Scand J Soc Med, Vol. 26, No.

Social support, social disability and their role as predictors of depression among patients with congestive heart failure
Terje A. Murberg1, Edvin Bru1, Torbjrn Aarsland2 and Sven Svebak3
1 Stavanger College, Stavanger, 2 Hjertelaget Research Foundation, Stavanger, 3 The Norwegian University of Science and Technology, Trondheim, Norway

Social support, social disability and their role as predictors of depression among patients with congestive heart failure. T.A. Murberg1, E. Bru1, T. Aarsland2, S. Svebak3. ( 1Stavanger College, Department for Health and Social Education, 2Hjertelaget Research Foundation, Stavanger, 3The Norwegian University of Science and Technology, Trondheim, Norway.) Scand J Soc Med 1998, 2 (8795). The purpose of this study was to assess the eect of social support variables, personality, clinical variables (New York Heart Associations classication), and social disability upon depression. The sample consisted of 119 clinically stable patients (34 females, 85 males) with symptomatic heart failure, recruited from an outpatient hospital practice. The patients underwent a brief physical examination and completed a set of questionnaires. Descriptive statistics were used to characterise the patients informal functional network. The analysis revealed that the intimate social network support (spouses) and primary social network support (close family) were rated as most supportive. Results from the path analysis showed that social disability was explained by the two personality factors, neuroticism and extraversion, and by the severity of disease (NYHA). No signicant eects of the social support variables upon social disability were detected. Moreover, path-analyses showed that poor intimate network support, social disability and neuroticism were signicantly positively associated with depression. Key words: chronic heart failure, depression, social disability, social support.

INTRODUCTION Congestive heart failure (CHF ) is a virulent syndrome, characterised by insucient myocardial work capacity and a high rate of morbidity and mortality. Prevalence estimates indicate that approximately 12% per annum are suering from CHF (1), and the prevalence and incidence of heart failure increase dramatically with ageing. In the last decade, medical interventions and pharmacological therapy have succeeded in reducing symptoms, improving functional capacity and prolonging life in this patient group (2, 3). Despite this improvement in medical treatment
Scandinavian University Press 1998. ISSN 0300-8037

for patients with advanced heart failure, CHF still is a condition with chronic physical limitations that may have practical, emotional and social consequences for the individuals. As the age characteristics of the population change, CHF therefore represents both an increasing clinical problem and a policy challenge in the Western society. The cardinal symptoms of heart failure are breathlessness and fatigue resulting in exercise intolerance. There is vast empirical evidence that patients with heart failure experience limitations in the performance of walking and other physical activities, as well as in carrying out daily tasks (4). Consequently, most heart failure patients seek instrumental and emotional assistance from the formal and informal care system in order to compensate for abilities lost as a result of their disorder. Previous research has reported that elderly people primarily turn to their informal network and secondarily, they turn to their formal care system (5, 6). They are more likely to receive help from their spouse than from children and friends (710). However, according to our knowledge no studies have explored the informal support network system among patients with heart failure. Such data would be useful in planning the rehabilitation process of heart failure patients. One purpose of the present investigation was therefore to describe the CHF patients informal social support network. Congestive heart failure is a debilitating condition aecting social functioning as well as other aspects of quality of life even in its early stages (1115). Past research indicates that social functioning suers considerably in CHF patients (16). In a study of 134 heart failure patients, Dracup et al. (13), reported that the most negative changes occurred in the relationships with friends and members of the extended family. In a recent study (12), CHF patients were found to report poorer social function when compared to patients with other chronic diseases. Another purpose of the present study was therefore to assess the heart failure patients perceptions of social disability as a result of living with heart failure.
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T. A. Murberg et al. to depression may dier between dierent groups of cardiac patients or between stages of cardiac disease. This study is concerned with the heart failure patients, because studies that have previously explored associations between problems concerning social relationships and depression among CHF-patients are few. The heart failure patients perceived social disability, mainly imposed by the experience of physical limitations, may be an important predictor of depression in addition to the perceived lack of social support. However, depression as well as social support and social disability may be aected by personality factors such as neuroticism and extraversion (27). Individuals high in neuroticism, compared to more stable individuals, may have a general tendency to interpret all kinds of life events more negatively (17, 28). This could aect the perceptions of disease as well as other types of life events. Finally, the life threatening nature of heart failure may in itself result in resignation or depression. The last purpose of this study is therefore to explore the associations of (1) perceived social support, (2) perceived social disability, (3) personality factors and (4) medical indicators of heart failure severity (NYHA) with depression.

