Skip to main content

Depression and anxiety symptoms in cardiac patients: a cross-sectional hospital-based study in a Palestinian population

Abstract

Background

Mental health problems have an adverse effect on the course of cardiac disease. The integration of their diagnosis and treatment into cardiology care is generally poor. It is particularly challenging in cultural environments where mental health problems are stigmatized. The objective of the current study was to investigate the proportion of cardiac patients with depression and anxiety as well as factors associated with the presence of these symptoms in a Palestinian population.

Methods

This cross-sectional hospital-based study was conducted on patients consecutively admitted with a new or existing cardiac diagnosis to one of the four main hospitals in Nablus, Palestine over an eight-month period. Data was obtained from hospital medical charts and an in-person interview, using a structured questionnaire with a sequence of validated instruments. All subjects were screened for depression and anxiety using the Cardiac Depression Scale (CDS) and the Depression Anxiety Stress Scale (DASS-42). Multivariate ordered logistic regression analyses were performed to identify factors among four categories (socio-demographic, clinical, psychosocial, lifestyle) independently associated with depression and anxiety.

Results

In total, 1053 patients with a confirmed cardiac diagnosis were included in the study with a participation rate of 96%. Based on the CDS and DASS-42, 54% met the criteria for severe depression (CDS > 100) and 19.2% for severe-to-very severe anxiety (DASS-anxiety > 15), respectively. Symptoms of depression and anxiety were more prevalent among females and less educated patients. Factors independently associated with both depressive and anxiety symptoms were post-traumatic stress disorder symptoms, low level of self-esteem, high somatic symptoms, low physical and mental health component scores, active smoking, physical inactivity, and longer disease duration. Patients with depressive and anxiety symptoms also reported poor social support and lower resilience.

Conclusion

There was a high level of depression and anxiety in this sample of cardiac patients. The results point to characteristics of patients in particular need for mental health screening and suggest possible targets for intervention such as strengthening of social support and of physical activity. The integration of mental health services into cardiac rehabilitation in Palestine and comparable cultural settings is warranted from the time of first diagnosis and onward.

Peer Review reports

Background

Cardiovascular diseases (CVDs) and depression are among the leading causes of the global disease burden [1]. CVDs are the most common cause of death accounting for 17.9 million deaths globally, in 2015 [2]. Depression affects over 300 million people around the world [3], and is expected to become the main cause of disability globally, in 2030 [4]. Similarly, in 2010, anxiety affected approximately 272 million people, worldwide [5].

There is a high prevalence of mental disorders, particularly depression and anxiety, in CVD patients [6]. The bidirectional link between CVDs and these mental disorders has been extensively documented in literature [7,8,9]. Approximately, 15–30% of patients with CVD suffer from depressive disorders [10,11,12,13,14]. These rates of depression are two to three times higher than in the general population [15]. Moreover, depression and anxiety have been found to worsen prognosis and quality of life in patients with coronary artery disease (CAD), myocardial infarction (MI), heart failure (HF), unstable angina, and coronary artery bypass grafting (CABG) [16,17,18,19,20,21,22]. CABG is defined as a surgical procedure that is performed to treat people who have severe coronary heart disease, which improves blood flow to the heart [23]. They were also found to be the biggest driver of health care costs in coronary heart disease (CHD) patients [24].

Mental health problems have a direct physiological effect on the course of cardiac disease and their adverse effect may be mediated by non-compliance to lifestyle interventions, treatment and medication [25, 26]. Furthermore, these mental disorders add to the burden of managing CVD, from a perspective of treatment complexity and emotional distress. This problem is further aggravated by the high rate of additional co-morbidities such as diabetes, hypertension and obesity [27].

The American Heart Association (AHA) has recommended routine depression screening in cardiac patients [26]. However, health systems have not yet adequately responded and less than 15% of cardiac patients are being diagnosed and treated for depression [28]. Integrating mental health into cardiac treatment is of particular relevance in low-middle-income countries (LMICs), where the burden of depression and anxiety is often high and aggravated by adverse life and political conditions. Similarly, mental health problems are stigmatized in many of these non-western cultures [29]. Little is known on the prevalence of depression and anxiety among cardiac patients in LMICs [30]. This also applies to Palestine, where mental disorders commonly are not recognized, diagnosed or treated, despite the increase in their prevalence [31]. Unaddressed mental care needs may be an important barrier to the successful management of cardiac patients in Palestine, where CVD remains the leading cause of death [32].

Mental health problems have not been studied in cardiac patients in the Palestinian population. Therefore, the aim of the current study was to determine the proportion of patients with depression and anxiety symptoms admitted with a cardiac diagnosis, to one of the four main hospitals in Nablus, Palestine. To guide physicians in effective mental health screening in the future, we also identified socio-demographic, clinical, psychosocial, and lifestyle factors associated with a high risk of depression and anxiety symptoms.

Methods

Study design and population

This cross-sectional hospital-based study was conducted on patients consecutively admitted to the cardiology and cardiac surgery departments of An-Najah National University Hospital, Arab-Specialized Hospital, Watani Hospital and Nablus Specialized Hospital in the Northern West Bank city of Nablus, Palestine. Patients were eligible for the study if they were between 30 and 80 years of age and had an existing or newly confirmed cardiac diagnosis warranting hospitalization during the period between March and November 2017. In the present study, cardiac diagnoses considered included CAD, ST elevation or non-ST elevation MI, angina, HF, cardiac arrhythmia, valve disease or any other cardiac disease. Diagnoses were confirmed using hospital medical charts. Patients were excluded if they had a normal cardiac catheterization (CATH), an acute or past stroke, end-stage kidney disease (including dialysis patients), peripheral vascular disease, major co-morbidities affecting mental health (alcohol abuse, drug abuse), neurological disorders (dementia, Alzheimer’s disease, epilepsy, Parkinson’s disease), cognitive impairment, a severe clinically diagnosed psychiatric condition or any other condition affecting the quality of their responses.

Eligible patients were recruited for in-person interviews by trained medical research assistants. Patients were identified using hospital registries and medical records. Interviews were conducted while patients were awaiting treatment (after CATH) or after their treatment, within 1 week of their admission to the hospital. Eligible patients were informed about the study objectives and benefits and written informed consent was obtained from those who agreed to participate. The study was approved by the Ethics Committee of Nordwest-und Zentral Schweiz (EKNZ) in Basel, Switzerland, and by the Institutional Review Board (IRB) committee at An-Najah National University in Nablus, Palestine.

