Development of a short form of the Cardiac Distress Inventory.

BACKGROUND: Cardiac distress may be viewed as a persistent negative emotional state that spans multiple psychosocial domains and challenges a patient's capacity to cope with living with their heart condition. The Cardiac Distress Inventory (CDI) is a disease-specific clinical assessment tool that captures the complexity of this distress. In busy settings such as primary care, cardiac rehabilitation, and counselling services, however, there is a need to administer briefer tools to aid in identification and screening. The aim of the present study was to develop a short, valid screening version of the CDI. METHODS: A total of 405 participants reporting an acute coronary event in the previous 12 months was recruited from three hospitals, through social media and by direct enrolment on the study website. Participants completed an online survey which included the full version of the CDI and general distress measures including the Kessler K6, Patient Health Questionnaire-4, and Emotion Thermometers. Relationship of the CDI with these instruments, Rasch analysis model fit and clinical expertise were all used to select items for the short form (CDI-SF). Construct validity and receiver operating characteristics in relation to the Kessler K6 were examined. RESULTS: The final 12 item CDI-SF exhibited excellent internal consistency indicative of unidimensionality and good convergent and discriminant validity in comparison to clinical status measures, all indicative of good construct validity. Using the K6 validated cutoff of ≥ 18 as the reference variable, the CDI-SF had a very high Area Under the Curve (AUC) (AUC = 0.913 (95% CI: 0.88 to 0.94). A CDI-SF score of ≥ 13 was found to indicate general cardiac distress which may warrant further investigation using the original CDI. CONCLUSION: The psychometric findings detailed here indicate that the CDI-SF provides a brief psychometrically sound screening measure indicative of general cardiac distress, that can be used in both clinical and research settings.

The cardiac distress inventory: A new measure of psychosocial distress associated with an acute cardiac event.

BACKGROUND: Many challenges are posed by the experience of a heart attack or heart surgery which can be characterised as 'cardiac distress'. It spans multiple psychosocial domains incorporating patients' responses to physical, affective, cognitive, behavioural and social symptoms and experiences related to their cardiac event and their recovery. Although some measures of the psychological and emotional impacts of a cardiac event exist, none provides a comprehensive assessment of cardiac distress. To address this gap, the study aimed to develop a Cardiac Distress Inventory (CDI) using best practice in instrument design. METHOD: An item pool was generated through analysis of cognate measures, mostly in relation to other health conditions and through focus group and individual review by a multidisciplinary development team, cardiac patients, and end-users including cardiac rehabilitation co-ordinators. The resulting 144 items were reduced through further reviews to 74 for testing. The testing was carried out with 405 people recruited from three hospitals, through social media and by direct enrolment on the study website. A two-stage psychometric evaluation of the 74 items used exploratory factor analysis to extract the factors followed by Rasch analysis to confirm dimensionality within factors. RESULTS: Psychometric analysis resulted in the identification of 55 items comprising eight subscales, to form the CDI. The subscales assess fear and uncertainty, disconnection and hopelessness, changes to roles and relationships, overwhelm and depletion, cognitive challenges, physical challenges, health system challenges, and death concerns. Validation against the Kessler 6 supports the criterion validity of the CDI. CONCLUSION: The CDI reflects a nuanced understanding of cardiac distress and should prove to be a useful clinical assessment tool, as well as a research instrument. Individual subscales or the complete CDI could be used to assess or monitor specific areas of distress in clinical practice. Development of a short form screening version for use in primary care, cardiac rehabilitation and counselling services is warranted.

Managing Ischemic Heart Disease in Women: Role of a Women's Heart Center.

PURPOSE OF REVIEW: Heart centers for women (HCW) were developed due to the rising cardiovascular morbidity and mortality in women in the United States in the early 1990s. Our review encompasses the epidemiology, risk factors, diagnostic strategies, treatments, and the role of HCW in managing women with ischemic heart disease (IHD). RECENT FINDINGS: HCW use a multidisciplinary team to manage women with IHD. Due to the paucity of randomized controlled trials investigating various manifestations of IHD, some treatments are not evidence-based such as those for coronary microvascular dysfunction and spontaneous coronary artery dissection. Sex-specific risk factors have been identified and multimodality cardiac imaging is improving in diagnosing IHD in women. Treatments are being studied to help improve symptoms and outcomes in women with IHD. There has been progress in the care of women with IHD. HCW can be instrumental in treating women with IHD, doing research, and being a source of research study participants.