A life threatening illness like CHF, with considerable restrictions in physical exercise capacity and loss of social roles, is likely to inuence the social life of the patient. However, patients perceptions of social disability may also be aected by personality factors like neuroticism and extraversion. Individuals high in neuroticism are found more likely to interpret life events in more negative ways than are others (17, 18) and may, therefore, report less support than they actually receive. Neurotics may also be more disposed to worries about their medical condition than are stable individuals. Patients high in neuroticism may therefore avoid social interactions interpreted as physically demanding, fearing that such activities could make them critically ill. According to Eysenck (19), introverts are believed to be more reluctant to take social initiatives. This reluctance towards social engagement may increase and become critical for social contact when physical capacity is reduced. Perceptions of social disability may also be aected by the quality of the informal social network. If the environment takes into consideration the physical limitations of the CHF patients, the patients may experience less social debilitations as a result of the disorder. A third purpose of the present study was to explore the associations of the perception of social disability with: (1) the quality of the informal social network, (2) personality factors (neuroticism and extraversion), (3) disease severity as assessed by NYHA among CHF patients. Problems with or failing social relationships have consistently been found to display signicant associations with a wide range of physical and mental health problems, including depression (20). Most research in this area among cardiac patients have focused on structural properties (social network) or the supportive content (social support) of the social relationships, and ndings are somewhat inconsistent. Friedman (21) found in a study among women with chronic heart failure that perceived enacted emotional support was signicantly associated with positive aect. Also in studies among post myocardial infarction patients, signicant associations between lack of social support and depression are reported (22, 23). Contrary, in one of the few studies designed to assess depression among heart failure patients, Freedland et al. (24) suggested that social support was nonsignicantly related to depression. Moreover, recent studies of depression among post-MI patients indicate that social support is non-signicantly related to depression (25, 26). The inconsistencies in ndings could reect dierences in the dimensions of social relationships focused on in each study. It may also be that the dimension of social relationships critical
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PATIENTS AND METHODS

Subject sample A total of 204 patients were invited by letter to participate in the survey. They were all diagnosed with CHF and were living within travelling distance from an outpatient hospital practice. A brief description of the study was included in the letter. A total of 152 patients (74.5%) responded, and out of these 29 (19.1%) were unwilling to participate. Of the total, 123 patients responded positively, which included 58,3% of all registered CHF patients in the local area. Three patients were excluded because they were unable to complete the questionnaires due to mental debilitation, and one patient was excluded due to previous heart transplantation. A remainder of 119 patients completed the study. The mean age was 66.0 years (range: 18 to 80, SD=9.1). Of these, 18 (15.1%) patients were employed and 66 patients (55.5%) had retired; and 35 patients (29.4%) were on sick leave or permanently disabled from work. More males (n= 85) than females (n= 34) participated in the study. Review of patient records provided information on history of the disease. The mean time since onset of heart failure was 61.0 months (SD=57.3). In 77 patients (64.7%) the aetiology of CHF was myocardial infarction, whereas cardiomyopathy was found in 14 cases (11.8%), valvular disease in 12 cases (10.1%), hypertension in 7 cases (5.9%), and other problems such as chronic myocardial ischemia, chronic atrial brillation or septum defects were found in 5 cases (4.2%). In 4 patients (3.4%) the reason for heart failure was unknown. Co-morbidity was prevalent in the subject sample. A total

