Psychosomatics 39:305-310, August 1998
© 1998 The Academy of Psychosomatic Medine
Psychopathology Following Cardioverter Defibrillator Implantation
Scott J. Crow, M.D.,
Joanne Collins, B.S.N.,
Marcia Justic, M.S.N.,
Robert Goetz, B.S., and
Stuart Adler, M.D.
Received September 5, 1997; revised December 2, 1997; accepted December 12, 1997. From the Department of Psychiatry, University of Minnesota, Minneapolis; the Department of Cardiology, University of Minnesota, Minneapolis; the Methodist Hospital, Nursing Administration, St. Louis Park, Minnesota; the Department of Psychology, University of Minnesota, Minneapolis; and the St. Paul Heart Clinic, St. Paul, Minnesota. Address reprint requests to Dr. Crow, University of Minnesota, Department of Psychiatry, Box 393 UMHC, Minneapolis, MN 55455.
|
ABSTRACT
|
Previous reports have found elevated rates of psychopathology in recipients of implantable cardioverter defibrillators (ICDs). Thirty-five consecutive ICD recipients were assessed by using the Structured Clinical Interview for DSM-III-R and a semistructured questionnaire; assessments were performed within 3 days of ICD implantation (Time 1) and again 9–18 months later (Time 2). At the initial assessment, alcohol dependence in remission was the most common diagnosis, followed by mood disorders. Two cases of depression were found at follow-up assessment, but those subjects had either a lifetime history of major depression or some depressive symptoms at Time 1. No new cases of anxiety disorders were seen at Time 2. It appears that ICD recipients have rates similar to the general population at the time of implantation, and the risk for new psychopathology is largely confined to those with a lifetime history of psychopathology.
Key Words: Psychopathology • Implantable Cardioverter Defibrillator • Defibrillator • Cardioverter
|
INTRODUCTION
|
The implantable cardioverter defibrillator (ICD) is gaining widespread acceptance as a treatment for ventricular dysrhythmias. Numerous studies have recently found it to be more effective in preventing cardiac sudden death following ventricular dysrhythmia than traditional antiarrhythmic medications.1,2 Since their initial introduction, technological advances have occurred, including the development of smaller devices that are easier to implant. The variety of devices available continues to grow, and for all these reasons their use is increasingly common.
Clinicians working with ICD recipients have noted previously that some recipients have comorbid psychiatric symptoms or illnesses. Substantial rates of both anxiety and depression have been described.3–5 A number of potential etiologies for these symptoms have been hypothesized. For example, most ICD recipients present following a potentially fatal dysrhythmia, and one might hypothesize that depression or anxiety symptoms could be the result of such near death experiences.6 Alternatively, the implantation procedure itself might constitute a substantial stress that would trigger symptoms. A third potential explanation would be the possibility that either the discharge of the device after implantation—or the fear of such a discharge—could precipitate symptoms.
Unfortunately, the existing studies suffer from several methodological limitations. First, structured diagnostic instruments, now considered to be the gold standard for making psychiatric diagnoses in research settings, have typically not been used. A second limitation is that assessment of subjects generally has not included pre- and postimplantation assessment.
This problem introduces two potential biases. First, it may be that the peri-implantation period is a time of such stress that the results of psychological measures are somewhat compromised. One might hypothesize that such stressors could precipitate new, transient symptoms that might then erroneously be identified as long-lasting. Alternatively, psychopathology at the time of assessment might be attributed to factors relating to ICD placement when it was actually preexisting. Many investigators have found higher rates of psychopathology for a variety of medical illnesses (including cardiovascular illness) than in the general population; since many ICD recipients are already medically ill, this group might be at elevated risk for preexisting psychopathology.
In this study, we assessed levels of psychiatric symptoms and psychiatric diagnoses in a series of ICD patients at the time of implantation and at subsequent follow-up. We hypothesized that substantial rates of psychopathology would be present at initial assessment and that rates would be higher still at follow-up assessment due to the occurrence of new mood and anxiety disorders.
|
METHODS
|
All patients age 18 and over presenting to an Electrophysiology Service for first-time ICD implantation were asked to participate in this study. After informed consent was obtained, the subjects completed the Structured Clinical Interview for DSM-III-R (SCID),7 and a semistructured questionnaire devised specifically for this study.
The subjects were initially contacted by the nurse clinician on the Electrophysiology Service when the decision was made for ICD implantation. Where possible, the interviews were completed prior to implantation, but for practical reasons it was often necessary to complete the interviews after implantation, when the patient had medically stabilized, shortly prior to discharge. Thus, all interviews were completed within 3 days of the time of implantation (Time 1).
