Objective: We investigated the prevalence of anxiety and depressive symptoms in patients with an implantable cardioverter defibrillator (ICD) and their partners, and the role of personality factors and social support as determinants of distress. 
Methods: Of all surviving patients (n = 221) having had an ICD implanted between October 1998 and January 2003, 182 patients and 144 partners completed the Hospital Anxiety and Depression Scale, the Type D Personality Scale, and the Perceived Social Support Scale. Type D personality defines those who tend to experience increased negative distress and who do not express these negative emotions in social interactions. Clinical variables for the patients were obtained from medical records. 
Results: Thirty-one percent of patients versus 42% of partners suffered from symptoms of anxiety (p = .048); symptoms of anxiety were particularly prevalent in male partners. Twenty-eight vs. 29% suffered from depressive symptoms (p = .901). In patients, Type D personality was independently related to anxiety (OR: 7.03; 95% CI: 2.32-21.32) and depressive symptoms (OR: 7.40; 95% CI: 2.49-21.94) adjusting for all other variables. Underlying cardiac disease pathology did not explain differences in patient distress. In partners, Type D personality was independently associated with increased symptoms of anxiety (OR: 8.77; 95% CI: 3.19-24.14) and depression (OR: 4.40; 95% CI: 1.76-11.01). 
Conclusion: Partners experienced similar levels of depression but higher levels of anxiety compared with ICD patients. Personality was an important explanatory factor of distress in both ICD patients and their partners. Research is now warranted to investigate the implications of this finding for the clinical course of ICD patients, as Type D personality has been associated with adverse prognosis in patients with coronary artery disease.

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Type D personality is associated with increased anxiety and depressive symptoms in patients with an implantable cardioverter defibrillator and their partners.

Significant mortality benefits have been documented in recipients of implantable cardioverter defibrillators (ICDs); however, the psychosocial distress created by the underlying arrhythmia and its potential treatments in patients and family members may be underappreciated by clinical care teams. The disentanglement of cardiac disease and device-related concerns is difficult. The majority of ICD patients and families successfully adjust to the ICD, but optimal care pathways may require additional psychosocial attention to all ICD patients and particularly those experiencing psychosocial distress. This state-of-the-science report was developed on the basis of an analysis and critique of existing science to (1) describe the psychological and quality-of-life outcomes after receipt of an ICD and describe related factors, such as patient characteristics; (2) describe the concerns and educational/informational needs of ICD patients and their family members; (3) outline the evidence that supports interventions for improving educational and psychological outcomes for ICD patients; (4) provide recommendations for clinical approaches for improving patient outcomes; and (5) identify priorities for future research in this area. The ultimate goal of this statement is to improve the precision of identification and care of psychosocial distress in ICD patients to maximize the derived benefit of the ICD.

Educational and Psychological Interventions to Improve Outcomes for Recipients of Implantable Cardioverter Defibrillators and Their Families A Scientific Statement From the American Heart Association

Background: The partner of the implantable cardioverter-defibrillator (ICD) patient serves as an important source of support for the patient, which may be hampered if the partner experiences increased distress. We examined (1) potential differences in anxiety and depressive symptoms in ICD patients compared to their partners, and (2) the extent to which the partner's personality is a more important determinant of partner distress than patient clinical characteristics, using a prospective design.



Methods: Consecutively implanted ICD patients (n = 196) and their partners (n = 196) completed a set of psychological questionnaires at baseline and 6 months after implantation.



Results: Analysis of variance with repeated measures showed that partners had significantly higher levels of anxiety compared to patients (F(1,390) = 16.431; P < 0.001) but not depressive symptoms (F(1,390) = 0.186; P = 0.67). There was a significant overall reduction in anxiety (F(1,390) = 79.552; P < 0.001) and depressive symptoms (F(1,390) = 39.868; P < 0.001) over 6 months, with group (i.e., patient vs partner) exerting a stable effect on anxiety (F(1,390) = 0.966; P = 0.33) and depressive symptoms (F(1,390) = 0.025; P = 0.87). These results remained in adjusted analysis. Determinants of anxiety and depressive symptoms in partners included secondary prophylaxis in patients (Ps < 0.001–0.002), Type D personality of the partner (Ps < 0.001–0.001), secondary prophylaxis by shock interaction (P = 0.002; anxiety only), and secondary prophylaxis by Type D interaction (Ps = 0.001–0.003).



