In reply

Abstract

In reply: Dr. Reyes-Ortiz provides an informative review of recent literature on the psychosocial factors that affect outcomes in coronary disease. This is an interesting and burgeoning area that has seen interesting results from well designed studies in recent years. Prospective data linking depression with cardiovascular mortality has been derived from clinical1 and population-based studies.2 Social isolation has also been shown to be an independent risk factor for mortality in those with coronary disease.3 There are fewer studies of the effect of psychosocial factors on non-mortality outcomes in coronary disease. We have another report on the same sample in press,4 which prospectively demonstrates a significant effect of anxiety and depression on physical function, daily activity interference, and role function after controlling for coronary disease severity, medical comorbidity, medical versus surgical coronary disease management during follow-up, age, gender, education, and social class. Dr. Reyes-Ortiz centers his attention on the question of hope, which he places rightfully at the intersection of the psychological and spiritual domains. There have been some interesting studies that addressed the issue of hopelessness specifically. Anda et al. reported data on 2832 adults, aged 45 to 77 years followed for a mean of 12 years in the National Health Examination Follow-up Study (NHANES II).5 After controlling for demographic and known risk factors, they noted a relative risk for fatal ischemic heart disease of 1.5 for depressed affect and 1.6 for those endorsing a single item about moderate to severe hopelessness. These findings are consistent with a large series of studies conducted over the last 30 years that demonstrate the importance of “negative affectivity” in coronary disease.6 Research to identify the pathophysiological mechanisms by which these psychosocial factors exert their effects on the heart remains largely to be done. However, there have been intriguing hypotheses concerning the role of platelet reactivity7 and autonomic tone8 raised in the literature. The next few years will, we hope, provide information leading to interventions to improve quality of life for patients with one of our most common and disabling chronic diseases.