The subjects were reassessed 9 to 18 months after implantation at a follow-up visit (Time 2). Assessment at that time included the SCID and semistructured questionnaire. Assessments were done in person, when possible, or if the assessment could not be done during the patient's return visits, completed by telephone. Subjects were specifically excluded from the follow-up portion of the study if they received heart transplantation in the intervening follow-up, as this procedure was felt to be sufficiently complex and invasive as to confound the measurement of ICD-related psychopathology. Approval was obtained from the human subjects committee of the Institutional Review Board prior to initiation of this study.
|
RESULTS
|
Forty-one subjects were approached for study participation during the 25-month study period. One potential subject signed consent to participate in the study just prior to ICD implantation but died in the operating room; of the remaining 40 potential subjects, 35 agreed to participate. Initial assessments occurred prior to implantation for 20 subjects (57.1%) and after implantation, before discharge for 15 subjects (42.9%).
Twenty-seven subjects completed the follow-up assessment. Three subjects had died during the follow-up, two had received heart transplantation, two could not be located at the time of follow-up, and one refused. Follow-up contact was made between 9 and 18 months after implantation (mean=12.3 months). Six subjects had follow-up assessments in person (22.2%); the other 21 had telephone assessments (77.8%).
Rates of current and lifetime psychopathology are displayed in Table 1. Alcohol dependence in remission was the most common diagnosis, occurring in 5 subjects (14.3%); mood disorders were second most common, with 8.6% having current major depression and 5.7% past major depression. Including dysthymia and adjustment disorder with depressed mood, 20% of the subjects had a current or lifetime depression diagnosis of some type. Panic disorder was reported by 5.8% of the subjects (1 current, 1 past).
Rates of psychopathology at the follow-up assessment are also found in Table 1. One case of organic anxiety syndrome, not diagnosed at assessment one (Time 1), was found at assessment two (Time 2). However, upon thorough review, the syndrome was related to periods of panic attack-like anxiety, always occurring during congestive heart failure exacerbations, prior to implantation. These symptoms were not reported at the initial assessment but did clearly refer to a time prior to the initial assessment.
Two cases of current major depression were found at the second assessment (Time 2) that did not exist at assessment one (Time 1). In one instance, a subject diagnosed with adjustment disorder with depressed mood at Time 1 went on to develop clear-cut major depression, which resolved during the follow-up period. In a second instance, a subject with a lifetime (but not current) history of major depression diagnosed at assessment one (Time 1) had a recurrence of that major depression during the follow-up interval.
Semistructured questionnaire data were available for 33 of 35 subjects at Time 1 and 25 of 27 subjects at Time 2. When asked at the time of implantation, 48.5% of the subjects (16/33) said they had "a great deal of time to learn and prepare" for ICD implantation, 39.4% (13/33) had "some time to learn and prepare," and 12.1% (4/33) "very little time to learn and prepare." No subject endorsed having "no time" to prepare.
For the 25 subjects completing the follow-up questionnaire, 12 (48.0%) had no device discharges since implantation (apart from routine testing in the electrophysiology suite). Six subjects reported 1 discharge, 4 subjects reported 2 to 4 discharges, and 3 subjects reported 10 or more discharges. At the time of follow-up, five (41.7%) of those subjects who had received at least one shock from their ICD said they felt prepared for it, whereas 8 (58.3%) did not feel prepared. The majority of those receiving shocks (9/13, 69.2%) were unable to ever predict them. Twelve subjects reported no fear of receiving a shock from their ICD, 13 subjects were somewhat fearful, and no subject endorsed being extremely fearful. Of those subjects reporting fear of shocks, eight had received no shock, three had received one shock, and two had received more than one shock. Conversely, of those who had received at least one shock, eight reported never fearing a shock from their ICD, whereas five reported some fear of receiving a shock.
Twenty-four of 25 subjects at follow-up (96.0%) said they would advise someone in a similar situation to have a device implanted. When asked about sense of well-being following implantation, 6 (24%) said it was significantly improved, 12 (48%) somewhat improved, 5 (20%) the same, and 2 (8%) somewhat worsened. When asked about anxiety related to their ICD, 6 (24%) were fairly anxious, 8 (32%) infrequently anxious, and 11 (44%) never anxious. No subject reported being greatly anxious. Similarly, 3 subjects (12%) said they were fairly depressed about their ICD, 4 (16%) infrequently depressed, and 18 (72%) never depressed. Only 1 (4%) subject endorsed being fairly angry about the device, 3 subjects (12%) were infrequently angry, and 21 (84%) had no anger.