Study assessments and measures

Data was collected using a structured questionnaire consisting of two parts (Tables 1 and 2; see Additional file 1 for more detailed description). The first part included detailed socio-demographic and clinical information obtained from patients’ administrative and medical charts.

Table 1 Predictor blocks used in bivariate and ordered logistic regression analyses
Table 2 Study Instruments (see Additional file 1 for further descriptions)

The second part was administered during a private interview and consisted of a sequence of screening instruments. These validated tools have demonstrated to be suitable for clinical populations to assess for depression and anxiety symptoms, QoL, post-traumatic stress disorder (PTSD), social support, resilience, self-esteem, somatic symptoms and lifestyle behaviors. The questionnaire, including the instruments, was translated from English to Arabic and back-translated from Arabic to English by two bilingual experts.

Statistical analyses

The primary endpoints in the present study were depression and anxiety. Descriptive statistics for stress as an endpoint are presented in an Additional file 2: Table S2, with no further description. The four predictor blocks investigated for association with depression and anxiety were socio-demographic, clinical, psychosocial and lifestyle factors (Table 1). Endpoints and predictors were described as means and standard deviations (SD) for quantitative variables and as absolute values and percentages for categorical variables. Differences in predictor variables according to presence or absence of depression and anxiety symptoms were described using chi-squared test and the Wilcoxon rank sum test, as appropriate. Fisher’s exact test was used for results presenting a frequency below five. Multivariate ordered logistic regression analyses were performed to examine the independent association between predictor variables and depression or anxiety symptoms. All variables were entered in each of the models at once. Results are presented in separate models for depression and anxiety and are expressed as odds ratio (OR) and 95% confidence intervals (95% CI). The cut-offs for the respective outcome variables were normal, mild/moderate, and severe/very severe according to standardized cut-offs. Correlations between the outcome variables and other instruments used in the study were assessed using Spearman’s rank correlation coefficient. Cronbach alpha was used to assess the internal consistency of the different scales. Statistical significance was defined as a two-sided p-value <0.05. All data was analyzed using the STATA Data Analysis and Statistical Software, version 14.

Results

In total, 1092 patients were eligible and approached for an interview. Among the 1053 (96%) patients which agreed to participate in the study, 1022 patients with complete outcome and predictor information were used in the analysis.

Characteristics of study population

Characteristics of the participants are presented in Table 3.

Table 3 Socio-demographic, clinical, psychosocial and lifestyle characteristics of study population, (n = 1022)

Socio-demographic factors

Among the 1022 patients, 73.4% were males. The mean age of patients was 58.9 ± 10.1 years (range 30–80 years). The majority of participants were married (90.6%), 37% were unemployed, and 58.7% did not have a high school diploma. Most of the study population lived in cities (46.4%) or villages (46.3%), while 7.3% resided in refugee camps.

Clinical factors

The primary diagnoses among the sample were MI (39.7%), CAD (32.7%), angina (15.9%) and other diagnoses (11.7%), including mitral or aortic valve stenosis, valve regurgitation, heart block and others. Among the category of other diagnoses, 29 (2.8%) patients had heart failure. Over 60% of participants had a previous cardiac diagnosis and had been diagnosed with a cardiac disease for 1 year or less. About half of participants underwent a CATH with a stent (52.2%), while others underwent a CATH with a CABG (23.5%), or some kind of other procedure (24.3%), which was not yet performed at the time of the interview. Forty one percent of participants reported having two or more co-morbidities (mainly diabetes and hypertension) and 72.2% were on three or more medications. In addition, more than half of the participants’ reported a family history of CVD. Approximately 37% of participating patients exhibited high somatic symptoms on the PHQ-15. The mean score of the participants on the SF-12- PCS score was 37.6 ± 12.4.

Psychosocial factors

Forty Percent of patients reported having PTSD symptoms on the PTSD-PCL-S. Social support was generally high (64%) among participants, according to the ESSI. Almost half of the participants presented with moderate to moderately-high resilience. The mean score for self-esteem was 5.8 ± 1.4, while the mean score for the SF-12-MCS was 39.7 ± 13.2.

Lifestyle factors

Almost half of the participants were current smokers while 35.6% had never smoked before. The vast majority of participants (83.4%) reported not being on a diet, 47% low fat consumption, and 55.5% high vegetable and fruit consumption. The reported alcohol consumption was very low with 95% of participants not consuming any alcohol. Almost half of the patients reported no-to-minimal daily physical activity. Eighty percent of patients were either overweight or obese.

Proportion of patients with depressive and anxiety symptoms at different severity levels

Table 4 shows the proportion of patients with depression (CDS), depression (DASS-depression), anxiety (DASS-anxiety) and stress (DASS-stress) symptoms at different severity levels. Cutoffs for the levels of CDS and DASS subscales are also presented in Table 4. Based on our findings, the mean ± SD depression score on the CDS was 101.3 ± 15.6 and the overall proportion of patients with depression was 78.7%. According to the recommended cutoffs for the CDS, 21.3, 25.2 and 53.5% of the sample had no, mild-to-moderate and severe-to-very severe depression symptoms, respectively. The means ± SDs on the DASS-42 were 9.4 ± 8.6, 9.4 ± 6.8 and 15.2 ± 9 for depression, anxiety, and stress, respectively. It was found that the overall proportion was 52.9, 53.1 and 37.4% for the presence of depressive, anxiety and stress symptoms according to the DASS-42. Based on recommended cutoffs, 47.1, 33.4 and 19.5% of patients reported normal, mild-to-moderate and severe-to-very severe depressive symptoms (DASS-depression). In addition, 46.9% patients did not report any anxiety, while 33.9% reported mild-to-moderate anxiety and 19.2% reported severe-to-very severe anxiety symptoms. According to the stress scale, 62.6% reported having no stress, 30% reported having mild-moderate stress symptoms and 7.4% severe-very severe stress symptoms. Patients that had mild-moderate and severe-very severe symptoms of depression or anxiety according to the DASS-42 were more likely to have severe depressive symptoms on the CDS. Nevertheless, 8 (4.0%) and 9 (4.6%) patients without any signs of depressive symptoms on the CDS, showed symptoms of depression and anxiety, respectively, on the DASS-42.

