Psychosocial risk factors in women with coronary heart disease : stress, social support and a behavioral intervention

Abstract

Background: Studies have shown that psychosocial factors such as stress at work and from marriage as well as lack of social support and depression may influence recovery following an acute coronary event. Rehabilitation programs after these events including stress management may improve both general health and prognosis. Women have been studied less often than men, and may also respond differently to psychosocial interventions.

Aim: In study I we examine how marital and work stress are associated to social support. Study II investigates work and marital status in relation to depressive symptoms, social support and daily stress behavior. Study III examines the effects of a 1-year stress management program on daily stress behavior and social support in female patients. Study IV investigates how financial strain the year before the CHD event relates to depressive symptoms, social support and recurrent events.

Materials and methods: Study I is based on data from the Female Coronary Risk Study designed to survey psychosocial and physiological risk factors for CHD in women. Participants were 292 women <65 years (mean age 55±8 yrs) recruited while hospitalized, for acute myocardial infarction (AMI) or unstable angina pectoris from all hospitals in Stockholm between 1991-1994. Study II-IV are from the study Healthier Female Hearts in Stockholm, a randomized controlled stress management intervention comprising 247 women <75 years (mean age 62±9 yrs) hospitalized at Karolinska University Hospital, Huddinge and St. Görans Hospital between 1996-2000 recruited consecutively during the event of either AMI, percutaneous transluminal angioplasty, or for coronary by-pass operation. Patients were randomized to either participating in a behavioral stress management therapy and medical care by a cardiologist or to a control group obtaining usual care of the health care system. Twenty groups were formed with 48 women in each, who met 20 times during 1 year. All patients were assessed at baseline 6-8 weeks after randomization, at 10 weeks (after 10 intervention sessions), at 1 year (after completed intervention), and at a follow-up 1-2 years later.

Results: In study I, marital stress was negatively associated to social support, whereas work stress was not associated to social support. In study II, working after the CHD event was associated with lower levels of depressive symptoms and higher levels of social support as compared to not working, whereas marital status was not related to depressive symptoms or social support. There was no significant interaction between marital and working status on depressive symptoms, social support or daily stress behavior. In study III, intention to treat analyses showed that the decrease of daily stress behavior was more pronounced in the intervention group as compared to controls, although there were no significant differences between the groups at any given time point. There was no significant difference over time between the groups concerning social support. Study IV showed that financial strain was negatively related to social support and depressive symptoms and women who experienced financial strain had an increased risk of recurrent CHD events over a five-year period after controlling for standard risk factors.

Conclusions: Results imply that marital stress was of importance for social support among CHD women and working after a CHD event was associated with a better psychosocial profile as compared to not working. There was no evidence that the intervention had an effect on daily stress behavior or social support. Financial strain was a risk factor for CHD progress after controlling for depression and a number of standard clinical risk factors.