Social support, social disability and depression in CHF

of 85 patients (71.4%) had a history of myocardial infarction, which meant that some of these patients suered from CHF secondary to another diagnosis than myocardial infarction. Thirty-two patients (26.9%) had occasional angina pectoris. Thirty-seven patients (31.1%) had been revascularized by coronary artery bypass grafting or percutaneous translumial coronary angioplasty, with a mean time of 56.6 months (SD=45.9) since the procedure. Nine patients (7.6%) had undergone valvular surgery. Eleven cases (9.2%) of diabetes mellitus were found, and six of these were on insulin treatment. Eight patients (6.7%) had a history of chronic obstructive lung disease, and four of these received anti-asthmatic therapy. Inspection of electrocardiography recordings revealed sinus rhythm in 84 cases (70.6%), atrial brillation in 27 cases (22.7%) and pacemaker-induced heart rhythm in 8 cases (6.7%). At the time of the interview, 104 patients (87.4%) used angiotensin converting enzyme inhibitors or angiotensin II blockers, 103 patients (86.6%) were on diuretic therapy, 77 (64.7%) used digitalis, and 49 patients (41.2%) used longacting nitrates. Twenty patients (16.8%) used amiodarone for heart rhythm stabilisation, while only 8 patients (6.7%) were on beta-blocker therapy. Instruments Social network support: Social support was assessed by 15 items concerning emotional and instrumental support from spouse, close family, relatives, neighbours and friends. Emotional support was assessed by the use of 5 items of which 2 items were scored according to a 5-step Likert format (neveralways), and 3 items were scored by a dichotomous format (agreedisagree). Instrumental support was assessed by 10 items scored according to a 4-step Likert format (very likelyquite unlikely). All 15 items are listed in Table III. Social disability: Social disability was assessed by 4 items: (1) You feel that the disease makes it dicult to visit family and friends, (2) You feel that the disease makes it dicult to have visits from family and friends, (3) You feel that the disease makes it dicult to take part in social events, (4) You feel that the disease makes it dicult to go with family and friends on holidays. The social disability items were scored according to a 6-step Likert format (not at allvery much). A social disability index score for use in the path analyses was computed as the sum of all four items. Depression: The Zung Self-Depression Scale (SDS) (29) was used to measure the level of depression. The SDS scale has 20 items on depressive symptoms. Respondents describe how frequently they experience each symptom on a 4-point scale ranging from none or little of the time to most or all of the time. The scale has been shown to have good reliability and validity characteristics (30). Clinical variables: The New York Heart Association classication is the most widely used measure of functional status in individuals with chronic heart disease. Grouping of patients is based on their symptoms during activity of daily living. NYHA class I includes patients without limitation of physical activity (no fatique, palpitation, dyspnea

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or anginal pain during ordinary activity). NYHA class II includes patients with slight or moderate limitation of physical activity. NYHA class III covers patients with more marked limitations of physical activity (able to walk a maximum of 200 m on at ground before resting). NYHA class IV includes patients with inability to carry on physical activity without discomfort (symptoms of heart failure are present also at rest) (31). The NYHA criteria may be inuenced not only by physical status of disease but also by the patients psychological characteristics such as diseaserelated expectations. The patients were grouped by their physician according to the NYHA criteria. Personality: The E and N Scale of the Eysenck Personality Inventory ( EPI ) (32) was used to assess extraversion (E ) and neuroticism (N ). The E scale consists of 21 items and the N Scale of 22 items, respectively, and are scored according to a yesno format. Study procedures The study protocol was approved by the Regional Medical Ethical Committee. Eligible patients were contacted and appointments on a voluntary basis were made with those willing to be enrolled in the study. All patients provided written informed consent prior to entry into the study. The patients completed the scales described above during a structured interview conducted by the rst author. The interview session lasted for approximately 1 hr. Statistical analysis Statistical analyses were carried out using the SPSS-PC statistical package (33). In factor analyses, a least-square model with varimax rotation was implemented. Analyses included descriptive statistic, path analyses and factor analyses. Uncorrelated factor scores derived from the factor analyses of responses to social support items were included in the path analyses. Standardised scores (z-score) were used in the factor analyses due to three dierent scoring formats across these 15 items (see Table III ). An index-score for social disability was computed by adding the scores for each of the four items included to assess this experience (see Table II ). Chronbachs alpha for the social disability index was .83. The path-analyses treated each variable as a regressor upon the simultaneous and previous variables in the equation (see Fig. 1 which includes Beta-coecient estimates on power of unique covariance).