Table 4 Proportion of patients with CDS-depression, DASS-depression, DASS-anxiety, DASS-stress at different severity levels (n = 1022)

Unadjusted correlations between continuous scores of the scales used in study

Spearman correlation coefficients were calculated between the CDS and other instruments used in the study (see Fig. 1). The correlation of the CDS with the DASS-depression was =0.57 (p = < 0.001), with DASS-stress =0.51 (p < 0.001), and with DASS-anxiety =0.50 (p < 0.001). The correlations between the DASS subscales were as follows: DASS-depression and DASS-anxiety (0.65, p < 0.001); DASS-depression and DASS-stress (0.63, p < 0.001); DASS-anxiety and DASS-stress (0.61, p < 0.001). CDS was positively correlated with the PHQ-15 (0.44, p < .001) and the PTSD-PCL-S (0.37, p < .001)and the DASS-depression was also positively correlated with the PTSD-PCL-S (0.57, p < .001).

Fig. 1
figure1

Spearmen correlations between CDS, DASS-depression, DASS-anxiety, DASS-stress and other instruments used in the study. Note. CDS = Cardiac Depression Scale; PHQ = Patient Health Questionnaire-15; PTSD = Post-Traumatic Stress Disorder; MCS = Mental Component Summary; PCS = Physical Component Summary; RS = Resilience Scale-14; SE = Self-esteem; ESSI = ENRICHD Social Support Instrument. Blue colors represent positive correlations and red colors represent negative correlations. Correlations measured are expressed as rho spearman.

The above cluster of positively associated factors were weakly correlated to the physical and mental QoL components of the SF-12, social support, resilience, and self-esteem, which were strongly correlated among each other. Specifically, weak correlations were observed between CDS and the SF-12-MCS (− 0.39, p < 0.001), SF-12-PCS (− 0.29, p < 0.001), ESSI (− 0.12 p < 0.001), RS-14 (− 0.24, p < 0.001) and with the self-esteem scale (− 0.23, p < 0.001).

Association between socio-demographic, clinical, psychosocial, lifestyle factors and depressive and anxiety symptoms

The bivariate distribution of socio-demographic, clinical, psychological, and lifestyle characteristics according to the presence or absence of depression symptoms (CDS), anxiety symptoms (DASS-anxiety) and stress symptoms (DASS-stress) is presented in Additional file 3: Table S1 (depression (CDS) and anxiety) and Additional file 2: Table S2 (stress). Briefly, with regard to socio-demographic factors, bivariate analysis revealed depressive and anxiety symptoms were more frequent among females than males (depression: 84.9% vs. 76.4%, p = 0.003; anxiety: 72.4% vs. 55.6%, p = < 0.001) and among those with lower educational level (depression: 81.0% [no high school diploma] vs. 78.0% [high school diploma] and 71.1% [college degree], p = 0.02; anxiety: 63.2% [no high school diploma] vs. 59.8% (high school diploma) and 52.8% (college degree), p < 0.05). Both, depressive and anxiety symptoms were most prevalent among those unemployed and housewives (depression: p < 0.001; anxiety: p < 0.001).

Multivariable ordered logistic regression was performed to determine the independent association of factors in the four predictor blocks with a) depressive symptoms, categorized as no depressive symptoms, moderate depressive symptoms, and severe depressive symptoms according to the CDS and b) anxiety symptoms, categorized as minimal anxiety symptoms, mild-moderate anxiety symptoms, and severe-severe anxiety symptoms according to the DASS-anxiety subscale. The results for the four blocks of variables are presented in Table 5.

Table 5 Factors associated with DEPRESSION and ANXIETY in multivariate ordered logistic regression

Overall, most of the psychosocial factors were consistently associated with both, depression and anxiety. Participants with depression or anxiety were more likely to exhibit at least some symptoms of PTSD. Odds ratios tended to be higher for anxiety than for depression (moderate symptoms vs. minimal symptoms: ORdepresssion 1.87 (95% CI 1.29–2.71) vs. ORanxiety 3.01 (95% CI 2.12–4.27). Patients with depression or anxiety had a lower score for the mental component of QoL (SF-12-MCS) [ORdepression 0.96 (95% CI 0.95–0.97); ORanxiety 0.98 (95% CI 0.97–0.99)]. High resilience and high social support were inversely associated with depression and anxiety [high vs. low social support: ORdepression 0.71 (95% CI 0.52–0.97); ORanxiety 0.74 (95% CI 0.54–1.00)]. The inverse association with resilience tended to be stronger in the presence of anxiety [high vs. very low resilience: ORdepression 0.42 (95% CI 0.18–0.94); ORanxiety 0.22 (95% CI 0.11–0.48)].

In addition to psychosocial factors, the physical component of QoL (SF-12-PCS) and somatic symptoms (PHQ-15) also showed consistent associations with both depression and anxiety [high vs. minimal somatic symptoms: ORdepression 3.00 (95% CI 1.73–5.18); ORanxiety 7.64 (95% CI 3.96–14.78)]; [SF-12-PCS: ORdepression 0.98 (95% CI 0.97–1.00); ORanxiety 0.97 (95% CI 0.96–0.99)]. Current smoking was associated with depression with the strongest odds ratio observed for depression and former smoking: OR 1.87 (95% CI 1.17–2.97). Finally, patients with depression and anxiety were more likely to be physically inactive compared to patients without the respective psychological problems.

A few factors exhibited associations with only one of the two mental health outcomes. For example, patients residing in villages or camps were less likely to show symptoms of anxiety compared to patients living in the city [(ORvillage 0.74 (0.54–1.00); ORcamp 0.56 (0.31–1.01)]. Unemployment was positively associated with depression, but not anxiety. The presence of previous cardiac diagnoses was positively associated with anxiety, but inversely associated with depression [(ORdepression 0.67 (95% 0.47–0.96); ORanxiety 1.52 (95% 1.05–2.21)]. Symptoms of depression were more frequent among patients with a cardiac diagnosis for more than 10 years compared to patients with a diagnosis for a year or less [years since first diagnosis ≥10 vs. ≤ 1 year OR 1.71 (95% 1.06–2.75)]. Patients who were diagnosed with angina were more likely to have anxiety symptoms than those diagnosed with an MI. Underweight and obese participants were more likely to exhibit symptoms of anxiety than those of normal weight and overweight.

