health. People with existing chronic medical illnesses may be more vulnerable to the stressful effects of the ongoing pandemic.
This study was conducted on patients with CAD during the COVID-19 pandemic to estimate the prevalence of psychological distress, the factors associated with distress, and their coping mechanisms.
Materials and Methods: A cross-sectional study was conducted at a tertiary care teaching hospital in Kerala in the cardiology department. After informed consent was obtained from the patients with CAD, sociodemographic details were collected, Kessler Psychological Distress Scale (K-10 scale) was administered to assess psychological distress and the Brief COPE scale was administered to assess their coping mechanisms.
Results: Among 50 patients who participated, the prevalence of psychological distress was 50%. The factors associated with distress were female gender, semiskilled occupation, incomplete COVID-19 vaccination status, exposure of family to COVID-19, experiencing financial difficulties, and experiencing difficulty acquiring medications prescribed for CAD. Religion and acceptance were the most common coping strategies applied by the patients and acceptance was found to be a better coping strategy than religion.
Conclusion: There is a high prevalence of psychological distress among patients with CAD during the pandemic, owing to the emotional, financial, and familial instability faced during the pandemic.
Keywords: Coping, coronary artery disease, COVID-19, distress
|How to cite this article:|
Maheshwari P, Lakshmi K P, Menon B, Thachathodiyl R, Bhaskaran R, Chandra S. Psychological distress in patients with coronary artery disease during the COVID-19 pandemic and its association with coping mechanisms. Heart Views 2022;23:201-7
|How to cite this URL:|
Maheshwari P, Lakshmi K P, Menon B, Thachathodiyl R, Bhaskaran R, Chandra S. Psychological distress in patients with coronary artery disease during the COVID-19 pandemic and its association with coping mechanisms. Heart Views [serial online] 2022 [cited 2022 Nov 29];23:201-7. Available from: https://www.heartviews.org/text.asp?2022/23/4/201/361401
| Introduction|| |
The current pandemic of COVID-19 infection has impacted the personal, social, and occupational spheres of people's lives and has negatively affected mental health. People with existing chronic medical illnesses may be more vulnerable to the stressful effects of the ongoing pandemic.
Coronary artery disease (CAD) has been associated with increased stress both etiologically and as a consequence. In a prospective cohort study assessing 662 patients with stable CAD, higher psychological distress was associated with a higher risk of further cardiovascular disease with 1.44 times adjusted hazard of cardiovascular disease events.
Psychosocial risk factors such as depression, stress, and socioeconomic disadvantages are associated with increased morbidity and mortality from CAD in older patients and daily life events trigger myocardial ischemia in CAD patients. Patients with CAD are particularly susceptible to developing stress in the current situation of emotional, financial, and familial instability as a result of the ongoing COVID-19 pandemic, which may also affect their coping strategies.
Previous research has documented that smoking, reduced physical activity, poor dietary habits, alcohol consumption, C-reactive protein, and hypertension are some of the factors associated with psychological distress in CAD patients.
Our study aimed to assess the distribution of psychosocial distress in patients with CAD during the COVID pandemic and its association with their coping mechanisms.
| Materials and Methods|| |
The study was a cross-sectional study conducted in the Cardiology department, an outpatient section of a tertiary care teaching hospital in September 2021. It was approved by the Scientific Research and Ethics Committee of the institute. Patients who had been diagnosed with CAD with documented evidence by angiography or history of CABG, aged 18 years or older were selected for the study.
Those who were suffering from an acute/evolving or recent MI, those with a positive history of COVID-19 infection, and those with a known history of psychiatric disorder were excluded from the study. Written informed consent for the study was obtained from the patients in the study. Sociodemographic details and information regarding the COVID-19 pandemic-related factors such as vaccination status, exposure status, financial status, and accessibility to health care and medications were collected.
The percentage prevalence rate of psychological distress in CAD patients was computed with a 95% confidence limit. To test the statistical significance of the association of categorical factors and psychological distress and coping mechanisms used with psychological distress, the Chi-square test was used. P < 0.05 was considered statistically significant. Multivariate regression analysis was used to analyze the relationship between a single-dependent variable and several independent variables.
Psychological distress was assessed using the Kessler Psychological Distress Scale (K-10). This scale comprises 10 questions questioning the participant's emotional state in the past 4 weeks each to be answered with a Likert scale ranging from 1 (none of the time) to 5 (all of the time). The response is then graded as the likelihood of having a mental disorder/psychological distress, with a cutoff score of 19, above which the response of further stratified as mild, moderate, and severe distress.