RESULTS Descriptive statistics for indicators of social support are presented in Table I. From this table it will be seen that 70.3% of the sample reported that it was likely or very likely that spouse would assist both in the case of need for care and in the case of need for instrumental aid. 78.9% indicated that close family likely or very likely would assist in regard to caring aid, whereas 75.6% reported that close family likely or very likely would assist in regard to instrumental
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Table I. The probability (%) of receiving care and instrumental aid, in case of need, reported by the CHF patients (n=119)
The frequency of support Very likely Care from: Spouse Close family Relatives Friends Neighbours Instrumental aid: Spouse Close family Relatives Friends Neighbours Likely Uncertain Quite unlikely No spouse

67.8 69.7 20.2 21.0 18.5 67.8 75.6 23.5 24.4 21.8

2.5 9.2 14.3 32.8 23.5 1.7 9.2 19.3 37.0 25.2

0.8 12.6 27.7 20.2 23.5 0.0 7.6 22.7 16.8 19.3

0.8 8.4 37.8 26.1 34.5 2.4 7.6 34.5 21.8 33.6

28.1

28.1

aid. As seen in Table I, relatives, friends and neighbours were appraised frequently as less available for assistance in case of need for nursing and/or instrumental aid. Approximately 20% of the patients reported that it was likely that they would receive nursing and practical help from their secondary network. The result from the descriptive analyses of patients perceived social disability are presented in Table II. Inspection of the table show that 68.9% reported having no problems in connection with visiting friends or family, and a total of 74.8% of the CHF patients reported having no problems concerning receiving visits from family or friends. 37% reported having problems with participating in social activities where people were gathering in larger groups, and 36.1% reported that they in some way had problems with going away for a holiday with their family and/or friends. Dimensionality of responses given to social support items were explored by factor-analysis. A three factor

solution presented meaningful factors with adequate within-factor consistence. This factor solution had a minimum eigenvalue of 1.37 and accounted for 70% of the total item variance. The rst factor, accounting for 43.1% of the variance, included ve items on relations to spouse and was labelled intimate network support. (Chronbachs alpha for this factor was .96.) The second factor, accounting for 17.7% of the total item variance, was constructed on the basis of the items regarding support from relatives and neighbours. This factor was labelled secondary network support. (Chronbachs alpha for the second factor was .83.) The third factor accounted for 9.2% of the total item variance and was constructed on basis of the items expressing social support from close friends and family. It was labelled primary network support. (Chronbachs alpha for the third factor was .74). The three factor-scores were included in path analyses to predict social disability and depression. Fig. 1 presents coecients for the path analyses

Table II. Descriptive statistics for responses to items on social disability (see method for more detailed descriptions of items; n=119)
Items Extent of social disability perceived Not at all (%) Very little (%) 8.4 12.6 10.1 10.1 Little (%) A bit (%) Much (%) Very much (%) 3.4 1.7 4.2 11.8 Mean score

