|Year : 2017 | Volume
| Issue : 3 | Page : 107-111
Perception of depressive symptoms in patients after myocardial infarction: Qualitative study
Lilian Lopes Sharovsky1, Bellkiss Wilma Romano2, Jose Antonio Franchini Ramires3
1 Department of Psychology; Department of Clinical Psychology, Heart Institute of Medical School of University of Sao Paulo, Brazil
2 Department of Psychology, Heart Institute of Medical School of University of Sao Paulo, Brazil
3 Department of Cardiology, Heart Institute of Medical School of University of Sao Paulo, Brazil
|Date of Web Publication||17-Jul-2018|
Dr. Lilian Lopes Sharovsky
Rua Monte Alegre 428 Cj 136, Perdizes- São Paulo - SP, 05006-014
Source of Support: None, Conflict of Interest: None
Background: The association between depressive symptoms and adverse outcomes in patients with coronary artery disease (CAD) is well recognized. However, few studies address the patient's perception of his physical and mental condition after a myocardial infarction (MI). The present study was designed to explore the subjective aspects of the psychological conditions in post-MI patients. Method and Results: A subject population of 8 male patients (age 59±5), selected by saturation sampling, with an average of 6 months post-MI, were submitted to an individual semi-structured interview and afterwards participated in 12 psychodynamic group sessions. Conclusion: There was a predominant non-acceptance of MI due to emotional barriers and this attitude has the potential to influence negatively the adherence to a comprehensive cardiovascular treatment, including pharmacological intervention for depression
Keywords: Depressive symptoms, myocardial infarction, qualitative study
|How to cite this article:|
Sharovsky LL, Romano BW, Franchini Ramires JA. Perception of depressive symptoms in patients after myocardial infarction: Qualitative study. Heart Mind 2017;1:107-11
| Introduction|| |
Cardiovascular events represent very distressing life occurrences. It is also known that the prevalence of depressive symptoms (DS) is 40% higher in the population that has already presented cardiovascular events in general. In patients who have had recent coronary events, the prevalence is still higher; 74% having DS.
The presence of DS in patients with coronary artery disease (CAD) predicting adverse outcomes is well recognized. DS tends to increase the relative risk of future ischemic events by 1.64, an effect comparable to traditional risk factors, such as hypertension or smoking. The presence of DS also affects significantly the prognosis of this population., A meta-analysis study conducted by Barth et al., studied depression as a risk factor for mortality in patients with CAD showed a positive association between DS and the incidence of coronary events. The risk of depressed patients dying within 2 years after the initial assessment was two times higher than for nondepressed patients.,
Often, DS following ischemic events are associated with the adoption and/or maintenance of risk behaviors such as smoking, inadequate diet, physical inactivity, and poor adherence to treatment responses, alongside a melancholic mood, and irritability. Depression refers to both a diagnostic entity and a clustering of psychological symptoms such as feelings of sadness, psychosomatic symptoms, sleep disturbances, and sexual dysfunction.
The literature suggests there is an improvement of CAD as depression gets better, which emphasizes the importance of the inclusion of interventions with specific attention to mental health in a cardiac rehabilitation program for patients who have experienced coronary events.
The patient's perception of their psychological and physical condition after myocardial infarction (MI), as well as the sharing of their own perception with other patients in a similar clinical condition, may favor the increase in the overall adherence to the treatment proposed by the health team. For the subject who is sick, the recognition of the disease is associated with its symbolic universe, the social constructions in which they are inserted, and their capacity to think and interpret the reality they are experiencing.
The objective of the present study was to explore the perception and experience of patients who suffered a coronary event regarding their own DS.
| Methods|| |
A total of 8 male patients with the diagnosis of MI and a course of deteriorating psychological conditions were enrolled in the study. All were treated with antidepressant medications and submitted to serial psychological evaluations, performed as a semi-structured individual interview. The criteria adopted in this study for the diagnosis of depression were according to the Diagnostic and Statistical Manual of Mental Disorders-V.
In the follow-up, the patients were submitted to 12 psychodynamic psychotherapy group sessions.
All the interview and interventions were done by the same investigator, the first author of this study.
Interviews were conducted in an ambulatory context at the Heart Institute, São Paulo, with the presence of the participant and the interviewer. The interviews lasted approximately 1 h.
Interviews were transcripted with the patient's consent, and they were informed that everything that was expressed during the interviews would be anonymous and confidential, according to the guideline of the Helsinki Declaration of 1975, as revised in the 2000 World Medical Association Declaration of Helsinki. All of them agreed to informed consent, and the study was approved by the Heart Institute Ethics Committee.
The interview structure was conducted according to the Qualitative Method.,,,, In this study, the guiding axes were:
- Attributed causes, according to the patient's perception, hold responsible to the onset of the coronary event
- Possible mandatory lifestyle changes after MI/medication adherence, in the past month, as the doctor prescribed
- Perception of the physical condition after MI
- Perception of the experience of living with DS
- Interpretation and belief of the effect of the pharmacological intervention on depression/medication adherence, in the past month, as the doctor prescribed
- Perception of the participation of thoughts on the improvement/worsening of DS.