Reliability assessment (Cronbach’s alpha) of the study instruments

Cronbach α for the primary outcome variable, CDS was 0.86 and 0.92 (DASS-depression), 0.82 (DASS-anxiety), and 0.89 (DASS-stress) for the DASS subscales, respectively, indicating high consistency for the relevant psychometric scales. This indicates all scales exhibit acceptable internal consistency with little likelihood of item redundancy. Inter-item correlations between the 26 items of the CDS and the total CDS scores ranged from 0.08 to 0.58, and all correlations were statistically significant at the 0.01 level. Cronbach α for the other scales used in the study was: 0.78 for PHQ-15, 0.86 for PTSD-PCL-S, 0.82 for ESSI and 0.88 for RS-14.

Discussion

In the present study, the observed rates of depressive and anxiety symptoms were high. Only 21% (CDS) and 46% (DASS-anxiety) of patients did not exhibit any symptoms of depression and anxiety, respectively. Our findings point to the need for integrating mental health care into cardiac treatment. It is noteworthy that several factors found to be associated with depression and anxiety may serve as screening and possibly as intervention targets.

Rates of mental health problems reported in earlier studies for patients with different cardiac diagnoses and in different cultural and health system settings ranged from 14 to 73% [33,34,35,36,37,38] for depressive symptoms and 15 to 48% [33,34,35,36,37] for anxiety symptoms. These varying rates are explained in part by differences in sample sizes, the instruments and cutoffs used for classifying depression and anxiety and the type of cardiac disease targeted in studies.

Lower rates of depression than in the current study were observed in other settings including Norway (14%) [33], USA (15%) [39], Brazil (26.4%) [34] and Pakistan (14%) [36]. Similar among these studies, was the common psychiatric instruments used to assess for depression, all of which were not specific for cardiac populations. In contrast, a different study assessing depression using the CDS found a rate of 73.2% of severe depression in Iranian patients with acute coronary syndrome (ACS), a rate even higher than in this study [38].

Similar anxiety rates to the current study were observed in Iran (28.5%) [37] and Pakistan (18%) [36]. Interestingly, in another study conducted in Brazil, Meneghetti et al. found a very high prevalence of 48.4% for anxiety symptoms among ACS patients using the Hospital Anxiety and Depression Scale (HADS) [34]. A study in the USA also reported, 37% of patients with MI due to spontaneous coronary artery dissection screened for anxiety using the Generalized Anxiety Disorder 7-Item Scale (GAD-7) [35].

Mental health problems are generally high in the Palestinian population [31]. In the absence of a healthy control group the results of this study do not allow to conclude that depression and anxiety are more common in cardiac patients. However, cardiac patients are in particular need of treatment for depression and anxiety given that existing evidence points to their adverse effect on the course of heart disease. Furthermore, cardiac rehabilitation may be an efficient starting point to address mental health issues beyond the patient and to the extended family and social network. Given the shortage of mental health services available and the local economic instability in Palestine, the provision of additional services needs to be implemented in a cost-effective way. The identification of subgroups of cardiac patients at higher risk of depression and anxiety can guide screening and interventions.

In perspective of mental health screening among cardiac patients, focus should be given to females and less educated patients. The higher rates of depression and anxiety seen in these sub-groups were previously described in literature [34, 37, 40, 41]. Women seem to be more vulnerable to the trauma caused by cardiac events, which leads to a deterioration in depression and anxiety symptoms [37]. As observed in some [34, 42, 43], but not all studies [37, 38, 44], the association between gender and social status may not be direct as suggested by the disappearance of gender and social status differences in the fully adjusted models [34, 37, 38, 42].

The presence of the following additional characteristics in cardiac patients should be a red flag for cardiologists to consider mental health care in cardiac practice: symptoms of PTSD, low levels of self-esteem, somatic symptoms, low QoL components, active smoking, physical inactivity, and longer disease duration. In contrast, a high level of resilience seems to reduce symptoms of psychological problems, as previously observed in patients with heart failure [45, 46]. Unlike findings reported previously, comorbidities were not consistently more common in the presence of mental health disorders [47]. Little is known about the association of PSTD symptoms with depression and anxiety in cardiac patients. A study conducted on 813 patients who received angiograms at a large U.S. Veterans Administration Medical Center found depression to be positively associated with PTSD, smoking and alcohol consumption [48]. Low MCS and PCS scores on the SF-12, smoking, and chest pain were recently identified as the strongest predictors of longitudinally sustained high levels of depression and anxiety in CHD patients [24].

Factors serving as targets for intervention include smoking, physical activity and social support. Smoking cessation interventions are crucial for cardiac rehabilitation, however in the presence of depression, results are less successful and interventions may need to be adapted [49]. Sedentary behavior, a risk factor for depression in the general population [50], was previously associated with depression according to the Beck Depression Inventory-II in patients hospitalized for ACS [51]. In a small non-randomized intervention study with heart failure patients, aerobic interval training decreased symptoms of depression over a period of 12-weeks [52]. In studies on breast cancer [53], promotion of physical activity may have the additional benefit of improving self-esteem, a factor associated with depression and anxiety in this study and a predictor of mortality in the general population [54]. In addition, according to previous studies [43, 55,56,57,58], the inverse association between high social support and low levels of anxiety and depression points to another important target for prevention as it is supported by firm evidence from previous studies. Poor social support among patients with ACS was observed in secondary analyses of a randomized trial to reduce the effectiveness of treatment with antidepressants [59]. The quality of social support plays an important role, as overprotective behaviors of partners can have an adverse effect [58]. Interestingly, in the current study marital status and social support were associated with presence of depressive symptoms independently and in opposite directions.