Prevalence of Anxiety, Depression, and Distress in SCAD and Non-SCAD AMI Patients: A Comparative Study.

PURPOSE: Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute myocardial infarction (AMI), particularly in younger women without classic cardiac risk factors. Spontaneous coronary artery dissection is considered to be particularly stressful; however, few studies have quantified SCAD survivor stress levels. This study compared anxiety, depression, and distress levels in SCAD and non-SCAD AMI patients. METHOD: A sample of 162 AMI (35 [22%] SCAD) patients was recruited from hospitals and via social media, in Australia and the United States. All had had their AMI in the past 6 mo. Participants completed an online questionnaire comprising the Generalized Anxiety Disorder-2 (GAD2), Patient Health Questionnaire-2 (PHQ2), Kessler-6 (K6), and Cardiac Distress Inventory (CDI). T-tests, χ 2 tests, Mann-Whitney tests, and analysis of covariance were used to compare SCAD and non-SCAD samples. Logistic regression was used to identify the unique predictors of anxiety, depression, and distress, controlling for relevant confounders. RESULTS: Patients with SCAD were more commonly female and significantly younger than non-SCAD patients. Patients with SCAD scored significantly higher on the GAD2, PHQ2, K6, and CDI and a significantly larger proportion was classified as anxious, depressed, or distressed using these instruments. In logistic regression, together with mental health history, having had a SCAD-AMI predicted anxiety, depression, and distress, after controlling for female sex, younger age, and other confounding variables. CONCLUSION: This study supports the view that anxiety, depression, and distress are more common after SCAD-AMI than after traditional AMI. These findings highlight the psychosocial impacts of SCAD and suggest that psychological support should be an important component of cardiac rehabilitation for these patients.

Association Between Insomnia, Stress Events, and Other Psychosocial Factors and Incident Atrial Fibrillation in Postmenopausal Women: Insights From the Women's Health Initiative.

Background The association between psychosocial factors and atrial fibrillation (AF) is poorly understood. Methods and Results Postmenopausal women from the Women's Health Initiative were retrospectively analyzed to identify incident AF in relation to a panel of validated psychosocial exposure variables, as assessed by multivariable Cox proportional hazard regression and hierarchical cluster analysis. Among the 83 736 women included, the average age was 63.9±7.0 years. Over an average of 10.5±6.2 years follow-up, there were 23 954 cases of incident AF. Hierarchical cluster analysis generated 2 clusters of highly correlated psychosocial variables: the Stress Cluster included stressful life events, depressive symptoms, and insomnia, and the Strain Cluster included optimism, social support, social strain, cynical hostility, and emotional expressiveness. Incident AF was associated with higher values in the Stress Cluster (hazard ratio [HR], 1.07 per unit cluster score [95% CI, 1.05-1.09]) and the Strain Cluster (HR, 1.03 per unit cluster score [95% CI, 1.00-1.05]). Of the 8 individual psychosocial predictors that were tested, insomnia (HR, 1.04 [95% CI, 1.03-1.06]) and stressful life events (HR, 1.02 [95% CI, 1.01-1.04]) were most strongly associated with increased incidence of AF in Cox regression analysis after multivariate adjustment. Subgroup analyses showed that the Strain Cluster was more strongly associated with incident AF in those with lower traditional AF risks (P for interaction=0.02) as determined by the cohorts for heart and aging research in genomic epidemiology for atrial fibrillation score. Conclusions Among postmenopausal women, 2 clusters of psychosocial stressors were found to be significantly associated with incident AF. Further research is needed to validate these associations.

Unraveling the Complexity of Cardiac Distress: A Study of Prevalence and Severity.

