The impact of psychological distress on long-term recovery perceptions in survivors of cardiac arrest

Highlights

• 53% of patients reported negative perceived recovery 6-months post-cardiac arrest.

• Psychological symptoms were independently associated with perceived recovery.

• Cognitive and functional impairment were not associated with perceived recovery.

• Depression and PTSD are intimately tied to subjective well-being.

Abstract

Purpose

To determine the association of depressive and PTSD symptoms with cardiac arrest survivors' long-term recovery perceptions, after accounting for cognitive status, functional independence, and medical comorbidities.

Methods

Perceived recovery of 78 cardiac arrest survivors at 6-months post-hospital discharge was assessed through the question, “Do you feel that you have made a complete recovery from your arrest?” Psychological symptoms were measured using the Center for Epidemiological Studies-Depression scale (CES-D) and the PTSD Checklist-Specific (PCLS). Logistic regression was utilized to assess the association between psychological symptoms with positive and negative recovery perceptions, adjusting for demographics, cognitive impairment, functional dependence, and medical comorbidities.

Results

At 6 months, 53% of patients (n = 41) had negative recovery perceptions. 32.1% (n = 25) of patients screened for depression and 28.2% (n = 22) for PTSD. Patients with higher CES-D scores were significantly more likely to have negative recovery perceptions in both unadjusted and adjusted analyses (OR: 1.10, 95% CI [1.03, 1.16], p < .01). PCL-S scores were significantly associated with negative recovery perceptions in an unadjusted model (OR: 1.05, 95% CI [1.01, 1.10], p < .01), but not after adjustment of covariates.

Conclusions

In contrast with cognitive and functional measures, depressive symptoms were strongly associated with cardiac arrest survivors' negative recovery perceptions at 6-months post-discharge.

Introduction

Innovations in technology and treatment protocols have led to improvements in survival rates after cardiac arrest [1]. With the advent of greater survivability, there has been increased recognition of post-cardiac arrest survivorship as a chronic condition implicated in cognitive, functional, and psychological sequelae secondary to anoxic brain injury [[2], [3], [4]]. Given the overall increase in patients with multiple chronic conditions, value based health care systems [5] have prioritized outcomes deemed important by the patient (i.e. patient reported outcome measures (PROMs)), which can help facilitate shared decision making. Utilization of PROMs has led to improvements in patients' daily lives, such as satisfaction with care [6] and depressive symptoms [7]. Accordingly, identifying underlying factors contributing to an encompassing PROM, such as perceived recovery, could improve the daily and multifaceted challenges faced by cardiac arrest survivors.

Despite the various chronic symptoms that cardiac arrest survivors face, it remains unclear which deficits are most strongly associated with long-term perceived recovery. For example, Steinbusch et al. [8] found that post-arrest patients' perceived cognitive impairments were not indicative of their actual cognitive impairments at 3- and 12-month follow-ups. On the contrary, Juan et al. [9] found post-arrest patients' cognitive impairments, but not depressive symptoms, to be strongly correlated with negative perceptions of recovery at 6-months; however, the incidence of depression in that cohort was low (6%), and the relatively small sample size (n = 50) precluded definitive conclusions. In samples of stroke survivors and older adults, subjects' cognitive complaints were correlated with emotional well-being and depressive symptoms, rather than objective measures of cognitive impairment [10,11].

There is strong support linking psychological sequelae with subjective well-being, and potentially perceived recovery, in patients with cardiac disease. For example, the prevalence of posttraumatic stress disorder (PTSD) secondary to a cardiac event has ranged from 0 to 38% (averaging 12%) [12]. This condition has been linked to negative illness perceptions, emotional distress, reduced quality of life, and preoccupation with somatic symptoms [12]. Depressive symptoms also pose a challenge for cardiac patients; 20–40% meet criteria for major depressive disorder or experience an increase in chronic and persistent depressive symptoms post-diagnosis [13]. Further, in cardiac patients, depression has been found to be a stronger predictor of quality of life than measures of disease severity including cardiac function, ejection fraction, and ischemia [14].

We recently demonstrated that posttraumatic stress and depressive symptoms, not cognitive or functional impairment, were associated with cardiac arrest survivors' negative recovery perceptions at hospital discharge [15]. The present study aims to extend this work by examining the correlates of perceived recovery in these cardiac arrest survivors at 6 months after their hospital discharge. This is especially important to delineate in order to identify possible modifiable factors for improving perceived recovery, as is vital in value based health care systems. Based on the strong link between cardiac disease-induced psychological symptoms and outcomes of subjective well-being, we tested the hypothesis that depressive and PTSD symptoms are correlated with cardiac arrest survivors' long-term recovery perceptions even after accounting for cognitive status, functional independence, and medical comorbidities. In addition, we examined the stability of recovery perceptions from discharge to 6 months.