The current study has several strengths. First, it utilized a broad set of validated instruments to identify depression and anxiety symptoms as well as associated factors. The overall validity of the CDS in this study was almost similar to levels originally reported by Hare and Davis [60]. The validity of the DASS-42 was satisfactory, in line with other findings of other studies, including those originally reported by Lovibond and Lovibond [61]. Furthermore, the CDS is the only psychometric scale suitable for the comparative depression assessment in heart disease patients, subjected to different interventions [60, 62] . This is evident in the present study, as depression rates were lower when assessed by the DASS-42. The CDS, also has excellent properties for the diagnosis of MDD, a score of ≥95 having a 97% sensitivity at 85% specificity (AUC 0.96) [62]. Second, the large sample size provided sufficient statistical power for testing independent associations. Third, the study subjects are well characterized, which allowed for addressing confounding. Fourth, the high participation rate decreased the likelihood of selection and participation bias. Finally, the findings of the study despite being hospital-based are likely generalizable to the entire cardiac patient population in the city of Nablus and surrounding cities of Palestine, considering the study sites provide cardiac care to a large percentage of cardiac patients in the area.

Nonetheless, the cross-sectional nature of the study does not enable us to make causal inferences. A long-term follow-up is foreseen to investigate the predictive effect of the study characteristics and predictors with regard to the course of depression, anxiety and heart disease. While the reliability of the previously validated instruments was confirmed in our study, the instruments have not been validated specifically for the context of cardiac patients in Palestine. Furthermore, some of the risk factors could only be captured broadly to avoid lengthy interviews. This likely caused some misclassification, as in the case of physical activity. Recall bias may have added to the misclassification of risks, given the retrospective nature of the interview. Also, the study was not sufficiently powered to investigate differences in the frequency of depression and anxiety as well as associated factors between relevant subgroups of clinical diagnoses, for example MI and HF. Finally, some patients were recruited at the time of admission and for the most part before receiving their intervention or diagnosis, and thus were under much pressure and stress. The level of depression and anxiety could have been overestimated and may decrease in part over the course of disease. The most appropriate time point to assess depression and anxiety from a prognostic perspective is unknown.

Conclusions

The alarmingly high rate of depression and anxiety symptoms observed in cardiac patients in Palestine points to the need for integrating mental health care into cardiac rehabilitation. The prognostic value of depression and anxiety with regard to the course of heart disease, adherence to treatment and quality of life needs to be investigated. Treatment of psychological problems from the disease onset and onwards is crucial considering longer disease duration puts individuals at higher risk of being depressed. The expertise of social scientists and medical anthropologists is needed for identifying efficient means to overcome barriers related to the stigmatization of psychological disorders.

Abbreviations

ACS:

Acute coronary syndrome

AHA:

American Heart Association

BMI:

Body mass index

CABG:

Coronary artery bypass grafting

CAD:

Coronary artery disease

CATH:

Catheterization

CDS:

Cardiac Depression Scale

CHD:

Coronary heart disease

CI:

Confidence interval

CVD:

Cardiovascular disease

CVDs:

Cardiovascular diseases

DASS-42:

Depression Anxiety Stress Scale-42

DSM-IV:

Diagnostic and Statistical Manual of Mental Disorders-IV

EKNZ:

Ethics Committee of Nordwest-und Zentral Schweiz

ENRICHD:

Enhancing Recovery in Coronary Heart

ESSI:

ENRICHD Social Support Instrument

HF:

Heart failure

HS:

High school

IRB:

Institutional Review Board

LMIC:

Low-middle income countries

MCS:

Mental Component Summary

MDD:

Major depressive disorder

MI:

Myocardial infarction

MOS:

Medical Outcomes Survey

OR:

Odds ratio

PCS:

Physical Component Summary

PHQ-15:

Patient Health Questionnaire-15

PTSD:

Post-traumatic stress disorder

PTSD-PCL-S:

Post-Traumatic Stress Disorder Checklist

QOL:

Quality of life

RS-14:

Resilience Scale-14

SD:

Standard deviation

SE:

Self-esteem

SF-12:

The 12-item Short Form Health Survey

References

  1. 1.

    Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the global burden of disease study 2010. Lancet. 2012;380:2197–223.

    Article  Google Scholar 

  2. 2.

    Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyu G, Ahmed M, Aksut B, Alam T, Alam K, et al. Global, regional, and National Burden of cardiovascular diseases for 10 causes, 1990 to 2015. J Am Coll Cardiol. 2017;70:1–25.

    Article  Google Scholar 

  3. 3.

    WHO. Depression fact sheet. 2012. http://www.who.int/news-room/fact-sheets/detail/depression. Accessed 25 Sept 2018.

    Google Scholar 

  4. 4.

    Mensah GA, Collins PY. Understanding mental health for the prevention and control of cardiovascular diseases. Glob Heart. 2015;10:221–4.

    Article  Google Scholar 

  5. 5.

    Baxter AJ, Vos T, Scott KM, Norman RE, Flaxman AD, Blore J, Whiteford HA. The regional distribution of anxiety disorders: implications for the global burden of disease study, 2010. Int J Methods Psychiatr Res. 2014;23:422–38.

    Article  Google Scholar 

  6. 6.

    Rutledge T, Linke SE, Krantz DS, Johnson BD, Bittner V, Eastwood JA, Eteiba W, Pepine CJ, Vaccarino V, Francis J, et al. Comorbid depression and anxiety symptoms as predictors of cardiovascular events: results from the NHLBI-sponsored Women's ischemia syndrome evaluation (WISE) study. Psychosom Med. 2009;71:958–64.

    Article  Google Scholar 

  7. 7.

    Lippi G, Montagnana M, Favaloro EJ, Franchini M. Mental depression and cardiovascular disease: a multifaceted, bidirectional association. Semin Thromb Hemost. 2009;35:325–36.

    Article  Google Scholar 

  8. 8.

    Holt RIG, Phillips DIW, Jameson KA, Cooper C, Dennison EM, Peveler RC, Hertfordshire Cohort Study G. The relationship between depression, anxiety and cardiovascular disease: findings from the Hertfordshire cohort study. J Affect Disord. 2013;150:84–90.

    Article  Google Scholar 

  9. 9.

    Riba MWL, Rubenfire M. Psychiatry and heart disease: the mind, brain, and heart. Hoboken: Wiley-Blackwell; 2011.

    Book  Google Scholar 

  10. 10.