The subjects were treated with weekly psychodynamic group sessions that focused on the psychosomatic and DS. After data collection, the interpretation was performed with the use of content analysis.
The interviews were analyzed by content analysis and using the Qualitative Method., Categories can be defined as “great statements that included a variable number of themes, according to their degree of closeness, and which can, through their analysis, express important meanings that meet the study objectives and create new knowledge, providing a differentiated view of the proposed themes.”
The interviews were transcribed, and the content analyzed according to the method proposed by Bardin, identifying categories that allowed the study of the experience and the vision of the participants of the study.
| Results|| |
The eight participants were all men aged between 48 and 70 (±59 years of age), initially diagnosed with DS by the medical team after MI. They were consecutive and intentional sampled, all of them had initiated antidepressant medication for at least 30 days, after the coronary event. In the moment of data collection, by clinical psychologist, the average time post-MI was 6 months [Table 1]. Three thematic axes were obtained in the individual interview, as described below:
Myocardial infarction repercussions on the psychological condition
It was observed that the participants presented recurrent thoughts of disability after MI, confusing the psychic with the physical condition. These thoughts were associated with the work incapacity attributed to MI, although the objective clinical condition did not correspond to the limitations perceived by the patient. Another recurrent thought was associated to the inability to maintain sexual activity, also attributed to the cardiac condition.
L. clearly expresses this point of view: “The MI did not break my heart as much as it blew my head, I am no longer the brave and determined man I have always been.”
Or J.'s perception: “Now everyone sees me as unimportant; they hide information about family problems because they consider me useless. They saved my heart, but what about my head? I feel like a living dead.”
Another participant believes that the MI was the trigger for a decision to separate: “I am absolutely convinced that it was this woman who got me sick, angioplasty is also a minor surgery and it is giving me strength to change my life, operate on life. I see that it is a gain amid so many losses, what will it be like to live alone from now on? But I must try, why did I wait to get sick like this? This is unbearable to me.”
“My situation is the opposite: My wife simply left home, she told me that she will not be my nurse, just when I need her, it is a running over in the chest (referring to the surgical incision) and a running over in life, in 5 months I do not know who I am, who I can count on. People say I should be grateful to life because I did not die, but did I not really die? I have no control over anything and on top of that there is this threat jumping inside my chest, I wake up at night and I can tell that the heart rate is not normal, is this living? But being able to listen to others here, brings me relief and comfort, we understand each other.”
“What do we have left? Friends of infarction and misfortune, let's unite here to accept this Hiroshima bomb in our lives (referring to the MI), it's no use pretending we'll rescue everything, we will not. Imagine my situation (waiting for a heart transplant), I still depend on someone's death, to have a heart, I have always made a lot of money, I did bank operations involving big sums, today I depend on someone to save me, I do not recognize myself anymore.”
Or another participant being the spokesperson for the fear of dying that appears latently in the group sessions: “I try not to be nervous in the traffic, in the supermarket, but I get even more nervous because I cannot be nervous, otherwise I die, but not recognizing myself anymore is also a way of dying, isn't it?”
“Our health is a minefield. In the past I had pleasure in eating in good restaurants, drinking good wine, but today I remember the heart attack, and nothing is fun anymore. If I'm in a good restaurant, I order a tasty dish, but the negative and judgmental thought comes: I should not be eating this, there goes off the pleasure.”
Perception of pharmacological intervention for depression: “It is not good”
“The doctor prescribed this medication, he did not even want to listen to me, he simply told me that it was not a good sign to feel down and that this could lead to another MI, and that the medicine was there to help me and that I had to be strong and get up and walk. How can I get out of bed? I feel like a living dead. I took this medicine for 1 week and I felt worse, so I stopped taking it. I take medicine for blood pressure, cholesterol and now another one? It is no good.”
“The pleasure of drinking wine is gone, taking antidepressant does not give... besides, if I insist the police arrive (referring to his wife) and begins to question, hence the nervousness comes, how fun is it to live like this?”
“Our splendor was in the past, now we even need an antidepressant. You know what for? For not killing ourselves, a heart attack is just like suicide... we saved our heart, but who are we today?”
“I'm not going to take this medication: Think that if our heart failed, an antidepressant should speed up our heart rate, and then we have a heart attack again... I will have to force myself out of this sadness, you cannot count on more medicine.”
The attribution of sexual impotence to the antidepressant
“This is the place where I can talk, the doctor does not know, but I stopped taking the antidepressant, I already take a lot of medicine, and I'm sure I'm impotent because of the antidepressant, but the consultation is so fast that I cannot clarify that with the doctor and I also feel embarrassed since my wife is always present to the consultations and I have secrets, you know, I told you about them in the interview.”
My best antidepressant would be to continue my extramarital life, but with this zipper (referring to the thoracic incision of the coronary bypass surgery) in the chest? And how to do it if my wife cared for me throughout the hospital stay? However, has my life ended after this bomb here?”
