ICD
Psychological implications of ICD implantation in a New Zealand population
1 Department of Surgery and Anaesthesia, Wellington School of Medicine, Wellington, New Zealand; 2 Department of Cardiology, Capital and Coast District Health Board, Wellington, New Zealand; 3 Psychological Medicine, Capital and Coast District Health Board, Wellington, New Zealand
Manuscript submitted 27 June 2006. Accepted after revision 6 September 2006.
* Corresponding author. Tel: +64 4 385 5999. E-mail address: peter.larsen{at}otago.ac.nz
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Abstract |
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Aims Previous studies have raised concerns about high levels of anxiety and depression in implanted cardioverter-defibrillator patients, and suggested that adverse psychological outcomes have been related to delivered therapy, age, and gender. This study aimed to assess the prevalence of anxiety and depression and to analyse quality-of-life in a New Zealand patient group.
Methods and results We questioned 46 ICD and 49 pacemaker patients regarding device and treatment satisfaction, depression, anxiety (Hospital Anxiety and Depression Scale), and quality-of-life (SF 36). The prevalence of clinical depression and anxiety in the ICD group was 7 and 13%, respectively, and did not differ from the pacemaker group. ICD patients mean anxiety and depression scores did not differ from the pacemaker group, although more ICD patients had subclinical levels of anxiety. Quality-of-life scores were normal for all ICD patients with respect to both mental and physical component scores, and not different from the pacemaker group. Anxiety, depression, and quality-of-life scores were unrelated to time from implantation, delivered therapy, age, or gender. Overall, 93% of the ICD patients thought their device was worthwhile.
Conclusion We found a lower than expected level of anxiety and depression in ICD patients, and suggest that this may be due in part to the small team approach adopted locally in the follow-up of this patient group.
Key Words: Implantable cardioverter-defibrillators, Anxiety, Depression, Pacemakers, Quality-of-life
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Introduction |
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Implanted cardioverter-defibrillators (ICDs) have proven benefit for both primary and secondary prevention of sudden cardiac death.1
,2 However, an adverse consequence of ICD treatment, combined with the underlying condition necessitating this treatment, can be the emergence of feelings of anxiety, depression, anger, and fear.3 Hauer4 identified that psychiatric disorders may interfere seriously with acceptance of ICD therapy and with ICD follow-up. Clinically significant levels of depression and/or anxiety have been found in 30% of patients in ICD populations.5–7 Sears8–10 reported levels of clinical depression ranging from 9–15% and anxiety from 13–38%. Anxiety and depression are associated with fears of receiving a shock from the device, that the device will not work, that physical activity will trigger the device and fears of death.3 Duru11 found that ICD patients who had not experienced device therapy had similar measured levels of anxiety, depression, and quality-of-life to those who experienced device therapy and to pacemaker patients. However, those who had received ICD therapy reported greater anxiety and more lifestyle limitations.
There is some evidence that adverse psychological consequences associated with ICD implantation may be relatively short-term. During the year after ICD implantation, Carroll12 observed increasing mental and physical adjustment to the device. May13 reported a decline in the physical and psychosocial profile of ICD recipients in the first 6 months following implantation due to problems in emotional behaviour, alertness, and social interaction. However, at 1 year, patients psychosocial profiles had returned to pre-implant levels.
In addition to the negative effects on quality-of-life associated with anxiety and depression, Burg14 has suggested that there is an association between emotional dysfunction in ICD recipients and the occurrence of arrhythmic events. The possibility that screening and intervention, where appropriate, may prevent some of these arrhythmic events adds extra support to the concept of psychological assessment of ICD recipients.
Wellington Hospital began implanting ICDs in 2001, with a single clinician providing a tertiary referral service for the central region of New Zealand. These patients were not receiving any routine psychological assessment prior to implantation and did not have access to any ICD specific support groups. Given concerns that were raised regarding the potential adverse psychological consequences of ICD implantation, we studied the level of depression and anxiety in this patient population in order to assess the need for specific support or screening processes for these patients.
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Methods |
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Patient population
After gaining local Ethics Committee approval and informed consent, we surveyed 50 ICD patients and 50 pacemaker patients at Wellington Hospital, New Zealand. Follow-up of ICD and pacemaker patients involves a device parameter check with a technologist and a physician consultation, immediately after device implant, at 4 weeks, and thereafter every 6 months provided there are no complications. Patients receive device education delivered by technologists and a single cardiologist while in hospital or on the first follow-up appointment. A single cardiologist oversees the entire ICD and pacemaker population.
We randomly selected pacemaker and ICD follow-up clinics between July and November 2005 and invited all scheduled patients over the age of 18 attending the selected clinics to participate in this cross-sectional study. Patients completed their device check with the technologist, and prior to physician consultation, participated in a structured interview with an independent investigator. Three ICD patients declined to participate in the study due to time constraints, and one patient was excluded from the ICD group because of significant cognitive impairment. Three pacemaker patients were excluded because of poor comprehension of the English language. Following the survey, four patients within the ICD group and one patient from the pacemaker group were excluded because they were taking antidepressant medications for pre-existing depression.