|
DISCUSSION
|
Our major hypothesis, that elevated rates of diagnosable psychopathology would occur following ICD implantation, was not supported in this study. No new anxiety diagnoses were seen at follow-up, and only two cases of major depression occurred over the follow-up interval. As noted earlier, one case might be viewed as the evolution of depressive symptoms initially diagnosed as adjustment disorder, and the other could merely represent the chance recurrence of a prior major depressive illness. Alternatively, it may be that the process of ICD implantation did play a role in the development of depressive syndromes in these individuals, but it is noteworthy that no new mood syndrome occurred in any subject free of a current or lifetime history of mood symptoms at the time of implantation. Thus, we conclude that if ICD implantation is a risk factor for the onset of diagnosable psychiatric syndromes, this risk may be confined to those with some current or lifetime history of psychopathology at the time of implantation.
The findings of this study do differ from prior studies examining psychological symptoms and psychopathology in this group. Rates of psychopathology identified in the current study were lower than those seen in other studies, and this psychopathology did not appear temporally related to the event of implantation itself, which has been hypothesized previously. Because the rates of new-onset psychopathlogy were so low, we were unable to examine whether ICD discharge was associated with new psychopathology, as has been suggested previously.3,8 Of note, the average number of discharges over the follow-up period was quite low. It remains an important possibility that in those individuals receiving many discharges from their ICD, new-onset psychopathology would be seen. Interestingly though, there did not appear to be a strong relationshp between receiving shocks and being fearful of them: most subjects reporting "some fear" had not been shocked, and most reporting at least one shock did not fear them.
Several factors may contribute to the lower rate of psychopathology seen in the current study. First, the use of structured diagnostic instruments would be expected to result in more conservative estimates of psychopathology rates than rating scales. Second, the published studies assessed individuals receiving earlier generations of these devices, and it may be that whatever risk for anxiety or depression existed with the first generations of these devices has been ameliorated by technical and technological advances. Third, it may be that those individuals destined to develop new-onset psychopathology either did not choose to participate initially or were among the group unable to be followed up. Because compliance rates with the study were quite high, the refusal by potential subjects to participate seems unlikely to present a major confound. Likewise, the majority of those not completing the follow-up assessment were either deceased or had gone on to receive heart transplantation. Since heart transplantation, like other types of solid organ transplantation, has been widely identified to be an extremely stressful event in its own right,9–11 we had chosen heart transplantation as an exclusion criterion for the follow-up portion of the study. In fact, only one subject contacted refused participation in the second phase of the study. If that individual had developed an anxiety or depressive syndrome, this would then have been missed; however, this would still represent a very low incidence rate. One might hypothesize, based on prior work in other cardiovascular illness such as myocardial infarction,12–15 that the deceased subjects could have developed psychopathology and that this could have been a specific risk factor contributing to their death. This hypothesis, while intriguing, remains untestable.
Finally, another potential explanation for the lack of new psychopathology in our group might be that the follow-up period was too short. However, further psychopathology directly attributable to ICD implantation seems unlikely to have its onset more than 1 year after implant. Perhaps the experience of receiving occasional shocks from the device could precipitate anxiety, depression, or other psychopathology over longer follow-up. About half of the subjects had received one or more discharges at follow-up. Most subjects receiving shocks reported inability to predict when they would occur. Overall, the subjects rated themselves as well prepared prior to implantation but generally not well prepared for the shocks themselves at follow-up; frequently the subjects commented to the effect that "nothing could really prepare you for that." Despite this, the subjects were not highly fearful of receiving shocks and self-ratings of anxiety, depression, and anger relating to the device were low. Also, overall acceptance of the device seemed to be excellent, as nearly all said they would recommend it to others considering the procedure.
One limitation to the current study is that the number of subjects is relatively low. A much larger sample would undoubtedly have identified some cases of new-onset psychopathology; the existing literature, knowledge about incidence rates of psychopathology in the general population, and our own clinical experience all support this. Regardless, our data do not support high incidence rates of psychopathology in this patient population.
A second potential limitation of this study is that the main measure is a categorical, diagnostic one rather than dimensional. This is an advantage insofar as it allows for the identification of full-fledged psychiatric illnesses. However, it is also a disadvantage in that substantial psychological distress may be missed by traditional, structured diagnostic instruments.
Finally, for practical reasons most of the follow-up interviews were conducted by telephone. It remains possible that some new-onset psychopathology could have been missed through the use of telephone interviews. The reliability of telephone vs. in-person SCID interviews has not yet been published, to our knowledge. However, another semistructured interview, the Schedule for Affective Disorders and Schizophrenia, or SADS, does have well-documented, acceptable telephone vs. in-person reliability.16,17
The ICD recipients in this study did not have new-onset psychopathology following implantation. The subjects felt well prepared prior to implantation but somewhat less so after receiving discharges. Overall levels of device acceptance appeared to be high.
|
ACKNOWLEDGMENTS
|
This study was presented in part at the American Psychiatric Association Annual Meeting in San Diego, CA, May 1997.
