Upbeat attitudes ease severity, complications of chronic diseases
Approach patients positively, and they’ll have better outcomes
Does a positive mental attitude really equal good health? It may sound like some New Age psychobabble, but a growing body of research is solidifying the concept that attitude and mood play a crucial role in the development and progression of a wide variety of chronic diseases. Consider the following studies:
• Recent research from the University of Texas Medical Branch in Galveston shows emotional well-being lowers risk of stroke by two-thirds,1 and Scottish scientists have found that stroke survivors with fatalistic attitudes were 79% more likely to die than those with a more hopeful outlook.2
• A study from the University of South Carolina in Columbia shows patients with Type 1 diabetes with a positive attitude about their illnesses have better physical and mental health.3
• A study from the Albert Einstein College in Bronx, NY, shows depressed hypertensive patients have double the risk of heart attack compared to those with simple hypertension.4
• Women who are depressed and angry are more likely to have cardiovascular disease than others, say University of Pittsburgh researchers.5
Here are some details of the studies:
Stroke
Feeling happy and hopeful appears to be a powerful protection against stroke, says Glenn Ostir, PhD, assistant professor of geriatrics at the Sealy Center on Aging at the University of Texas Medical Branch in Galveston. Ostir’s study shows patients with positive mental attitudes had a stroke incidence that was two-thirds less than those with fatalistic attitudes.
Ostir and his colleagues assessed signs of depression separately - termed negative effect — from signs of emotional well-being — termed positive effect. "Our results suggest that increasing levels of positive effect are strongly associated with reduced risk of stroke. This inverse relationship between positive effect and stroke held for the entire sample, by gender and by race, after controlling for known risk factors of stroke and for negative effect score," Ostir says. The study followed 2,478 patients ages 65 years and older for six years.
Using the 20-item Center for Epidemiological Studies-Depression (CES-D) scale questionnaire, investigators found that subjects scoring high in terms of emotional well-being had significant reductions in their stroke risk while risk increased for those who showed depressive symptoms. (See "Center for Epidemiological Studies-Depression Scale," in this issue.) The reductions in the risk of stroke associated with positive attitudes were more pronounced in men than in women and in whites than in African-Americans, although Ostir says the size of the sample could have skewed the results, particularly as they relate to women.
"Positive effect has a relationship to several lifestyle choices that are known to relate to improved health and to protect against chronic disease. People with strong positive attitudes may be more likely to exercise, eat properly, and maintain a healthy lifestyle than those with more depressive symptoms," says Ostir.
The Scottish study on stroke and negative attitude bolsters Ostir’s results - and takes them a step further. The study published in the July issue of Stroke shows that stroke survivors with a fatalistic attitude are far more likely to die within three to five years than those with positive outlooks. Researchers at the University of Edinburgh found that individuals in the top 10% of those with fatalistic attitudes were 79% more likely to die than those in the lowest 10%, even after adjustment for significant factors such as age, stroke severity, and comorbidities.
Similarly, stroke survivors in the top 10% for helplessness and hopelessness viewpoints were 58% more like to die than those in the lowest 10% of that category. Research psychologists visited 372 individuals six months after they had a stroke. Each was evaluated for disability and independence in daily activities and given self-rated tests of their depression, anxiety, and attitudes toward their strokes. Follow-up was done three to five years later; 22% died within three years.
"Patients’ attitudes toward their illnesses seem to be associated with survival after a stroke. Patients who feel there is nothing they can do to help themselves six months after a stroke have a shorter survival," the study’s authors wrote.
Heart disease and heart attack
Depression doubles the risk of heart attack in patients who already have hypertension, says Hillel Cohen, DrPh, associate professor of epidemiology and social medicine at Albert Einstein College of Medicine. Cohen’s study showed that hypertensive patients with a history of depression were twice as likely to have a heart attack or other coronary event than nondepressed people with high blood pressure. "My theory is that something in their compensating behavior for depression puts them at risk," says Cohen.
Cohen’s study included 5,564 patients being treated for hypertension, but without a history of heart disease. Of 3,541 men in the study, 3.5% reported receiving treatment for depression, and 6.4% of the 2,023 women had been treated for depression.
After adjusting for heart attack risk factors, such as age, cholesterol, diabetes, and smoking, the depressed patients were still more than twice as likely to have a heart attack than those who were not depressed. That number rose to nearly 2.5 when cardiac procedures such as bypass surgery or angioplasty were taken into account. The incidence of hospitalizations or death from health problems not related to heart disease was similar in depressed and nondepressed patients, Cohen and his colleagues found.
Physiological and psychological changes that accompany depression may play a role in the increased heart attack risk, says Cohen. Depressed people may take a wide variety of health risks, knowingly or not, says Cohen. Some examples include:
• Behavioral risks such as smoking, eating too much, or being physically inactive.
• Hostility and anger — "what was once known as Type A behavior." Now we know that anger and hostility remain a risk factor. Depression, anger, and hostility are linked by anger at one’s self, Cohen says and have been shown to produce elevated catecholamines, increasing the risk for arrhythmia.
• Physiological risks associated with chronic elevation of serotonin levels that in turn are associated with stress, platelet aggregation, and coagulation. "Whatever is driving the depression may, with the serotonin receptors in parallel, be effecting the serotonin in the platelets," says Cohen. For this reason, he hypothesizes, the use of selective serotonin reuptake inhibitors in depressed patients actually may reduce the risk of heart attack.
A complementary study from the University of Pittsburgh suggests that anger and depression predict atherosclerosis in women, in part through physical and behavioral risk factors such as high cholesterol, obesity, and smoking. "Among women, there is evidence that psychosocial distress is prospectively associated with increased risk of disease and premature mortality from cardiovascular events," wrote the study’s authors.