Conclusions: Partners had higher levels of anxiety but not depression than ICD patients. Partner distress could be attributed not only to the partner's personality, but also to patient clinical characteristics, primarily secondary prophylaxis for ICD therapy. These results indicate that information on the clinical characteristics of the patient in addition to partner characteristics may help identify partners at risk of distress.

Increased Anxiety in Partners of Patients with a Cardioverter-Defibrillator: The Role of Indication for ICD Therapy, Shocks, and Personality

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When Should Patients with Lethal Ventricular Arrhythmia Resume Driving

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Patterns of risk of depressive symptoms among HIV-positive women in the Southeastern United States

Objective: To describe psychological reactions among family members of patients receiving an implantable cardioverter/defibrillator (ICD) during the first 9 months after implantation. Methods: Eighty-two family members (age 56 ± 12 years, 74 percent female, 79 percent married, 88 percent Caucasian) of ICD patients completed questionnaires regarding their mood (Profile of Mood State), cognitive illness appraisals (Meaning of Illness Questionnaire) and coping strategies (Jalowiec Coping Scale) prior to ICD implantation, and as well as 1 and 9 months postoperatively. Results: Total mood disturbance score (TMD), threat appraisal, and emotion- and problem-focused coping were highest prior to ICD implantation, and decreased during the first postoperative month showing stable values thereafter. There was no change in challenge appraisal. Multiple regression analysis found that the use of psychotropic drugs (anxiolytics, sedatives; Beta = .25), emotion-focused coping (Beta = .37), and challenge appraisal (Beta = -.21) at 1 month accounted for 26 percent of variance in TMD at 9 months. Conclusion: A spouse's ICD implantation is a major stressful event for family members leading to a diminished mood state prior ICD implantation. Reduction in emotion-focused coping and the use of challenge appraisal may improve mood state in family members of ICD patients during early follow-up.

Psychological reactions among family members of patients with implantable defibrillators.

BACKGROUND The miniaturization of implantable cardioverter defibrillators (ICDs) has made pectoral implantation possible. However, postoperative pain following the procedure has not been systematically studied. The aim of the current study was to prospectively assess patient discomfort and identify factors influencing pain perception during follow-up. METHODS Pain related to device implantation was quantified in 21 consecutive patients (age, 61 +/- 11 years; 17 men and 21 women; 16 of 21 had coronary artery disease; left ventricular ejection fraction, 32% +/- 15%) undergoing pectoral ICD implantation with conscious sedation (fentanyl 118 +/- 72 micrograms midazolam 14 +/- 9 mg). Patients completed the Visual Analogue Scale (VAS, 0-100) and the McGill Pain Questionnaire 24 hours and 1 month postoperatively. Regression analysis was used to define clinical and procedure related variables affecting patient discomfort and frequency of postoperative analgesic use. RESULTS The mean VAS score was 34 +/- 20 24 hours postoperatively. A single (4.8%) patient described postoperative pain as severe. Pain was reported to be moderate by 10 (47.6%) patients and mild by 10 (47.6%) patients. Intraoperative fentanyl requirement was a predictor of postoperative pain (R = 0.51, P = 0.036), and procedural duration was a strong predictor of postoperative analgesic use (R = 0.75, P < 0.001). Pain at 1 month decreased to a VAS score of 19 +/- 18 (P = 0.002 vs 24 hours) and was rated to be severe, moderate, and mild by 1, 3, and 17 patients, respectively. Late pain was related to a VAS score at 24 hours (R = 0.67, P = 0.004). CONCLUSIONS (1) Pectoral ICD implantation using conscious sedation is well tolerated. (2) Postoperative discomfort correlates with longer procedural times and larger intraoperative narcotic requirements.

Alexandra Marx

Papers

Psychological reactions among family members of patients with implantable defibrillators.

Patient Discomfort Following Pectoral Defibrillator Implantation Using Conscious Sedation