Denollet, J.

Pedersen, S.S.

English

Tilburg University Repository

    Tilburg UniversityPrognostic value of Type D Personality compared with depressive symptomsDenollet, J.; Pedersen, S.S.Published in:Archives of Internal MedicinePublication date:2008Link to publication in Tilburg University Research PortalCitation for published version (APA):Denollet, J., & Pedersen, S. S. (2008). Prognostic value of Type D Personality compared with depressivesymptoms. Archives of Internal Medicine, 168(4), 431-432.General rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.            • Users may download and print one copy of any publication from the public portal for the purpose of private study or research.            • You may not further distribute the material or use it for any profit-making activity or commercial gain            • You may freely distribute the URL identifying the publication in the public portalTake down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Download date: 12. May. 2021EDITOR’S CORRESPONDENCERESEARCH LETTERSPrognostic Value of Type D PersonalityCompared With Depressive SymptomsT he association between depression and coro-nary artery disease (CAD) is complex, and a moredetailed subtyping of high-risk patients isneeded.1-3 Type D personality (the tendency to experi-ence negative emotions and to be socially inhibited) isalso related to poor prognosis.4 There has been vigorousdebate about whether Type D personality adds to the evi-dence concerning depression.3 It is important to showthat the predictive validity of Type D personality ex-tends beyond that which can be predicted by depres-sion, but to our knowledge, no study to date has com-pared the cognitive-affective symptoms of depression, asmeasured by the Beck Depression Inventory (BDI), withthe Type D personality construct.We therefore examined the relative effect of Type Dpersonality and depressive symptoms on 5-year cardiacprognosis in 337 Belgian patients with CAD (297 men;mean age, 57.0 years).4 Covariates included exercise tol-erance, index myocardial infarction (MI), and left ven-tricular ejection fraction (LVEF). The BDI–short form(BDI-SF) has a correlation of 0.96 with the 21-item BDI5and was used to evaluate cognitive-affective symptomsof depression (eg, sadness, hopelessness, sense of fail-ure, guilt, suicidal thoughts, self-hate, dissatisfaction, in-decisiveness, and fatigue). A score greater than 5 on theBDI-SF denotes those with depressive symptoms5 andproved to be the optimal threshold for identifying pa-tients at risk of cardiac events in the present study. TheDS16 scale was used to assess personality4; 98 patients(29%) were classified as Type D personality.At baseline, 181 patients (54%) displayed no or lowlevels of distress. Among the 156 emotionally distressedpatients, only one-third (n=55) had elevated scores forboth Type D personality and depression; 28% (n=43) hada Type D personality but were not depressed; and 37%(n=58) were depressed but did not have a Type D person-ality. Shared variance between Type D personality and de-pression was only 9% ( coefficient, 0.31). Diagnosis ofType D personality was not a function of sex (P=.84), age(P=.27), or disease severity as indicated by exercise toler-ance (P=.34), index MI (P=.43), or LVEF (P=.49).After 5 years of follow-up, 46 patients (14%) had ex-perienced a major adverse cardiac event (MACE, de-fined as a composite of cardiac death, MI, coronary ar-tery bypass graft, or percutaneous coronary intervention),including 12 cardiac deaths or MIs. The Table shows thatMACE was associated with index MI, LVEF of 40% orlower, and no coronary artery bypass graft. Both Type Dpatients and depressed patients had an increased eventrate compared with non–Type D (P=.001) and nonde-pressed (P=.01) patients, respectively. When enteringboth factors in a multivariable model, Type D personal-ity (odds ratio, 2.44 [95% confidence interval, 1.25-4.76]; P=.009) but not depression (odds ratio, 1.71 [95%confidence interval, 0.88-3.33]; P= .12) was signifi-cantly associated with MACE.After adjustment for MI, LVEF, and coronary arterybypass graft, Type D patients had a 3-fold increased riskof MACE (Table, bottom); depression did not predictMACE. Analyses using continuous scores for the TypeD personality and depression measures did not changeTable. Predictors of Major Adverse Cardiac Events at the 5-Year Follow-up ExaminationaBaseline CharacteristicEvent Free, No. (%)(n=291)Cardiac Events, No (%)(n=46)Odds Ratio (95%Confidence Interval) P ValueUnivariate analysisMale sex 260 (89) 37 (80) 0.49 (0.22-1.11) .09Age 55 y 128 (44) 20 (44) 0.98 (0.52-1.83) .95Poor exercise tolerance 156 (54) 24 (52) 0.94 (0.51-1.76) .86Index MI at baseline 107 (37) 29 (63) 2.93 (1.54-5.59) .001LVEF 40% 24 (8) 9 (20) 2.71 (1.17-6.27) .02No CABG at baseline 93 (32) 33 (72) 5.40 (2.72-10.75)  .001Type D personality 75 (26) 23 (50) 2.88 (1.52-5.43) .001Depressive symptoms 90 (31) 23 (50) 2.23 (1.19-4.19) .01Multivariable analysisIndex MI at baseline 1.14 (0.48-2.76) .76LVEF 40% 4.46 (1.71-11.63) .002No CABG at baseline 5.88 (2.29-15.06)  .001Type D personality 3.06 (1.48-6.33) .003Depressive symptoms 1.29 (0.62-2.66) .49Abbreviations: CABG, coronary artery bypass graft; LVEF, left ventricular ejection fraction; MI, myocardial infarction.aComposite of cardiac death, recurrent MI, CABG, or percutaneous coronary intervention.(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 4), FEB 25, 2008 WWW.ARCHINTERNMED.COM431©2008 American Medical Association. All rights reserved. at University of Tilburg, on February 25, 2008 www.archinternmed.comDownloaded from the results, nor did the use of a different cutoff score forthe depression measure. Finally, Type D patients had agreater risk for cardiac death or MI compared with non–Type D patients (7 of 98 [7%] vs 5 of 239 [2%]; oddsratio, 4.84 [95% confidence interval, 1.42-16.52]; P=.01);depression was not related to this end point (P=.25).These findings show that Type D personality mayhave unique prognostic value beyond that of depressivesymptoms. Only one-third of distressed patients withCAD had both a Type D personality and were depressed(28% had Type D personality and were nondepressedand 37% had a depressed and non–Type D personality),Type D personality was associated with a 3-fold in-creased risk of MACE, controlling for depression, andType D personality but not depression predictedMACE, adjusting for disease severity. Another studyalso showed that Type D personality was associatedwith increased cortisol levels in patients with CAD,whereas depression as assessed by the BDI was not.6Hence, Type D personality is more than just a marker ofdepression and should be assessed in its own right inpatients with CAD.Correspondence: Dr Denollet, Department of MedicalPsychology, Tilburg University, PO Box 90153, 5000 LETilburg, the Netherlands (denollet@uvt.nl).Author Contributions: Study concept and design: Denol-let and Pedersen. Acquisition of data: Denollet. Analysisand interpretation of data: Denollet. Drafting of the manu-script: Denollet. Critical revision of the manuscript for im-portant intellectual content: Denollet and Pedersen. Sta-tistical analysis: Denollet. Administrative, technical, andmaterial support: Pedersen.Financial Disclosure: None reported.1. Dickens C, McGowan L, Percival C, et al. Depression is a risk factor for mor-tality after myocardial infarction: fact or artifact? J Am Coll Cardiol. 2007;49(18):1834-1840.2. de Jonge P, van den Brink RH, Spijkerman TA, Ormel J. Only incident de-pressive episodes after myocardial infarction are associated with new cardio-vascular events. J Am Coll Cardiol. 2006;48(11):2204-2208.3. Steptoe A, Molloy GJ. Personality and heart disease. Heart. 2007;93(7):783-784.4. Denollet J, Pedersen SS, Vrints CJ, Conraads VM. Usefulness of type D per-sonality in predicting five-year cardiac events above and beyond concurrentsymptoms of stress in patients with coronary heart disease. Am J Cardiol. 