    Lesperance F, Frasure-Smith N. Depression in patients with cardiac disease: a practical review. J Psychosom Res. 2000;48:379–91.

    CAS  Article  Google Scholar 

  11. 11.

    Frasure-Smith N, Lesperance F. Depression and coronary artery disease. Herz. 2006;31(Suppl 3):64–8.

    PubMed  Google Scholar 

  12. 12.

    Rudisch B, Nemeroff CB. Epidemiology of comorbid coronary artery disease and depression. Biol Psychiatry. 2003;54:227–40.

    Article  Google Scholar 

  13. 13.

    Thombs BD, de Jonge P, Coyne JC, Whooley MA, Frasure-Smith N, Mitchell AJ, Zuidersma M, Eze-Nliam C, Lima BB, Smith CG, et al. Depression screening and patient outcomes in cardiovascular care: a systematic review. JAMA. 2008;300:2161–71.

    CAS  Article  Google Scholar 

  14. 14.

    Carney RM, Freedland KE. Depression in patients with coronary heart disease. Am J Med. 2008;121:S20–7.

    Article  Google Scholar 

  15. 15.

    Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095–105.

    Article  Google Scholar 

  16. 16.

    Lett HS, Blumenthal JA, Babyak MA, Sherwood A, Strauman T, Robins C, Newman MF. Depression as a risk factor for coronary artery disease: evidence, mechanisms, and treatment. Psychosom Med. 2004;66:305–15.

    PubMed  Google Scholar 

  17. 17.

    Nicholson A, Kuper H, Hemingway H. Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. Eur Heart J. 2006;27:2763–74.

    Article  Google Scholar 

  18. 18.

    Rutledge T, Reis VA, Linke SE, Greenberg BH, Mills PJ. Depression in heart failure a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. J Am Coll Cardiol. 2006;48:1527–37.

    Article  Google Scholar 

  19. 19.

    Jiang W, Alexander J, Christopher E, Kuchibhatla M, Gaulden LH, Cuffe MS, Blazing MA, Davenport C, Califf RM, Krishnan RR, O'Connor CM. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Arch Intern Med. 2001;161:1849–56.

    CAS  Article  Google Scholar 

  20. 20.

    de Jonge P, Spijkerman TA, van den Brink RH, Ormel J. Depression after myocardial infarction is a risk factor for declining health related quality of life and increased disability and cardiac complaints at 12 months. Heart. 2006;92:32–9.

    Article  Google Scholar 

  21. 21.

    Blumenthal JA, Lett HS, Babyak MA, White W, Smith PK, Mark DB, Jones R, Mathew JP, Newman MF. Depression as a risk factor for mortality after coronary artery bypass surgery. Lancet. 2003;362:604–9.

    Article  Google Scholar 

  22. 22.

    de Jager TAJ, Dulfer K, Radhoe S, Bergmann MJ, Daemen J, van Domburg RT, Lenzen MJ, Utens E. Predictive value of depression and anxiety for long-term mortality: differences in outcome between acute coronary syndrome and stable angina pectoris. Int J Cardiol. 2018;250:43–8.

    Article  Google Scholar 

  23. 23.

    Harris R, Croce B, Tian DH. Coronary artery bypass grafting. Ann Cardiothorac Surg. 2013;2:579.

    PubMed  PubMed Central  Google Scholar 

  24. 24.

    Palacios J, Khondoker M, Mann A, Tylee A, Hotopf M. Depression and anxiety symptom trajectories in coronary heart disease: associations with measures of disability and impact on 3-year health care costs. J Psychosom Res. 2018;104:1–8.

    Article  Google Scholar 

  25. 25.

    Chaddha A, Robinson EA, Kline-Rogers E, Alexandris-Souphis T, Rubenfire M. Mental health and cardiovascular disease. Am J Med. 2016;129:1145–8.

    Article  Google Scholar 

  26. 26.

    Lichtman JH, Bigger JT Jr, Blumenthal JA, Frasure-Smith N, Kaufmann PG, Lesperance F, Mark DB, Sheps DS, Taylor CB, Froelicher ES. Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation. 2008;118:1768–75.

    Article  Google Scholar 

  27. 27.

    Leon BM, Maddox TM. Diabetes and cardiovascular disease: epidemiology, biological mechanisms, treatment recommendations and future research. World J Diabetes. 2015;6:1246–58.

    Article  Google Scholar 

  28. 28.

    Huffman JC, Smith FA, Blais MA, Beiser ME, Januzzi JL, Fricchione GL. Recognition and treatment of depression and anxiety in patients with acute myocardial infarction. Am J Cardiol. 2006;98:319–24.

    Article  Google Scholar 

  29. 29.

    Rathod S, Pinninti N, Irfan M, Gorczynski P, Rathod P, Gega L, Naeem F. Mental health service provision in low- and middle-income countries. Health Serv Insights. 2017;10:1178632917694350.

    PubMed  PubMed Central  Google Scholar 

  30. 30.

    Ormel J, Von Korff M, Burger H, Scott K, Demyttenaere K, Huang YQ, Posada-Villa J, Pierre Lepine J, Angermeyer MC, Levinson D, et al. Mental disorders among persons with heart disease - results from world mental health surveys. Gen Hosp Psychiatry. 2007;29:325–34.

    Article  Google Scholar 

  31. 31.

    Marie M, Hannigan B, Jones A. Mental health needs and services in the West Bank, Palestine. Int J Ment Health Syst. 2016;10(1):23.

    Article  Google Scholar 

  32. 32.

    Mosleh M, Dalal K, Aljeesh Y. Burden of chronic diseases in the Palestinian health-care sector using disability-adjusted life-years. Lancet. 2018;391:S21.

    Article  Google Scholar 

  33. 33.

    Hanssen TA, Nordrehaug JE, Eide GE, Bjelland I, Rokne B. Anxiety and depression after acute myocardial infarction: an 18-month follow-up study with repeated measures and comparison with a reference population. Eur J Cardiovasc Prev Rehabil. 2009;16:651–9.

    Article  Google Scholar 

  34. 34.

    Meneghetti CC, Guidolin BL, Zimmermann PR, Sfoggia A. Screening for symptoms of anxiety and depression in patients admitted to a university hospital with acute coronary syndrome. Trends Psychiatry Psychother. 2017;39:12–8.