Structured interview
We collected basic demographic information including age, gender, time since implant, delivered therapy, complications, co-morbidities, and beta-blocker use. Of the patients receiving shocks, they were further separated as appropriate, defined as ‘treatment of life threatening arrhythmia’ and inappropriate defined as ‘shock received due to atrial fibrillation or other supraventricular tachycardia or device malfunction. Patients who had lead or device problems leading to rehospitalization, and those with alerts on their devices were also defined as having a complication.
Specifically designed questions were adapted from Duru11 to evaluate understanding of device and condition, reported anxiety, satisfaction with ICD, and attitude to psychological support (Table 1). Anxiety and depression were quantified using the Hospital Anxiety and Depression scale (HADS), and quality-of-life was evaluated using SF-36 version 2. The HADS was used as a recognized and effective tool for measuring anxiety and depression in both in- and out-patient settings.15 Bambauer15 reported a sensitivity and specificity of 81 and 54%, respectively, for the depression scale and 81 and 40%, respectively, for the anxiety scale using a cut-off of seven or higher compared with a diagnosis based on DSMIV criteria. SF-36 consists of 36 questions relating to eight health concepts of physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health. These health concepts were selected on the basis that they are most affected by disease and illness. They are calculated into representative summary values of physical and mental functioning expressed in a 0–100 scale.16
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The patients were offered referral to a psychiatrist or psychologist from the consultation-liason psychiatry service if they gained a clinically significant score in the HADS or if requested. No patients requested a referral.
Statistical analysis
Data are given as mean (standard deviation) unless otherwise stated. Patient demographic variables and HADS scores were not normally distributed, and were analysed using the non-parametric tests: Kruskill–Wallis; Mann–Whitney; Spearman correlation; chi-square. SF-36 scores were normally distributed and were analysed using the parametric tests: ANOVA; unpaired t-test. Statistical analysis was performed using Statview 5 (SAS Institute, Cary, NC, USA).
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Results |
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Demographic data for the two groups are given in Table 2. The ICD and pacemaker groups were significantly different with respect to age, gender, time since implantation, number of co-morbidities, and use of beta-blockade. Mean anxiety and depression scores, and diagnostic distribution based upon HADS scores are given for the two groups in Tables 3 and 4. There were no significant differences between the two groups with respect to depression scores or classification, with 7% of patients classified as having clinically significant depression in the ICD group and 4% in the pacemaker group. There was no significant difference with respect to anxiety score between the two groups, although the diagnostic groupings were statistically different (P = 0.001, chi-squared), with a higher number of ICD patients having sub-clinical anxiety levels. The number of patients with clinical anxiety did not differ between the two groups. Clinically significant anxiety was observed in 13% of ICD patients and 12% of pacemaker patients.
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Physical and mental component scores from the SF-36 were not significantly different between the two groups (Table 3).
Fourteen of the ICD patients had received therapy from their device, with five of these experiencing a ‘storm’ defined as more than five shocks within a 24-h period. Seven patients experienced appropriate therapy and seven experienced inappropriate therapy. We observed no relationship between depression or anxiety scores, physical component or mental component, quality-of-life scores and device therapy, number of shocks delivered, or inappropriate therapy.
We examined correlation between HADS anxiety and depression scores and ‘SF-36v2’ physical component and mental component scores and age, gender, ICD therapy, complications, and beta-blocker use. Increased age in the pacemaker group was positively correlated with depression scores (P = 0.036, Rho = 0.28, Spearman) and inversely related to physical component quality-of-life scores (P = 0.001, Rho = –0.47, Spearman). In ICD patients, mental component quality-of-life scores were inversely related to time since implantation (P = 0.04, Rho = –0.30, Spearman). However, there was no relationship between time since implant and depression or anxiety.
The ICD specific questionnaires (Table 1) were analysed for differences in response between the ICD and pacemaker groups. ICD patients thought about their devices more frequently than pacemaker patients, with only three pacemaker patients reporting thinking about their device daily, compared with 16 ICD patients (Q2, P = 0.0006, chi-square). ICD patients took an average of up to 6 months to adjust to their device, whereas pacemaker patients took less than a month (Q17, P = 0.002, chi-square).
Pacemaker and ICD patients were significantly different in their perception of the need for support groups (Q15) and psychological support (Q14) (P = 0.03 and P = 0.01, respectively, chi-square). Sixteen (32%) pacemaker patients considered a support group desirable compared with 25 (54%) ICD patients. Only 8 (16%) pacemaker patients considered psychological counselling would be beneficial compared with 18 (39%) ICD patients.
Overall 95% of the study participants and 93% of the ICD group thought it was worthwhile having the device while the remaining 5% thought it was ‘probably’ worthwhile having the device (Q18). Forty-six (100%) of the ICD patients felt well or very well informed about their device, and 46 (100%) felt well or very well informed about their heart condition. Forty-five (98%) were satisfied with the length and frequency of their appointments with their cardiologist.
