Depression as a predictor of return to work in patients with coronary artery disease
Introduction
Return to work is a vital goal of cardiac rehabilitation and an important social indicator of functional recovery after coronary artery disease (CAD) events. However, return to work rates vary widely around the world. Results from different studies are not always comparable because of methodological differences such as the use of different kinds of clinical groups, the pre-hospitalization employment status, the definition of return to work, and the lengths of follow-ups.
Although factors emerging as predictors of return to work vary over different studies, the most commonly reported variables are age (Boudrez, De Backer, & Comhaire, 1994; Mark et al., 1992; Mittag, Kolenda, Nordmann, Bernien, & Maurischat, 2001; Siegrist & Broer, 1997; Speziale, Bilotta, Ruvolo, Fattouch, & Marino, 1996), and level of education (Mark et al., 1992; Smith & O’Rourk, 1988; Speziale et al., 1996; Turkulin, Cerovec, & Baborski, 1988). The younger and the better educated seem to have the greatest chances of returning to work, although results on this matter are somewhat inconsistent (Engblom et al., 1994; Turkulin et al., 1988). Gender has also been reported as a predictor in some (Mark et al., 1992) but not in all studies (Riegel & Gocka, 1995), with men returning to work more than women.
The relation of psychological factors, especially depression, to the CAD recovery process has become a major research focus during the last decade (Carney, Freedland, Rich, & Jaffe, 1995; Carney et al., 1988; Frasure-Smith, Lespérance, Juneau, Talajic, & Bourassa, 1999; Frasure-Smith, Lespérance, & Talajic, 1993; Ladwig, Röll, Breithardt, Budde, & Borggrefe, 1994). However, not only depression at a clinical level, but also milder forms of depressive symptoms have been found to be important (Frasure-Smith, Lespérance, & Talajic, 1995; Sullivan et al., 1999). Depression also seems to be associated with poorer adherence to, and drop out from, rehabilitation programs (Blumenthal, Williams, Wallace, Williams, & Needles, 1982; Guiry, Conroy, Hickey, & Mulcahy, 1987; Stern, Pascale, & Ackerman, 1977). Furthermore, depression level has been reported as a determinant of work resumption (Maeland & Havik, 1987; Schleifer et al., 1989; Stern et al., 1977; Strauss et al., 1992), implying that depressed CAD patients are less likely to return to work. However, some studies also show contradictory results (Guiry et al., 1987; Mulcahy, Kennedy, & Conroy, 1988). High levels of depression seem to have the greatest impact on work resumption. Schleifer et al. (1989) found, for example, that only 38% of patients with major depression, whereas as many as 72% with mild depression and 63% of non-depressed patients returned to work 3–4 months after a CAD event.
Two psychosocial factors, the Type A behavior pattern and social support, might be of special interest in relation to work resumption. Persons with a Type A behavior pattern were originally characterized by excessive involvement in their jobs, extreme competitiveness, striving for achievement, aggressiveness, impatience, haste, restlessness and feelings of being challenged by responsibility under the pressure of time (Friedman & Rosenman, 1974). Because such persons are generally considered to be strongly committed to their work, they might be motivated to return to work after a coronary event (e.g. Shrey & Mital, 2000). Low social support (Berkman, Leo-Summers, & Horwitz, 1992) and social isolation (Orth-Gomér, Undén, & Edwards, 1988; Ruberman, Weinblatt, Goldberg, & Chaudhary, 1984) have also been determined as risk factors for cardiac events. Social support seems to have a buffering effect in that the negative impact of depression on CAD mortality decreases with increasing social support (Frasure-Smith et al., 2000). Thus, the beneficial effect of social support on cardiac outcomes might improve return to work rates.
Work resumption is considered to be a criterion of a good outcome after CAD. However, if the work is too mentally or physically demanding, work resumption might be an additional hardship and hence constitute a risk factor for new CAD events (Theorell, Perski, Orth-Gomér, Hamsten, & de Faire, 1991). Because the extent of work resumption partly reflects the amount of work strain, work resumption may be important to recovery and secondary prevention.
Since depression is closely linked to CAD outcomes, the aim of the present study was to assess the impact of depression as a predictor of work resumption, at full-time and reduced working hours, in cardiac patients participating in a comprehensive behaviorally oriented rehabilitation program.
Section snippets
Subjects
Participants were consecutively referred by local social insurance agencies to the rehabilitation program between January 1992 and June 1994. Subjects fulfilled the following inclusion criteria: (a) acute myocardial infarction (AMI), coronary bypass surgery (CABG) or percutaneous transluminal coronary angioplasty (PTCA) as the patients last diagnosis at the most six months before the start of the program, (b) age below 60 years, (c) employed, (d) able to perform a bicycle ergometer test with a
Results
Initial analyses revealed that there were no differences between the patients included in the study and those not participating on any of the predictor variables, except for body mass index showing that the non-participators had a higher weight (p=0.016).
When the rehabilitation program was completed after 12 months, 103 patients (52%) had returned at full-time, 52 patients (26%) at reduced working hours and 43 patients (22%) had not returned to work. One-way ANOVAs and χ2 tests were performed
Discussion
Return to work rates are due to many societal factors, such as the number of vacant jobs on the labor market at a particular time, as well as resources available to the social security system, rehabilitation agencies, and so on. In line with results reported by Boudrez and De Backer (2000) almost 80% of the patients in the present study had returned to work by the time the 12-month rehabilitation program was completed, two-thirds of those at full time. It was much easier to identify correctly
Acknowledgements
This study is part of projects initiated and headed by professor Åke Nygren, Karolinska Institute, and was funded by the AMF insurance company and the SPP insurance company. We also express our gratitude to all the members of staff at the rehabilitation center (HälsoInvest Föllinge).
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