To To To To

visit others receive visits take part in social events go on holiday

68.9 74.8 52.9 53.8

4.2 5.0 11.8 5.0

10.1 4.2 13.4 12.6

5.0 1.7 7.6 6.7

1.84 1.50 2.25 2.44

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Table III. Distribution and factor loading of responses given to the social support items across the three principal components (the factor loading inclusion criterion is set to .40, n=119)
Items Intimate network support I can talk to my partner about intimate aairs. I feel satised and content with my marriage/partnership. I nd little pleasure in my marriage/partnership. If you fell ill and had to stay in bed, how likely would you receive help from your spouse? If you should need practical help because of your condition, how likely would you receive help from your spouse? Secondary network support If you fell ill and had to stay in bed, how likely would you receive help from your relatives? If you should need practical help because of your condition, how likely would you receive help from your relatives? If you fell ill and had to stay in bed, how likely would you receive help from your friends? If you should need practical help because of your condition, how likely would you receive help from your friends? If you should need practical help because of your condition, how likely would you receive help from your neighbours? If you fell ill and had to stay in bed, how likely would you receive help from your neighbours? Primary network support How often do your close friends and relatives make you feel loved and cared for? If you should need practical help because of your condition, how likely would you receive help from close family? How often are your close friends and relatives willing to listen when you need to talk about problems or worries? If you fell ill and have to stay in bed, how likely would you receive help from close family? Eigenvalues Total variance explained: 70% Factor loading I .97 .97 .96 .96 .94 II III

.82 .78 .72 .70 .53 .52

.84 .69 .64 .58 6.46 43.1 2.66 17.7 1.37 9.2

using neuroticism, extraversion, NYHA, intimate network support, secondary network support and primary network support as the independent variables, social disability as an intermediate variable, and depression (SDS) as the dependent variable. The path analyses show that neuroticism was signicantly positively associated to social disability, whereas extraversion was signicantly negatively associated with social disability. Moreover, a signicant and positive association between the severity of disease variable (NYHA) and social disability appeared. For the social support variables no signicant eect on social disability was detected. Bivariate correlations were detected between social disability and secondary network support (r=.31, p<.01) and between social disability and primary network support (r=.20, p<.05). Furthermore, the analysis revealed a signicant direct association

between social disability and depression. A signicant positive and direct eect of neuroticism upon depression appeared, whereas intimate network support was directly negatively associated with depression. The other variables in the analysis were not found to be directly related to depression. There was a signicant positive and indirect eect of neuroticism upon depression through social disability, whereas a moderate but signicant positive eect of NYHA appeared through social disability. Also for the other personality variable, extraversion, a signicant negative eect upon depression was found via social disability. The regression equation accounted for 50% of the variance in depression. DISCUSSION One purpose of this study was to examine the supportive social network of the heart failure patient.
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Fig. 1. path analysis of the eects of the medical status indicator (NYHA), neuroticism ( EPQN ), extraversion ( EPQE), social support, and social disability upon depression (SDS). (Note: Beta-coecients; *p<.05, **p<.01).

The ndings indicated that for this sample of patients, spouses and close family provide a highly supportive social network. Descriptive analyses stated that a total of approximately 68% of the patients reported that they were very likely to receive assistance from spouse if they fell ill. One should keep in mind at this point that 28.1% of the patients were single. 94.3% of the married patients reported that it was quite obvious that they would receive nursing and practical help from their spouse if they were in need. 70% reported that close family to a high degree would provide assistance in case of need. The secondary network (relatives and neighbours) seemed to be of marginal importance in providing support when needed. These results support the ndings in previous empirical studies, reporting that spouse and close family are the most important supportive network for patients with cardiovascular disease (34) as well as for elderly people in general (5, 35, 6, 36). It has been shown that almost 80% of the assistance given to the elderly originates from their primary social network (37). Limitations of physical activity is a hallmark of heart failure and may result in social debilitation for the CHF patient. One purpose of this study was, therefore, to assess the CHF-patients perceptions of
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social disability. Several investigators have reported a considerable change in patients social functioning (4, 13, 15). Our data showed that a total of 38.8% of the patients reported varying degrees of problems, ranging from some to extensive in at least one of the social elds assessed. Patients frequently reported more problems related to leaving their home for a holiday (31.1%) and participating in social activities where people were gathering in larger groups (25.2%), than to paying visits to family (18.5%) or receiving such visitors (7.6%) (see Table II ). These data may be reecting the continuous anxiousness and uncertainty about the future experienced by many heart failure patients. Leaving their home may provoke exaggerated fear and anxiousness about disease-related symptom provocations. This explanation was supported by a number of patients during the interview. As expected, the results from the path analyses show that perceived social disability was signicantly positively related to the severity of the disease (NYHA). Furthermore, bivariate correlation analyses detected positive signicant associations between the primary network support, secondary network support and social disability. However, these associations were of marginal signicance when con-