Following that, coping mechanisms were assessed using the Brief COPE scale which consists of 28 items that are rated on a four-point Likert scale, ranging from 1 = I usually don't do this at all and to 4 = I usually do this a lot. Scales of coping strategies include: “(1) Self-distraction (employing strategies to divert concentration away from the condition); (2) Active coping (exerting effort to remove or circumvent the stressor); (3) Denial (attempt to reject the reality of the stressful event and consider how the stressor might be confronted); (4) Substance use (use of alcohol and other drugs as a means of disengaging from the stressor); (5) Use of emotional and instrumental support (obtaining sympathy or emotional support from someone and seeking assistance, information, or advice about what to do); (6) Behavioral disengagement (giving up or withdrawing effort and the attempt to attain the goal with which the stressor is interfering); (7) Venting (use of a concomitant tendency to ventilate or discharge those feelings); (8) Positive reframing (changing one's view of a stressful situation to see it in a more positive light); (9) Planning (planning one's active coping efforts); (10) humor (making jokes about the stressor); (11) Acceptance (accepting the fact that the stressful event has occurred and is real); (12) Religion (engaging in religious activities), and (13) Self-blame (accounting him/herself culpable of the situation). These 13 coping strategies have been further classified in studies into problem-focused coping strategies (active coping, instrumental support, positive reframing, and planning), emotion-focused coping strategies (use of emotional support, venting, humor, acceptance, religion, and self-blame), and avoidant strategies (self-distraction, denial, substance use, and behavioral disengagement).”
A pilot study was conducted with 15 participants with CAD. Eleven participants were identified to have psychological distress according to the K-10 scale. The formula for calculating sample size: 4pq/d2, where P stands for prevalence, q is 100-p, and d stands for relative precision, was applied. The minimum sample size then was calculated to be 37 with a 95% confidence interval and 20% allowable error. Convenient sampling was used in the study.
This study was completed in 1 month with a sample size of 50 participants. SPSS software was developed by IBM-International Business Machines Corporation (IBM) is an American multinational technology corporation headquartered in Armonk, New York, with operations in over 171 countries.
| Results|| |
Fifty patients with CAD were analyzed for the study. The percentage prevalence rate of psychological distress in CAD patients was computed with a 95% confidence limit. To test the statistical significance of the association of categorical factors and psychological distress and coping mechanisms used with psychological distress, the Chi-square test was used. P < 0.05 was considered statistically significant. Multivariate regression analysis was used to analyze the relationship between a single dependent variable and several independent variables.
The mean age was found to be 60 years, as shown in [Table 1].
As shown in [Figure 1], 25 (50%) patients had psychosocial distress. Three (6%) patients had mild psychological distress, 16 (32%) had moderate psychological distress, and 6 (12%) had severe psychological distress.
As shown in [Table 2], there was a statistically significant association between psychological distress in CAD patients with their sex (P = 0.002) and occupation (P = 0.022) and there was no statistically significant association with age, education, residence, family type, marital status, family history of CAD, and family history of psychiatric disorders.
|Table 2: Association of sociodemographic variables with psychological distress|
Click here to view
As shown in [Table 3], COVID-19 pandemic-related variables were also assessed and it was found that there was a statistically significant association between psychological distress in CAD patients and vaccination status (P = 0.012), exposure of family to COVID-19 virus (P = 0.021), financial difficulties (P = 0.001), and difficulty acquiring medications (P = 0.005), and consulting doctors (P = 0.042). Seventy-two percent of the patients who felt that they needed psychiatric help during the pandemic were found to have psychological distress and this was statistically significant (P = 0.002).
|Table 3: Association of COVID-19 pandemic-related variables with psychological distress|
Click here to view
Multivariate regression analysis showed that there was a significant association between female gender and psychological distress, with a P = 0.005 and an odds ratio of 7.94.
As shown in [Figure 2], it was seen that religion (48%, n = 24), followed by acceptance (28%, n = 14) were the most common coping mechanisms used by CAD patients during the COVID-19 pandemic.
|Figure 2: Distribution of different types of coping mechanisms in CAD patients. CAD: Coronary artery disease|
Click here to view
As shown in [Table 4], there was a statistically significant association between using acceptance and religion as a coping mechanism for psychological distress (P = 0.027 and 0.011, respectively).
| Discussion|| |
The research study was done to assess the psychological distress faced by patients with CAD and their coping mechanisms during the COVID pandemic. The study was done with 50 patients, who attended the cardiology department outpatient services. The study comprised 32% females and 68% males.
