The associations between psychological distress and healthcare use in patients with non-cardiac chest pain: does a history of cardiac disease matter?

Ghassan Mourad,Erland Svensson,Peter Johansson,Tiny Jaarsma,Anna Strömberg

doi:10.1186/s12888-018-1689-8

Ghassan Mourad, Erland Svensson + Show 3 more

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https://doi.org/10.1186/s12888-018-1689-8

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Abstract

BackgroundPsychological distress such as somatization, fear of body sensations, cardiac anxiety and depressive symptoms is common among patients with non-cardiac chest pain, and this may lead to increased healthcare use. However, the relationships between the psychological distress variables and healthcare use, and the differences in relation to history of cardiac disease in these patients has not been studied earlier. Therefore, our aim was to explore and model the associations between different variables of psychological distress (i.e. somatization, fear of body sensations, cardiac anxiety, and depressive symptoms) and healthcare use in patients with non-cardiac chest pain in relation to history of cardiac disease.MethodsIn total, 552 patients with non-cardiac chest pain (mean age 64 years, 51% women) responded to the Patient Health Questionnaire-15, Body Sensations Questionnaire, Cardiac Anxiety Questionnaire, Patient Health Questionnaire-9 and one question regarding number of healthcare visits. The relationships between the psychological distress variables and healthcare visits were analysed using Structural Equation Modeling in two models representing patients with or without history of cardiac disease.ResultsA total of 34% of the patients had previous cardiac disease. These patients were older, more males, and reported more comorbidities, psychological distress and healthcare visits. In both models, no direct association between depressive symptoms and healthcare use was found. However, depressive symptoms had an indirect effect on healthcare use, which was mediated by somatization, fear of body sensations, and cardiac anxiety, and this effect was significantly stronger in patients with history of cardiac disease. Additionally, all the direct and indirect effects between depressive symptoms, somatization, fear of body sensations, cardiac anxiety, and healthcare use were significantly stronger in patients with history of cardiac disease.ConclusionsIn patients with non-cardiac chest pain, in particular those with history of cardiac disease, psychological mechanisms play an important role for seeking healthcare. Development of interventions targeting psychological distress in these patients is warranted. Furthermore, there is also a need of more research to clarify as to whether such interventions should be tailored with regard to history of cardiac disease or not.

Highlights

Psychological distress such as somatization, fear of body sensations, cardiac anxiety and depressive symptoms is common among patients with non-cardiac chest pain, and this may lead to increased healthcare use
There was no direct association between depressive symptoms and healthcare use, which suggests that depressive symptoms may act more as an underlying variable than an outcome as in the fear avoidance model [15], which is shown in our revised Structural Equation Modeling (SEM) model (Fig. 2)
Depressive symptoms had in both groups an indirect effect on healthcare visits, this effect was significantly stronger in patients with history of Cardiac Disease (CD) than in those without

Summary

Introduction

Psychological distress such as somatization, fear of body sensations, cardiac anxiety and depressive symptoms is common among patients with non-cardiac chest pain, and this may lead to increased healthcare use. Our aim was to explore and model the associations between different variables of psychological distress (i.e. somatization, fear of body sensations, cardiac anxiety, and depressive symptoms) and healthcare use in patients with non-cardiac chest pain in relation to history of cardiac disease. Many patients with NCCP are not convinced by their ‘ruled out’ cardiac diagnosis, and lack an explanation for their chest pain [5,6,7] They continue to experience chest pain and avoid activities that they think might be harmful to their heart [1, 8,9,10], leading to substantial use of healthcare and societal resources [11]. Informed by the Fear-Avoidance model, a model was suggested implying that patients who experience recurrent and persistent chest pain that they perceive as threatening may express psychological distress in physical symptoms (i.e. somatization) and experience pain-related fear, which in turn can lead to cardiac anxiety and depressive symptoms, and increase healthcare use due to fear of having a cardiac event (Fig. 1a)

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