Social support, social disability and depression in CHF trolling for personality and NYHA (see Fig. 1). The marginal inuence of the social network upon social disability may reect that the social network is aware of the CHF patients physical and psychosocial conditions and, therefore, to a great extent takes the physical limitations of these patients into account. The strong associations between neuroticism and social disability may indicate that patients high in neuroticism are more likely to experience social disability than are those low in neuroticism. One possible explanation of these ndings is that patients high in neuroticism are more anxious about the consequences of the disease and that they therefore may be frightened by and withdraw from social interactions. Another explanation may be that patients high in neuroticism are likely to underestimate their social situation. The signicant and negative association between extraversion and social disability supports the assumption that introverts may be more likely than extroverts to withdraw from social interactions due to CHF symptoms. A main purpose of the present study was to examine the associations between indicators of perceived social support, personality, severity of disease, and social disability with depression. Results from the path analyses show that intimate network support was directly negatively related to depression. This nding is consistent with previous research indicating that a good relation with spouse is associated with a lower level of depressed mood among patients with cardiovascular diseases (22, 38, 23). What remains puzzling, is the current failure to detect a direct eect of the primary network support upon depression. The results show that both primary network support and secondary network support were unrelated to depression, when controlling for eects of personality variables. A possible explanation of these ndings is that various forms of social support may be of varying importance in the prediction of depression, depending upon the type of life events confronted. For the heart failure patients, most of them being elderly, support from spouse may be a more important factor for psychological well-being than support from primary and secondary network. In contrast, experience of social disability was related to depression even when controlling for personality and severity of disease. In this way, ndings indicate that social impairment due to the disease may be a signicant risk factor for depression among CHF patients. This is an interesting nding considering inconsistent results reported for relations between social support and depression among cardiac patients in previous studies (2026). Moreover, the weak associations between social support variables and

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social disability indicate that the latter variable assesses other dimensions of the individuals perception of social relations than the traditional social support variables. Results from this study imply that disease-related social disability should be included as an additional predictor in studies aimed at exploring the eects of social relations upon depression among cardiac patients. Finally, the NYHA classication of medical severity yielded a non-signicant association with depression. This result is consistent with ndings from previous research in cardiac disease (25, 39), and showed that the medical indicator of heart failure severity among these patients are less important as predictor of depression than is patients perception of social disability. However, the medical indicators of heart failure severity was indirectly related to depression through its eects upon social disability. Results from this study indicate that in order to facilitate or improve patients quality of life, attention should be directed towards patients that report social disability due to CHF. Health care professionals should inform the patients of the potential social consequences of living with heart failure, as well as of how the social consequences might lead to depression. Moreover, the patients relatives should be well informed about how to arrange social gatherings and social life in general so that the family member with CHF is not excluded. Another way of improving CHF-patients social life could be to organise self help groups where patients could participate and give each other mutual support. This would be particularly important for those having a limited social network. Finally, professionals working with CHFpatients should try to identify patients high in neuroticism and introversion, because these patients are the most likely to experience disease-related social disability and depression. The selection of the present patient sample included 58,3% of all registered CHF outpatients in the area. Reasons for not wanting to be enrolled in the study were not investigated in detail although it is likely that patients who participated in the study were more healthy and less likely to complain about physical intolerance that those who wanted not to participate. In addition, this study is cross-sectional, requiring caution in drawing causal conclusions. Dierent results may have been obtained in a study with a longitudinal design, and further investigations of these variables among CHF patients should, therefore, be examined in a longitudinal study. ACKNOWLEDGEMENTS
The study participants and the sta at the Hjertelaget Research Foundation, Stavanger, are acknowledged for
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their generous assistance. The study was supported nancially by the Rogaland Central Hospital, and Hjertelaget Research Foundation, Stavanger.

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