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Discussion |
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This study found that levels of clinical depression (7%) and anxiety (13%) in ICD patients were not different from those in pacemaker patients and were lower than previously described in other populations.3
,7 In contrast to previous studies, we observed no relationship between depression and anxiety levels and time since implantation,3,13,17 or to whether patients had received therapy from their device.3,9,11
We compared ICD patients with pacemaker patients, despite the inherent differences between these groups. Finding a suitable control group for an ICD population is difficult, but pacemaker controls have been used in other studies11,18 and do provide a general reference population for assessing levels of anxiety and depression. Our pacemaker patients were older and consisted of more female participants, both of which could contribute to higher levels of anxiety and depression within this group. However, in both the ICD group and the pacemaker group, we found lower levels of anxiety and depression than we expected on the basis of previous studies.3,7
Although there was an increase in the level of subclinical anxiety in the ICD recipients compared with pacemaker controls, we observed no difference in the clinical level of anxiety and depression (defined as greater than seven on HADS) between the two groups. In contrast to previous studies, we also found no relationship between levels of depression and anxiety and delivered therapy, or time since implantation. It should be noted that the sample size in the study is relatively small, and given the low level of anxiety and depression in the study, our ability to detect associations with therapy and time since implantation was limited.
The low levels of clinical depression and anxiety found in the current study may be due to the structure of the ICD service, although we have not formally investigated this link. This involves a small number of staff responsible for pre-implant assessment and education at implantation and follow-up. A consequence of the consistent staff group involved in providing the service is that the patients know the team and see the same staff including the electrophysiologist at each follow-up clinic. This continuity of care may provide considerable reassurance, and the majority of ICD patients in the current study felt well, and did not believe they needed to be seen more frequently or for a longer period by their clinician, indicating a high degree of satisfaction with the support that this team has provided. It is also possible that the lower levels of anxiety and depression in our ICD population relative to older international studies may reflect advancement in ICD technology, and greater knowledge and acceptance of this form of intervention, or that our patient population had developed other adaptive coping mechanisms or were simply reluctant to disclose honestly levels of anxiety and depression.
It is unlikely that the low levels of depression and anxiety found in the current study reflect a generally low level of psychological problems within the New Zealand population. A local study of patients routinely attending general practitioners reported 18.1% of patients had clinical depression and 20.7% had significant anxiety in the last 12 months, with 1 in 5 defined as presently suffering psychological illness.19 This suggests that the pacemaker and ICD recipients in the present study may be ‘healthier’ in psychological terms than those members of the general New Zealand population making general practice visits.
While the level of psychological problems in the ICD population was low, there was still considerably more interest in the concept of psychological counselling in this group of patients than in the pacemaker group. The pacemaker patients were considerably more interested in specific support groups. Williams20 describes those who choose not to attend support groups to be less than 50 years, cope with their device by not thinking about it and find the groups inaccessible in terms of travel.8 It is possible that those pacemaker patients with lower physical functioning quality-of-life scores who were not interested in support groups viewed the need to travel to such a group as a significant barrier. Fitchet21 reviews the finding that patients with active psychological treatment reported less depression, anxiety, and less general psychological distress than a no treatment group, thus strengthening the argument for these services being available to ICD patients, even if clinically significant levels of anxiety and depression are not present.
The factors identified in the current study that were related to depression and anxiety scores were those relating to the extent of pre-occupation with their condition (Q4), the extent to which patients thought about their device (Q2), had anxieties about their device (Q7), and felt depressed at the time of implantation (Q3). Watkins22 describes rumination and worry as important components of depression and anxiety,23 and defined rumination as thoughts and behaviours that focus the depressed individuals attention on his or her symptoms and the possible causes and consequences of those symptoms. Rumination is similar to worry in that both involve recurrent streams of thoughts and images associated with unpleasant affect. We would expect there to be a certain amount of rumination and worry, as there are patients with anxiety and depression in this population. Whether this is a ‘reactive’ process or due to pre-existing co-morbidities is yet to be established.
We found no significant differences between mental component and physical component quality-of-life scores between pacemaker and ICD groups in the current study. Mental component quality-of-life scores decreased with time since implantation, showing a decrease in the ‘mental state’ of the patients. This contrasts with Dunbar3 who reports psychological distress in the form of mood disturbance to be highest at the time of hospitalization for implantation, and suggests that this may correspond with immediate distress after resuscitation or the initial diagnosis. Pelletier17 observed a similar decline in quality-of-life and proposed that this was due to declining cardiac function.
In summary, we observed high levels of patient satisfaction and low levels of clinical depression and anxiety in a group of ICD recipients, and suggest that these potential problems may have been avoided because the patients felt well cared for and treated. These results indicate that adverse psychological consequences of ICD implantation may not present a significant barrier to treatment in some population groups.
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References |
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