Introduction: While much research attention has been paid to anxiety and depression in people who have had a recent cardiac event, relatively little has focused on the broader concept of cardiac distress. Cardiac distress is a multidimensional construct that incorporates but extends beyond common mood disorders such as anxiety and depression. In the present study we assessed the prevalence, severity and predictors of a broad range of physical, affective, cognitive, behavioral and social symptoms of cardiac distress. This is the first study to investigate cardiac distress in this comprehensive way. Method: A sample of 194 patients was recruited from two hospitals in Australia. Eligible participants were those who had recently been hospitalized for an acute cardiac event. Data were collected at patients' outpatient clinic appointment ~8 weeks after their hospital discharge. Using a questionnaire developed through a protocol-driven 3-step process, participants reported on whether they had experienced each of 74 issues and concerns in the past 4 weeks, and the associated level of distress. They also provided sociodemographic and medical information. Regression analyses were used to identify risk factors for elevated distress. Results: Across the 74 issues and concerns, prevalence ratings ranged from a high of 66% to a low of 6%. The most commonly endorsed items were within the domains of dealing with symptoms, fear of the future, negative affect, and social isolation. Common experiences were "being physically restricted" (66%), "lacking energy" (60%), "being short of breath" (60%), "thinking I will never be the same again" (57%), and "not sleeping well" (51%). While less prevalent, "not having access to the health care I need," "being concerned about my capacity for sexual activity," and "being unsupported by family and friends" were reported as highly distressing (74, 64, and 62%) for those experiencing these issues. Having a mental health history and current financial strain were key risk factors for elevated distress. Conclusion and Implications: Specific experiences of distress appear to be highly prevalent in people who have had a recent cardiac event. Understanding these specific fears, worries and stressors has important implications for the identification and management of post-event mental health and, in turn, for supporting patients in their post-event cardiac recovery.

Clinical factors associated with a positive postpartum depression screen in people with cardiac disease during pregnancy.

Background: While people with cardiac disease are known to be at increased lifetime risk of depression, little is known about postpartum depression rates in this population. Describing rates of positive postpartum depression screens and identifying risk factors that are unique to cardiac patients may help inform risk reduction strategies. Methods: This retrospective cohort study included pregnant patients with congenital and/or acquired cardiac disease who delivered at a single institution between 2014 and 2020. The primary outcome was a positive postpartum depression screen, defined as Edinburgh Postpartum Depression Score (EPDS) ≥10. Potential exposures were selected a priori and compared between patients with and without a positive postpartum depression screen using Wilcoxon rank-sum and Fisher's exact tests. Secondary outcomes were responses to a longitudinal follow-up survey sent to English-speaking patients evaluating cardiac status, mental health, and infant development. Results: Of 126 eligible cardiac patients, 23 (18.3%) had a positive postpartum depression screen. Patients with a positive postpartum depression screen were more likely to have had antepartum anticoagulation with heparin or enoxaparin (56.5% versus 26.2%, p=0.007), blood transfusion during delivery (8.7% versus 0%, p=0.032), and maternal-infant separation postpartum (52.2% versus 28.2%, p=0.047) compared to patients with a negative screen. Among 29 patients with a positive screen who responded to the follow up survey, 50% reported being formally diagnosed with anxiety or depression and 33.3% reported child development problems. Conclusions: Our results highlight the importance of screening for postpartum depression in patients with cardiac disease, especially those requiring antepartum anticoagulation or maternal-infant separation postpartum.

Differential response of African American and Caucasian women to extended-care programs for obesity management.

OBJECTIVE: The current study examined ethnic differences in patterns of weight loss and regain in response to an initial behavioral weight loss intervention followed by an extended-care maintenance program. METHODS: We analyzed data from 224 women (African American n = 43, Caucasian n = 181) from rural communities who participated in an initial 6-month lifestyle intervention for obesity and were then randomized to a face-to-face, telephone, or educational/control extended-care condition. RESULTS: African American participants lost less weight during the initial phase of treatment than Caucasian participants (mean +/- SE = -6.8 +/-.80 vs -10.7 +/- .38 kg, respectively, P = .003). Investigating weight change during month 6 to month 18, we found a significant interaction between ethnicity and the provision of an extended-care program. Caucasian participants randomized to either of two extended-care programs regained less weight than those assigned to the control condition (1.2 +/- .58 and 4.2 +/- .79 kg, respectively, P=.003), but the provision of extended care did not influence weight regain among African American participants (1.9 +/- 1.12 and 1.34 +/- 2.04 kg, respectively, P = .815). CONCLUSION: Collectively, these findings suggest that although African American participants lost less weight during the initial phase of treatment, they exhibited better long-term weight-loss maintenance than Caucasian participants. Further, while the provision of extended care successfully enhanced weight maintenance among Caucasian participants, African American participants maintained their initial weight losses regardless of extended care.