“I take the antidepressant because the doctor ordered it, but it is very strange to me, it seems that I am another person inside myself, I feel the sadness, but I do not feel like crying, I am hungry, but I do not feel like eating, I am an avatar of myself, it seems that I look at myself and I do not recognize me. Before that I liked sex, now it has become boring. I have desire, but I am in no mood for it. I am another person… a boring person, without a job and without a heart.”
Thus, there is the perception that antidepressant medication is more of an obstacle than a fundamental aid in reducing the intensity of DS. In the study proposed by Kim et al. it was concluded that the pharmacological treatment of DS had no relevant cardiovascular side effects. On the contrary, the antidepressant may be an important contributor to improve the patient's quality of life following MI if the patient understands the importance of it.
Data about group psychotherapy intervention
During the weekly psychotherapy sessions, the participants addressed the issue of psychic change after MI. The development of depressive mood and self-imposed restrictions, among other factors, negatively impacted the perception and motivation towards life, the adherence to the medical advice and the maintenance of physical activity.
“I can barely get out of the house, what about the fear of going for a walk and having a heart attack again? I was playing tennis when I had a heart attack, if I were on the sofa at home, I would not have infarcted, how can I exercise and think it is not going to happen again?”
“A good physical activity was sexual intercourse, but it is the fear of embarrassment: The antidepressant… the fear of having a heart attack again is present all the time.”
The fear about sexual activity was an important aspect observed in all participants. Though the absolute risk is considered low, sexual activity can be perceived as a trigger to the onset of MI and it can decrease both the frequency and desire for sexual activity., However we have not discarded in our study the influence of DS on these beliefs.
In this group, the participants presented an excellent financial profile that was expected to facilitate their leisure activities, and yet they reported difficulty in getting involved with them, believing that they would not help them since they would not bring the “old heart back,” once “if you touched the machine (referring to the heart), the body will never be the same, so it is no use.”
Or another participant: “Everything depends on our head, it is not the antidepressant that will change everything and make this moment a paradise, I take antidepressant, but I know that everything depends on our head, it happens that this heart attack has messed with my head, I do not know who I am, I always stayed up late working on my engineering projects, today I even start, but I wonder what the sense of doing it is.”
A significant difficulty accepting MI, depicted by the transcription above and observed in all patients, constituted a potential intervening variable that could lead to new coronary events, through a nonadherence to the proposed medical treatment, be it cardiovascular, or the treatment of DS.
About the end of group intervention
Between 30% and 50% of inpatients treated in cardiology departments have emotional or psychosomatic problems that could benefit from psychotherapeutic information, consultation, as well as emotional support, which makes intervention with this population essential.
Although psychological interventions are recommended for the management of CAD, considerable uncertainty regarding their cost-effectiveness remains. However, psychotherapeutic interventions tend to reduce mortality due to coronary events.
Overall, the importance given by the participants of this study to the experience of participating in group psychotherapeutic intervention stands out.
“The disease implodes our heart because we do not allow ourselves to give way to emotions, we keep on touching life thinking that we are happy, leaving aside our anguish and the anguish appears in the form of an infarction, from now on we have to let life give us good things, we deserve it, we have come a long way here in therapy, and now, in the end, I see that it is no use negotiating whether or not I had the heart attack, but how happy we can be despite the heart attack”
Participants felt that they had benefits from participating in the group intervention, establishing connections with other participants, interacting with people who were experiencing a similar moment in life, and sharing social experience.
It has been observed that self-imposed intrapsychic barriers are more powerful limitations after an MI than the clinical condition or any financial hurdle due to eventual labor issues post-MI.,
It is important to consider that enrollment in a cardiac rehabilitation program was associated with a significant 34% relative decrease in the rate of discontinuation of statins and beta blockers. Cardiac rehabilitation program have considerable impact in the improvement of lifestyle factors that are involved in depression pathogeneses as physical inactivity.,
During the interviews, participants in this study expressed their well-being for the opportunity, first, to share their anguish with a professional who listened to them. In addition, they later expressed psychic well-being because they were able to feel recognized by and could relate with other members of the group during the group intervention, since “We did not have to hide information as we did in the family and/or social context.”
On the other hand, besides the free expression of feelings and anxieties, some participants addressed an interesting aspect about the gains of group psychotherapy intervention, in which all members “knew what the other was going through” (S.): The possibility of learning from each other and the possibility of building together a way to deal with destructive thoughts, of improving treatment adherence, and stopping “the omnipotence of excluding antidepressant medication.”
Clinicians should consider the patient's motivation and understanding of post-MI antidepressant medication and the importance of psychotherapeutic interventions that allow the expression of anxieties, fears, and help them to cope with the moment they are experiencing.
It was concluded that the predominant emotional nonacceptance of MI and DS are attributed to the fear of post-MI disability, which influences adherence to the overall treatment, including inappropriate adherence with the pharmacological intervention for DS.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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