The first objective was to find out the prevalence of CAD patients with psychological distress. Fifty percent of the patients with CAD were found to have psychological distress. Twelve percent had severe distress, 32% had moderate distress, and 6% had mild distress. This finding is higher than the study conducted by Stewart et al. (3.5% prevalence of persistent distress and 7.7% prevalence of mild distress) and differs from that of Bhagyalakshmi et al. Among 100 CAD patients in India in 2012, wherein none had increased stress and 43% had moderate stress., The difference could be explained by the presence of the COVID pandemic in the past year, and its variables that contributed to the psychological distress as explained further in our second objective.
The second objective was to find the association between sociodemographic factors, COVID pandemic-related variables, and psychological distress in CAD patients. It was found that psychological distress was more common in those with single-dose vaccination status than in those who were fully vaccinated (78% vs. 38%, P = 0.012). Patients whose families had been exposed to a confirmed case of COVID-19 had more prevailing distress (70%, P = 0.021). Patients who reported financial difficulty during the COVID pandemic experienced distress more commonly (66%, P = −0.001).
Furthermore, psychological distress was more common in patients who had difficulty acquiring medications during the COVID pandemic for their medical diagnoses (80%, P = 0.005).
Seventy-two percent of the patients who felt that they needed psychiatric help during the pandemic were found to have psychological distress and this was statistically significant (P = 0.002). The anxiety regarding the coronavirus, incomplete vaccination status, worries regarding the worsening of CAD during the pandemic, and financial issues, maybe some of the reasons which made them think of getting psychiatric help.
The above findings confirm the role of stressors arising due to the pandemic situation in contributing to increased psychological distress in patients with CAD.
Regarding sociodemographic variables, psychological distress was more common in females than in males (81% vs. 35%, P = 0.002). Psychological distress was also more prevalent (P = 0.02) in those with semiskilled occupational status (81%) and those who were unemployed (60%) than those who were professionals (34%). These findings were concordant with those by Bhagyalaskhmi et al. who also found a significant association of stress with gender and occupation. Pimple et al. also showed a sex-based interaction in CAD patients with psychological distress and concluded that in women, higher psychological distress was associated with a higher incidence of cardiovascular disease events. The increased burden of household responsibilities that women continue to carry compared to men, lower income, and lack of social support may be some of the factors which make females more distressed compared to males.
The third objective was to assess the coping mechanisms in patients with CAD. It was found that the most common coping mechanism was religion (48%), followed by acceptance (28%), both of which can be classified under emotion-focused strategies. Previous studies assessing coping mechanisms in patients with CAD reveal different study methodologies. Bhagyalakshmi et al. revealed that 91% of patients showed moderate coping. Svensson et al. showed that the premorbid use of an approach-oriented coping strategy was inversely associated with the incidence of stroke (hazard ratio [HR] = 0.85; 95% confidence interval [CI], 0.73–1.00) and CVD mortality (HR = 0.74; 95% CI, 0.55–0.99). Zare et al. used the same coping scale and showed that concerning coping mechanisms, the use of all coping mechanisms increased except behavioral disengagement, emotional support, instrumental support, and religion which decreased significantly postpercutaneous transluminal coronary angioplasty.
Previous studies assessing coping mechanisms also reveal different sample populations. Our finding is in line with Taheri-Kharameh and Elyasi in Iranian hemodialysis patients who also showed the maximum use of emotion-focused coping strategies. Our finding differs from that of Ismail et al. who showed that during the COVID pandemic, 71% of the medical interns used problem-focused strategies as their main coping mechanism. This difference could be explained by the difference in the mean ages between both the studies and the sample population (medical interns vs. CAD patients).