A multicomponent intervention reduces body weight and cardiovascular risk at a GEICO corporate site.

PURPOSE: To determine whether a multicomponent nutrition intervention program at a corporate site reduces body weight and improves other cardiovascular risk factors in overweight individuals. DESIGN: Prospective clinical intervention study. SUBJECTS/SETTING: Employees of the Government Employees Insurance Company (GEICO) (N = 113), aged 21 to 65 years, with a body mass index > or =25 kg/m(2) and/or previous diagnosis of type 2 diabetes. INTERVENTION: A 22-week intervention including a low-fat, vegan diet. MEASURES: Changes in body weight, anthropometric measures, blood pressure, lipid profile, and dietary intake. ANALYSIS: Multivariate analyses of variance were calculated for clinical and nutrient measures, followed by univariate analyses of variance, to determine the significance of differences between groups in changes over time. RESULTS: Intervention-group participants experienced greater weight changes compared with control-group participants (mean, -5.1 [SE, .6] kg vs. + .1 [SE, .6] kg, p < .0001), as well as greater changes in waist circumference (mean, -4.7 [SE, .6] cm vs. + .8 [SE, .6] cm, p < .0001) and waistratiohip ratio (mean, -.006 [SE, .003] vs. + .014 [SE, .005], p = .0007). Weight loss of 5% of body weight was more frequently observed in the intervention group (48.5%) compared with the control group (11.1%) (chi(2)[1, N = 113] = 16.99, p < .0001). CONCLUSIONS: Among individuals volunteering for a 22-week worksite research study, an intervention using a low-fat, vegan diet effectively reduced body weight and waist circumference.

A worksite programme significantly alters nutrient intakes.

OBJECTIVE: To examine whether a worksite nutrition programme using a low-fat vegan diet could significantly improve nutritional intake. DESIGN: At two corporate sites of the Government Employees Insurance Company, employees who were either overweight (BMI > or = 25 kg/m2) and/or had type 2 diabetes participated in a 22-week worksite-based dietary intervention study. SETTING: At the intervention site, participants were asked to follow a low-fat vegan diet and participate in weekly group meetings that included instruction and group support (intervention group). At the control site, participants received no instruction (control group). At weeks 0 and 22, participants completed 3 d dietary records to assess energy and nutrient intake. SUBJECTS: A total of 109 participants (sixty-five intervention and forty-four control). RESULTS: In the intervention group, reported intake of total fat, trans fat, saturated fat and cholesterol decreased significantly (P < or = 0.001), as did energy and protein (P = 0.01), and vitamin B12 (P = 0.002), compared with the control group. Intake (exclusive of any use of nutritional supplements) of carbohydrate, fibre, vitamin C, magnesium and potassium increased significantly (P < or = 0.0001), as did that for beta-carotene (P = 0.0004), total vitamin A activity (P = 0.004), vitamin K (P = 0.01) and sodium (P = 0.04) in the intervention group, compared with the control group. CONCLUSIONS: The present study suggests that a worksite vegan nutrition programme increases intakes of protective nutrients, such as fibre, folate and vitamin C, and decreases intakes of total fat, saturated fat and cholesterol.

A worksite vegan nutrition program is well-accepted and improves health-related quality of life and work productivity.