Researchers examined data on 688 women participating in the Women’s Ischemia Syndrome Evaluation (WISE) study, sponsored by the National Heart, Lung and Blood Institute in Bethesda, MD. The study enrolled women ages 18 years and older who were referred for coronary angiography to evaluate suspected myocardial ischemia (MI). Cynical hostility, defined as consistent lack of trust and bitterness toward others, also was associated with atherosclerosis risk factors such as smoking, poor physical fitness, and lower HDL levels.
The investigators initially detected an association between cynical hostility and high blood pressure, which was eliminated when they controlled for socioeconomic status. This suggests that low socioeconomic status may increase the risk for both cynical hostility and hypertension, investigators said. This means psychological factors may serve as a red flag for the risk of heart disease, but they also may offer methods of reducing the risk of heart disease through behavioral interventions.
The study showed that subjects with the highest scores on a depression scale were 2.5 times more likely to smoke than those with the lowest depression scores. Those who scored highest for outward displays of anger were most likely to have high LDL cholesterol levels and low HDL levels. They also were more likely to be overweight or obese.
Finally, Ostir’s MI study validates the other two recent reports, finding that every unit increase in the positive effect score resulted in a 10% decreased risk of MI.6 However, he did not find an increased risk for those with negative scores. The study looked at a three-year incidence of MI in a sample of 2,411 people ages 65 years and older.
Ostir suggests that decreased serotonin levels in platelets linked to depression increase coagulation and that increased release of norepinephrine and epinephrine, triggered by anger or hostility, decreases left ventricular ejection, causing coronary artery vasoconstriction. "Interventions targeted at improving an older person’s emotional well-being may reduce the risk of MI and aid in the recovery process," he concludes.
Diabetes
Stress, attitude, and ability to cope are all factors in the seriousness of a patient’s Type 1 diabetes and possibly in the progression of comorbidities of the disease, according to a review study from the University of South Carolina. Reviewing data from three evaluations of 49 patients ages 40 and older with Type 1 diabetes, lead researcher Kay McFarland, MD, FACE, professor of medicine, found that the more positive meaning patients attribute to their illness, the better their mental and physical health.
Investigators used the Meaning of Illness questionnaire, which is divided into five subsets, to determine the impact of illness; the stress and negative attitudes of harm, loss, threat, and function; the degree of stress and coping resources; positive attitudes of hope; motivation and control; and the expectancy of a recurrence or worsening of the illness. It explores questions such as, "Do you think your health is going to get worse?" and "How anxious do you feel about your health?"
McFarland calls it a "bidirectional relationship" between the meaning attributed to an illness and the health outcomes. "What is clearly established is a connection between the two; the meaning of illness influences health outcomes and health outcomes affect the meaning attributed to the illness," she wrote.
"Nearly every patient understands the complications that can occur with diabetes, so I discuss that with them on the first visit and then drop it," says McFarland. "I want to help empower people to take care of themselves. I don’t think guilt or fear or a physician taking a parental approach to the issue are effective motivators," she says. Her recommendation? "Explain HbA1c levels to them and ask where they would like to be. Enlist their support. Make it a joint effort, a team approach. Once they have an agenda, they’ll buy into it," she explains.
Healthy aging
"These are diseases commonly associated with the aging process, but I think they can convey a positive note, too. This can mean an active and healthy aging process for the vast majority of the population," Ostir says. Approximately 15% to 20% of older adults display some signs of clinical depression. But he sees the cup as half full. "That means 80% have a healthy outlook on life and may be actively reducing their risk of strokes, heart attacks, and other diseases due to a healthy attitude — and the healthier lifestyle is so often associated with an upbeat attitude," Ostir points out.
Clinicians should screen patients for depression or fatalistic attitudes, he says, and take action whenever it is necessary. "An easy screen is just to ask," Ostir explains. Asking goes beyond the ritualistic exchange of social niceties of "How are you?"/"I’m fine. "When you’re taking the blood pressure, just ask, Now tell me how you really are.’ If a patient seems depressed, ask the question directly, Ostir recommends, and then probe a little more and see if there is a direct cause. If a spouse or close family member has recently died, depression might be expected. But if there is no obvious cause for depression, you’ll want to follow up and explore the subject more deeply," he says.
Those simple questions may be enough, or clinicians can administer one of the many depression tests such as the CES-D to determine if pharmaceutical or behavioral interventions are necessary.
References
1. Ostir GV, Markides KS, Peek MK, et al. The association between emotional well-being and the incidence of stroke in older adults. Psychosom Med 2001; 63:210-215.
2. Lewis SC, Dennis MS, O’Rourke SJ, et al. Negative attitudes among short-term stroke survivors predict worse long-term survival. Stroke 2001; 32:1640-1645.
3. McFarland KF, Rhoads DR, Campbell J, et al. Meaning of illness and health outcomes in Type 1 diabetes. Endocrine Practice 2001; 7:250-254.
4. Cohen HW, Madhavan S, Alderman MH. History of treatment for depression: Risk factor for myocardial infarction in hypertensive patients. Psychosom Med 2001; 63:203-209.
5. Rutledge T, Reis SE, Olson M, et al. Psychosocial variables are associated with atherosclerotic risk factors among women with chest pain: WISE study. Psychosom Med 2001; 63:282-288.
6. Ostir GV, Peek MK, Markides KS, et al. The association between emotional well-being and future risk of myocardial infarction in older adults. Primary Psychiatry 2001; 8:22-27.
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