    Article  Google Scholar 

  35. 35.

    Liang JJ, Tweet MS, Hayes SE, Gulati R, Hayes SN. Prevalence and predictors of depression and anxiety among survivors of myocardial infarction due to spontaneous coronary artery dissection. J Cardiopulm Rehabil Prev. 2014;34:138–42.

    Article  Google Scholar 

  36. 36.

    Akhtar MS, Malik SB, Ahmed MM. Symptoms of depression and anxiety in post-myocardial infarction patients. J Coll Physicians Surg Pak. 2004;14:615–8.

    PubMed  Google Scholar 

  37. 37.

    Bayani B, Yousefi S, Bayani M, Shirmohammadi M, Alimoradi A, Falsoleiman H, Yazdi N, Arbabi M. Depression and anxiety in a cardiovascular outpatient clinic: a descriptive study. Iran J Psychiatry. 2011;6:125–7.

    PubMed  PubMed Central  Google Scholar 

  38. 38.

    Goudarzian AH, Nia HS, Tavakoli H, Soleimani MA, Yaghoobzadeh A, Tabari F, Taebei M. Prevalence of cardiac depression and its related factors among patients with acute coronary syndrome. Asian J Pharm Res Health Care. 2016;8(S1):30–5.

    Article  Google Scholar 

  39. 39.

    Moraska AR, Chamberlain AM, Shah ND, Vickers KS, Rummans TA, Dunlay SM, Spertus JA, Weston SA, McNallan SM, Redfield MM, Roger VL. Depression, healthcare utilization, and death in heart failure: a community study. Circ Heart Fail. 2013;6:387–94.

    CAS  Article  Google Scholar 

  40. 40.

    Dogar IA, Khawaja IS, Azeem MW, Awan H, Ayub A, Iqbal J, Thuras P. Prevalence and risk factors for depression and anxiety in hospitalized cardiac patients in Pakistan. Psychiatry (Edgmont). 2008;5:38–41.

  41. 41.

    Alexandri A, Georgiadi E, Mattheou P, Polikandrioti M. Factors associated with anxiety and depression in hospitalized patients with first episode of acute myocardial infarction. Arch Med Sci Atheroscler Dis. 2017;2:e90–9.

    Article  Google Scholar 

  42. 42.

    Shokrgozar S, Allahi M, Ahmadi R, Khairkhah J, Moorosi M. Severity of depression in hospitalized patients with cardiovascular diseases by cardiac depression scale (CDS). J Guilan UnivMed Sci. 2015;24:9–15.

    Google Scholar 

  43. 43.

    Su SF, Chang MY, He CP. Social support, unstable angina, and stroke as predictors of depression in patients with coronary heart disease. J Cardiovasc Nurs. 2018;33:179–86.

    Article  Google Scholar 

  44. 44.

    Al-Abbudi S, Faris L, Abd Wady Z. Prevalence and assessment of severity of depression among ischemic heart disease patients attending outpatient cardiology department Baghdad teaching Hospital, Baghdad, Iraq. J Psychiatry. 2018;21. https://doi.org/10.4172/2378-5756.1000438.

  45. 45.

    Toukhsati SR, Jovanovic A, Dehghani S, Tran T, Tran A, Hare DL. Low psychological resilience is associated with depression in patients with cardiovascular disease. Eur J Cardiovasc Nurs. 2017;16:64–9.

    CAS  Article  Google Scholar 

  46. 46.

    Chang LY, Wu SY, Chiang CE, Tsai PS. Depression and self-care maintenance in patients with heart failure: a moderated mediation model of self-care confidence and resilience. Eur J Cardiovasc Nurs. 2017;16:435–43.

    Article  Google Scholar 

  47. 47.

    Eng HS, Yean LC, Das S, Letchmi S, Yee KS, Bakar RA, Hung J, Choy CY. Anxiety and depression in patients with coronary heart disease: a study in a tertiary hospital. Iran J Med Sci. 2011;36:201–6.

    PubMed  PubMed Central  Google Scholar 

  48. 48.

    Shankman SA, Nadelson J, McGowan SK, Sovari AA, Vidovich MI. The predictive power of depression screening procedures for veterans with coronary artery disease. Vasc Health Risk Manag. 2012;8:233–8.

    Article  Google Scholar 

  49. 49.

    Doyle F, Rohde D, Rutkowska A, Morgan K, Cousins G, McGee H. Systematic review and meta-analysis of the impact of depression on subsequent smoking cessation in patients with coronary heart disease: 1990 to 2013. Psychosom Med. 2014;76:44–57.

    Article  Google Scholar 

  50. 50.

    Hamer M, Stamatakis E. Prospective study of sedentary behavior, risk of depression, and cognitive impairment. Med Sci Sports Exerc. 2014;46:718–23.

    Article  Google Scholar 

  51. 51.

    Zhu Y, Blumenthal JA, Shi C, Jiang R, Patel A, Zhang A, Yu X, Gao R, Wu Y. Sedentary behavior and the risk of depression in patients with acute coronary syndromes. Am J Cardiol. 2018;121:1456–60.

    Article  Google Scholar 

  52. 52.

    Isaksen K, Munk PS, Giske R, Larsen AI. Effects of aerobic interval training on measures of anxiety, depression and quality of life in patients with ischaemic heart failure and an implantable cardioverter defibrillator: a prospective non-randomized trial. J Rehabil Med. 2016;48:300–6.

    Article  Google Scholar 

  53. 53.

    Segar ML, Katch VL, Roth RS, Garcia AW, Portner TI, Glickman SG, Haslanger S, Wilkins EG. The effect of aerobic exercise on self-esteem and depressive and anxiety symptoms among breast cancer survivors. Oncol Nurs Forum. 1998;25:107–13.

    CAS  PubMed  Google Scholar 

  54. 54.

    Stamatakis KA, Lynch J, Everson SA, Raghunathan T, Salonen JT, Kaplan GA. Self-esteem and mortality: prospective evidence from a population-based study. Ann Epidemiol. 2004;14:58–65.

    Article  Google Scholar 

  55. 55.