BACKGROUND/AIMS: Vegetarian and vegan diets are effective in preventing and treating several chronic diseases. However, their acceptability outside a clinical trial setting has not been extensively studied. The aim of this study was to determine the acceptability of a worksite vegan nutrition program and its effects on health-related quality of life and work productivity. METHODS: Employees of a major insurance corporation with a body mass index > or =25 kg/m(2) and/or a previous diagnosis of type 2 diabetes received either weekly group instruction on a low-fat vegan diet (n = 68) or received no diet instruction (n = 45) for 22 weeks. RESULTS: The vegan group reported improvements in general health (p = 0.002), physical functioning (p = 0.001), mental health (p = 0.03), vitality (p = 0.004), and overall diet satisfaction (p < 0.001) compared with the control group. The vegan group also reported a decrease in food costs (p = 0.003), and increased difficulty finding foods when eating out (p = 0.04) compared with the control group. The vegan group reported a 40-46% decrease in health-related productivity impairments at work (p = 0.03) and in regular daily activities (p = 0.004). CONCLUSIONS: A worksite vegan nutrition program is well-accepted and can be implemented by employers to improve the health, quality of life, and work productivity of employees.

Psychological Distress Among Female Cardiac Patients Presenting to a Women's Heart Health Clinic.

Female cardiac patients are at greater risk for mental health disorders than their male counterparts, and these mental health disorders have been associated with increased cardiac morbidity and mortality. However, few studies have closely examined the mental health disorders found among the female cardiac population. The primary aim of this study was to examine the prevalence of psychological distress in a sample of female cardiac outpatients at an academic medical center. A secondary aim was to determine whether different demographic variables, cardiac risk factors, or cardiac diagnoses were associated with different levels of emotional distress. A survey, including demographic information, medical status, and standardized symptom measures was completed by 117 female patients scheduled for medical visits at an outpatient women's heart health clinic over a 4-month period. Using standardized self-report questionnaires, 38% scored in the moderate-to-severe range for at least 1 mental disorder and 50% endorsed current insomnia. Symptoms of clinical depression (20%) and anxiety (42)% were endorsed at higher rates than predominantly male or mixed comparison samples. Although there was no apparent relation between the severity of cardiac problems and the degree of psychological distress, women with diagnoses of hyperlipidemia, prediabetes, and diabetes reported greater psychological distress than those without these problems. Women with lower income also reported more psychological distress. In conclusion, our findings suggest an unmet need for integrated mental health services for female cardiac patients.

Internet access to Salvia divinorum: implications for policy, prevention, and treatment.

This study determined the degree to which Salvia divinorum, a potent hallucinogenic drug that is legal in most U.S. jurisdictions, is being proffered for sale over the Internet and how it is being characterized on popular Web sites. Search results revealed that between one half and two thirds (58%) of the Web sites either offered to sell S. divinorum or linked to other Web sites offering to sell the drug and that more than three quarters (78%) of the Web sites advocated for its use. Many of the statements issued on the Web sites were erroneous or falsely interpreted the absence of scientific data on the possible side effects of S. divinorum as evidence that no side effect exists. The portrayal and availability of S. divinorum on the Internet are similar to those of other illicit and prescription drugs of abuse. However, much less is known about the short- and long-term effects of this novel drug. Consequently, there is little basis to contradict the many Web sites that encourage its use. Implications for drug policy, prevention, and treatment are discussed.

Implementing evidence-based practices in community treatment programs: initial feasibility of a counselor "toolkit".

Community substance abuse treatment programs face many barriers to adopting "evidence-based" therapies. Training budgets are inadequate to permit acquisition of complex skills, there is little clinical supervision available, and almost all counseling is done in group sessions. The authors adopted an approach widely used in the teaching field-developing a resource "toolkit" for a specific topic, in this case, a Decisional Balance exercise often used in the evidence-based treatment approach of Motivational Interviewing. This trial toolkit was comprised of a DVD (televised during group to illustrate the clinical concept), a laminated counselor guide (to provide guidance and talking points for the counselor during group), and some worksheets and wallet cards for patients to retain key points (see Table 1). A feasibility trial assessed the acceptability, and sustainability of the "Decisional Balance" concept toolkit among 26 counselors and 210 of their patients, from 6 community-based substance abuse treatment programs. The great majority of patients (97%) and all counselors (100%) reported they were satisfied with the toolkit session; 84% of patients said they would like more groups like the toolkit session. Almost all counselors (96%) were still using at least one component of the toolkit 3 months after their initial exposure with no prompting. The toolkit curriculum-based approach may be a viable and attractive way of translating core concepts from sophisticated evidence-based therapies into use by counselors within contemporary, community-based treatment programs with minimal training.