2006;97(7):970-973.5. Beck AT, Beck RW. Screening depressed patients in family practice: a rapidtechnic. Postgrad Med. 1972;52(6):81-85.6. Whitehead DL, Perkins-Porras L, Strike PC, Magid K, Steptoe A. Cortisol awak-ening response is elevated in acute coronary syndrome patients with type Dpersonality. J Psychosom Res. 2007;62(4):419-425.Validation and Comparison of a NovelScreening Guideline for Kidney Disease:KEEPing SCOREDC hronic kidney disease (CKD) is one of the world’smajor public health problems. Nearly 1 in 9 adults(20 million people) in the United States have CKD,and it is estimated that another 20 million are at increasedrisk.1 Given the asymptomatic nature of kidney disease, af-fected individuals and health care providers may be un-aware of the condition in patients. Identifying individualswith early kidney disease would be a useful first step in pre-venting progression to end-stage renal disease as well asreducing morbidity and mortality from cardiovascular dis-ease (CVD).We recently published an instrument (SCreening forOccult REnal Disease [SCORED]) to systematically iden-tify individuals with a high likelihood of prevalent CKD.2Derived from the National Health and Nutrition Exami-nation Survey (NHANES) 1999-2002 and (partially) vali-dated in the Atherosclerosis Risk in Communities (ARIC)study, SCORED identified 9 demographic and medicalvariables that could be assigned integer values and thenentered into a scoring algorithm. The scoring algorithmwas intentionally simplified to be accessible to lay per-sons and health care providers.To our knowledge, SCORED is the only algorithm de-rived from scientific modeling, rather than expert scien-tific opinion, targeted for general population screening. Al-ternatively, the National Kidney Foundation has encouragedscreening strategies targeted at high-risk groups. Throughthe Kidney Early Evaluation Program (KEEP), the Na-tional Kidney Foundation recommends using the follow-ing characteristics to identify individuals with a high like-lihood of kidney disease: “if a person is 18 years or olderand has one or more of the following: diabetes; high bloodpressure; or a family history of diabetes, high blood pres-sure or kidney disease.”3,4It is unclear how the SCORED algorithm compareswith the KEEP guidelines. Such comparisons would beuseful for clinicians and others. Since the publication ofSCORED, we have performed an additional validationstudy using new, independent samples: (1) NHANES2003-2004 and (2) a combined cohort of the ARIC studyand Cardiovascular Heart Study (ARIC/CHS). We re-port the findings herein.Methods. The ARIC study enrolled 15 792 participantsaged 45 to 64 years between 1987 and 1989, and CHSrecruited 5201 subjects 65 years and older between 1989and 1990. Both are community studies, and detailed de-scriptions have been published previously.2,5,6 Some datadisparities and limitations to be noted are summarizedin a footnote of the Table.SCORED Model. The SCORED model is a multivariablemathematical function that gives an estimated probabil-ity of having CKD as follows:Probability(CKD)=1/[1exp(−x)],wherex=−5.41.55 I(Age 50-59 years)2.31 I(Age 60-69 years)3.23 I(Age 70 years)0.29 I(Female)0.93 I(Anemia)0.45 I(Hypertension)0.44 I(Diabetes)0.59 I(History of CVD)0.45 I(History of Heart Failure)0.74 I(Peripheral Vascular Disease)0.83 I(Proteinuria).Johan Denollet, PhDSusanne S. Pedersen, PhD(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 4), FEB 25, 2008 WWW.ARCHINTERNMED.COM432©2008 American Medical Association. All rights reserved. at University of Tilburg, on February 25, 2008 www.archinternmed.comDownloaded from 

Prognostic value of Type D Personality compared with depressive symptoms

https://pure.uvt.nl/ws/files/1062035/MedPsy_Denollet_Prognostic_ArIM_2008.pdf

Prognostic value of Type D Personality compared with depressive symptoms

Abstract

Similar works

Full text

Available Versions

Tilburg University Repository