    Compare A, Zarbo C, Manzoni GM, Castelnuovo G, Baldassari E, Bonardi A, Callus E, Romagnoni C. Social support, depression, and heart disease: a ten year literature review. Front Psychol. 2013;4:384.

    Article  Google Scholar 

  56. 56.

    Bucholz EM, Strait KM, Dreyer RP, Geda M, Spatz ES, Bueno H, Lichtman JH, D'Onofrio G, Spertus JA, Krumholz HM. Effect of low perceived social support on health outcomes in young patients with acute myocardial infarction: results from the VIRGO (variation in recovery: role of gender on outcomes of young AMI patients) study. J Am Heart Assoc. 2014;3:e001252.

    Article  Google Scholar 

  57. 57.

    Notara V, Panagiotakos DB, Papataxiarchis E, Verdi M, Michalopoulou M, Tsompanaki E, Kogias Y, Stravopodis P, Papanagnou G, Zombolos S, et al. Depression and marital status determine the 10-year (2004-2014) prognosis in patients with acute coronary syndrome: the GREECS study. Psychol Health. 2015;30:1116–27.

    Article  Google Scholar 

  58. 58.

    Zarbo C, Compare A, Baldassari E, Bonardi A, Romagnoni C. In sickness and in health: a literature review about function of social. Clin Pract Epidemiol Ment Health. 2013;9:255–62.

    Article  Google Scholar 

  59. 59.

    Kim JW, Kang HJ, Bae KY, Kim SW, Shin IS, Yoon JS, Hong YJ, Ahn Y, Jeong MH, Kim JM. Social support deficit and depression treatment outcomes in patients with acute coronary syndrome: findings from the EsDEPACS study. Int J Psychiatry Med. 2018:91217418791439. https://doi.org/10.1177/0091217418791439.

  60. 60.

    Hare DL, Davis CR. Cardiac depression scale: validation of a new depression scale for cardiac patients. J Psychosom Res. 1996;40:379–86.

    CAS  Article  Google Scholar 

  61. 61.

    Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the depression anxiety stress scales (DASS) with the Beck depression and anxiety inventories. Behav Res Ther. 1995;33:335–43.

    CAS  Article  Google Scholar 

  62. 62.

    Shi WY, Stewart AG, Hare DL. Major depression in cardiac patients is accurately assessed using the cardiac depression scale. Psychother Psychosom. 2010;79:391–2.

    Article  Google Scholar 

  63. 63.

    Wise FM, Harris DW, Carter LM. Validation of the cardiac depression scale in a cardiac rehabilitation population. J Psychosom Res. 2006;60:177–83.

    Article  Google Scholar 

  64. 64.

    Lovibond SHLP. Manual for the depression anxiety stress scales. 2nd ed. Sydney: Psychology Foundation; 1995.

    Google Scholar 

  65. 65.

    Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64:258–66.

    Article  Google Scholar 

  66. 66.

    Ware J Jr, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220–33.

    Article  Google Scholar 

  67. 67.

    Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD checklist (PCL). Behav Res Ther. 1996;34:669–73.

    CAS  Article  Google Scholar 

  68. 68.

    The ENRICHD Investigators. Enhancing recovery in coronary heart disease patients (ENRICHD): study design and methods. The ENRICHD investigators. Am Heart J. 2000;139:1–9.

  69. 69.

    The ENRICHD Investigators. Enhancing recovery in coronary heart disease (ENRICHD) study intervention: rationale and design. Psychosom Med. 2001;63:747–55.

  70. 70.

    Robins RW, Hendin HM, Trzesniewski KH. Measuring global self-esteem: construct validation of a single-item measure and the Rosenberg self-esteem scale. Personal Soc Psychol Bull. 2001;27:151–61.

    Article  Google Scholar 

  71. 71.

    Wagnild GM, Guinn PE. The resilience scale user’s guide: for the U.S. english version of the resilience scale TM and the 14-item resilience scale TM (RS-14 TM). USA: Resilience Center; 2009.

Download references

Acknowledgements

Professor Marcel Tanner (Swiss Tropical and Public Health Institute, Basel, Switzerland) initiated the collaboration between An-Najah National University and the Swiss Tropical and Public Health Institute. Professor Sabina de Geest (Director Institute of Nursing Science, University of Basel, Switzerland) provided highly valuable professional expertise and input for the manuscript.

Funding

The study was funded by a Swiss Government Excellence Fellowship for Foreign Scholars (ESKAS) for the PhD student, HA, working on the project and by the Freiwillige Akademische Gesellschaft, Basel, Switzerland. The funders of the project took no part in the design of the study, data collection and analysis, interpretation of the data or the writing of the manuscript.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Author information

Affiliations

Authors

Contributions

HA conducted data collection, analyzed and interpreted data, and wrote the manuscript. AAlka supervised the data collection and the implementation of the study in Palestine and edited the manuscript. AAlkh, AH, HO, JS, MT assisted in data collection. EZ and SHY contributed to designing the study. EZ and CS participated in planning the data analysis. CS supervised the statistical analysis. EZ, SHY, and CS contributed to the interpretation of the results. NPH designed the study, directed its implementation, data analysis and result interpretation. She edited all versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to N. Probst-Hensch.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Nordwest- und Zentral Schweiz (EKNZ) in Basel, Switzerland and by the Institutional Review Board (IRB) committee at An-Najah National University in Nablus, Palestine. All patients enrolled in the study provided written informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Additional files

Additional file 1:

Description of study instruments. (DOCX 39 kb)

Additional file 2:

Table S2. Socio-demographic, clinical, psychosocial, lifestyle factors by STRESS status, (n = 1022). (DOCX 24 kb)

Additional file 3:

Table S1. Socio-demographic, clinical, psychosocial, lifestyle factors by DEPRESSION and ANXIETY status, (n = 1022). (DOCX 24 kb)

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Allabadi, H., Alkaiyat, A., Alkhayyat, A. et al. Depression and anxiety symptoms in cardiac patients: a cross-sectional hospital-based study in a Palestinian population. BMC Public Health 19, 232 (2019). https://doi.org/10.1186/s12889-019-6561-3

Download citation

Keywords

  • Depression
  • Anxiety
  • Cardiovascular diseases
  • Predictors
  • Prevalence
  • Cardiac rehabilitation