The authors thank Ms. Janet Polich for her expert assistance in manuscript preparation and Ms. Barbara Praus for her assistance in conducting this study.
|
REFERENCES
|
-
Moss AJ, Hall WJ, Cannom DS, et al: Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. N Engl J Med 1996; 335:1933–1940[Abstract/Free Full Text]
-
Wever EFD, Hauer RNW, Schrijers G, et al: Cost-effectiveness of implantable defibrillator as first-choice therapy versus electrophysiologically guided, tiered strategy in postinfarct sudden death survivors. Circulation 1996; 93:489–496[Abstract/Free Full Text]
-
Morris PL, Badger J, Chmielewski C, et al: Psychiatric morbidity following implantation of the automatic implantable cardioverter defibrillator. Psychosomatics 1991; 32:58–64.[Abstract/Free Full Text]
-
Pycha C, Calabrese JR, Gulledge AD, et al: Patient and spouse acceptance and adaptation to implantable cardioverter defibrillators. Cleveland Journal of Medicine 1990; 57:441–444
-
Pycha C, Gulledge AD, Hutzler J: Psychological responses to the implantable cardioverter defibrillator: preliminary observations. Psychosomatics 1986; 27:841–845[Abstract/Free Full Text]
-
Dougherty CM: Longitudinal recovery following sudden cardiac arrest and internal cardioverter defibrillator implantation: survivors and their families. Am J Crit Care 1994; 3:145–153
-
Spitzer RL, Williams JBW, Gibbon M, et al: Structured Clinical Interview for DSM-III-R–Patient Version (SCID-P). New York State Psychiatric Institute, Biometrics Research Department, 1988
-
Vlay SC, Olson LA, Fricchione GL, et al: Anxiety and anger in patients with ventricular tachyarrhythmias. Responses after automatic internal cardioverter defibrillator implantation. PACE 1989; 12:366–373
-
Bohachick P, Anton BP, Wooldridge PJ, et al: Psychosocial outcome six months after heart transplant surgery: a preliminary report. Res Nurs Health 1992; 15:165–173[Medline]
-
Levenson JL, Olbrisch ME: Shortage of donor organs and long waits: new sources of stress for transplant patients. Psychosomatics 1987; 28:399–406[Abstract/Free Full Text]
-
Dew MA, Roth LH, Schulberg HC, et al: Prevalence and predictors of depression and anxiety-related disorders during the year after heart transplantation. Gen Hosp Psychiatry 1996; 18(suppl):48S–61S
-
Frasure-Smith N, Lesprance F, Talajic M: Depression following myocardial infarction: impact on 6-month survival. JAMA 1993; 270:1819–1825[Abstract/Free Full Text]
-
Frasure-Smith N, Lesprance F, Talajic M: Depression and 18-month prognosis after myocardial infarction. Circulation 1995; 91:999–1005[Abstract/Free Full Text]
-
Bruce ML, Leaf PJ: Psychiatric disorders and 15-month mortality in a community sample of older adults. Am J Public Health 1989; 79:727–730[Abstract/Free Full Text]
-
Aromaa A, Raita Salo R, Reunanen A, et al: Depression and cardiovascular disease. Acta Psychiatr Scand Suppl 1994; 377:S77–S82
-
Paulson AS, Crowe RR, Noyes R, et al: Reliability of the telephone interview in diagnosing anxiety disorders. Arch Gen Psychiatry 1988; 45:62–63[Abstract/Free Full Text]
-
Sobin C, Weissman MM, Goldstein RB, et al: Diagnostic interviewing for family studies: comparing telephone and face-to-face methods for the diagnosis of lifetime psychiatric disorders. Psychiatr Genet 1993; 3:227–230
This article has been cited by other articles:
|
|
|
|
 
J. K. Schulman, P. R. Muskin, and P. A. Shapiro
Psychiatry and Cardiovascular Disease
Focus,
April 1, 2005;
3(2):
208 - 224.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. Godemann, B. Ahrens, S. Behrens, R. Berthold, C. Gandor, F. Lampe, and M. Linden
Classic Conditioning and Dysfunctional Cognitions in Patients With Panic Disorder and Agoraphobia Treated With an Implantable Cardioverter/Defibrillator
Psychosom Med,
March 1, 2001;
63(2):
231 - 238.
[Abstract]
[Full Text]
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 1998
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