The final objective was to assess coping mechanisms in CAD patients with their psychological distress. It was found that 70% of those with religion as their coping mechanism had psychological distress as compared to 21% of those who used acceptance. Acceptance yielded as a better coping mechanism than religion for patients with CAD. Previous studies have had different aims and methodologies concerning the association of coping mechanisms with stress in different populations. Our findings are in line with Garcia et al. who showed that acceptance was more negatively correlated with stress (r = −0.23) than religion (r = 0.17) in the Chilean general population. Our study also found that the lowest prevalence of psychological distress with statistical significance was found in patients who employed coping mechanisms of acceptance (21.4%, P = 0.027). This finding differs from that of Kausar and Powell conducted on caregivers of neurological disorders that concluded that carers who were more dependent on emotion-focused coping styles (such as acceptance) reported greater distress as compared to those who depended more on problem-focused strategies. This difference could be explained in the difference between the sample population of the two studies, carers of the diseased versus the diseased themselves. However, Morimoto and Shimada concluded in their study on the Japanese population that it is the motivation for using a chosen coping strategy, whether for task-related stressors or interpersonal stressors that can affect the effectiveness of coping strategies, independent of the selective use of coping strategies made in consideration of sociocultural beliefs.
The strengths of our study lie in the assessment of psychological distress concerning issues related to the COVID-19 pandemic and the assessment of individual styles of coping mechanisms with psychological distress. The limitations of our study revolve around its small sample size and lack of correlation between the prepandemic and postpandemic status of distress in the study population. This study is a cross-sectional observational study, and the exact cause of the distress cannot be determined. More studies in this direction can determine the reasons for their distress and can address this bidirectional health issue in a better way.
| Conclusion|| |
In conclusion, regular assessment and identification of distressed patients in the cardiology departments and psychological interventions aimed at acceptance could prove to be useful in reducing psychological distress in patients with CAD.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Al-Rahimi JS, Nass NM, Hassoubah SA, Wazqar DY, Alamoudi SA. Levels and predictors of fear and health anxiety during the current outbreak of COVID-19 in immunocompromised and chronic disease patients in Saudi Arabia: A cross-sectional correlational study. PLoS One 2021;16:e0250554.
Pimple P, Lima BB, Hammadah M, Wilmot K, Ramadan R, Levantsevych O, et al
. Psychological distress and subsequent cardiovascular events in individuals with coronary artery disease. J Am Heart Assoc 2019;8:e011866.
Hamer M, Molloy GJ, Stamatakis E. Psychological distress as a risk factor for cardiovascular events: Pathophysiological and behavioral mechanisms. J Am Coll Cardiol 2008;52:2156-62.
Kessler RC, Barker PR, Colpe LJ, Epstein JF, Gfroerer JC, Hiripi E, et al
. Screening for serious mental illness in the general population. Arch Gen Psychiatry 2003;60:184-9.
Carver CS. You want to measure coping but your protocol's too long: Consider the brief cope. Int J Behav Med 1997;4:92-100.
Stewart RA, Colquhoun DM, Marschner SL, Kirby AC, Simes J, Nestel PJ, et al
. Persistent psychological distress and mortality in patients with stable coronary artery disease. Heart 2017;103:1860-6.
Bhagyalakshmi M, Ramana BV, Suresh H, Raj JM. Assessment of the level of stress and coping strategies among patients with coronary artery disease. J Sci Soc 20121;39:136.
Svensson T, Inoue M, Sawada N, Yamagishi K, Charvat H, Saito I, et al
. Coping strategies and risk of cardiovascular disease incidence and mortality: The Japan public health center-based prospective study. Eur Heart J 2016;37:890-9.
Zare L, Hassankhani H, Doostkami H, Brien FO, Aghdam AM. Illness perception, treatment adherence and coping in persons with coronary artery disease undergoing angioplasty. Open J Nurs 2016;6:549-57.
Zamanian H, Poorolajal J, Taheri-Kharameh Z. Relationship between stress coping strategies, psychological distress, and quality of life among hemodialysis patients. Perspect Psychiatr Care 2018;54:410-415.
Ismail M, Lee KY, Sutrisno Tanjung A, Ahmad Jelani IA, Abdul Latiff R, Abdul Razak H, et al
. The prevalence of psychological distress and its association with coping strategies among medical interns in Malaysia: A national-level cross-sectional study. Asia Pac Psychiatry 2020;13:e12417.
García FE, Barraza-Peña CG, Wlodarczyk A, Alvear-Carrasco M, Reyes-Reyes A. Psychometric properties of the brief-COPE for the evaluation of coping strategies in the Chilean population. Psicol Reflex Crit 2018;31:22.
Kausar R, Powell GE. Coping and psychological distress in carers of patients with neurological disorders. Asia Pacific Disabil Rehab J 1999;10:64-8.
Morimoto H, Shimada H. The relationship between psychological distress and coping strategies: Their perceived acceptability within a socio-cultural context of employment, and the motivation behind their choices. Int J Stress Manag 2015;22:159-82.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]