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ARTICLE CONTRIBUTORS

Deirdre Holly, BHF Assistant Psychologist

John Sharp, BHF Principal Clinical Psychologist

Clinical Articles, Featured

The psychological impact of the implantable cardioverter defibrillator: A systematic review

Psychologists Deirdre Holly and John Sharp assess the psychological effects of implantable cardioverter defibrillators (ICDs). Their systematic review reveals that anxiety and depression are common amongst the ICD patient population…

ICDs are associated with a multitude of psychosocial issues, including anxiety and depression. This systematic review was undertaken to investigate this relationship, and the clinical and demographic factors associated with the incidence of both anxiety and depression among people with ICDs.

PubMED, PsycINFO, EMBASE and CINAHL databaageses were searched using pre-determined search terms during May 2011. Thirty-three articles meeting inclusion criteria were subsequently included in the review. Findings revealed that anxiety and depression are common post-implantation with rates of up to 60% and 40%, respectively, reported by the literature. The influence of additional factors including time since implantation and receipt of shocks was also investigated, however, whether there is any association between these factors remains unclear.

The findings reported by this review are limited by the fact that there are gross inconsistencies in the literature in terms of the methodology employed and the time elapsed since implantation. Future research should be carried out prospectively and assess participants pre- and post-implantation.

Introduction

The implantable cardioverter defibrillator (ICD) is the recommended treatment for life-threatening ventricular arrhythmias.1 By identifying potentially fatal arrhythmias and administering therapeutic electrical shocks the ICD substantially reduces the risk of sudden cardiac death. 2,3 However, the ICD is associated with a multitude of psychosocial issues4 which can adversely affect the prognosis of coronary heart disease (CHD), such as depression4,5 and anxiety disorders,4-6 including panic attacks.5

The present paper seeks to examine the prevalence of psychopathology amongst people with ICDs. Specifically, this paper will: (1) examine the prevalence of anxiety and depression among adults (>18 years) receiving ICDs; (2) identify personal (age, gender) and clinical (diagnosis) factors associated with the experience of anxiety or depression among people with ICDs.

Methods

The current review considered studies of adults receiving ICDs for the primary or secondary prevention of sudden cardiac death.  Articles for inclusion (1985-2011) were identified in May 2011 by searching PubMED, PsycINFO, EMBASE and CINAHL databases using the following terms: implantable cardioverter defibrillator, anxiety, depression, depressive disorder, deprsudessive symptoms, quality of life, psychopathology, distress, emotional factors, psychosocial factors, symptom distress, mental health.  Reference lists from selected articles were examined and key authors contacted to identify relevant studies and recently published or “in press” journal articles.

Inclusion criteria:

  • Address issues of anxiety and depression
  • Use either structured/semi-structured interviews or standardised measures to assess anxiety and depression
  • Include participants of both genders, over the age of 18
  • Employ primary data
  • Reported in the English language.

Data extraction forms were used to summarise the characteristics of these studies and their results.   Studies were classified according to SIGN7 (table 1).

Table 1. Classification of studies based on levels of evidence

Table 1. Classification of studies based on levels of evidence

The methodological quality of these studies was scrutinised using checklists from SIGN/CASP,7,8 adapted for the purposes of this review.  The studies were then given an overall rating (table 2).

Table 2. Criteria for overall assessment of studies

Table 2. Criteria for overall assessment of studies

Any uncertainty relating to the inclusion of articles was discussed with the second author.  In the case of multiple articles using the same sample, employing the same assessment methods within the same period of time, only the study with the largest sample size was included.

Results

Using the outlined search terms 2,739 studies were identified.  Thirty-three studies were subsequently included in the review (figure 1).

Figure 1. Flow chart of review process

Figure 1. Flow chart of review process

Study characteristics

The overall sample size for the included studies was 4,501 (range 20-610).   The mean participant age was 62.4 years.  Seventy-seven percent of participants were male (table 3).

Table 3. Study assessment

Table 3. Study assessment

A variety of assessment methods were used by the studies, including the Hospital Anxiety and Depression Scale (HADS), the State Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and the Centre for Epidemiological Studies-Depression Scale (CES-D).  In addition, a number of studies employed structured or semi-structured interviews.

Seven studies recruited participants prior to the receipt of their device.  Of the remaining studies, the duration from implant to study participation varied from one day to 88 months.  Follow-up assessment ranging from one month to two and a half years featured in 17 studies.  Eight studies included more than one follow-up.

Anxiety

The prevalence of anxiety ranged from 5.8 to 62.8% dependent on when the assessment took place and the method employed.9,10 Pre-implant levels of anxiety measured in the days prior to receipt of the device ranged from 34% to 62.8%.10-16 The six studies assessing participants within three-months of implantation noted that between 5.8% and 48% may experience anxiety.9,15,17-20 The remaining studies, which addressed anxiety at least one year post-implant found that between 13% and 41% scored above the cut-off points suggestive of caseness.21-25 One study26 with a period of 88 months from implantation to recruitment found that 34.9% scored above the cut-off points on the STAI.  The six studies which included follow-up periods10,12,26-28 suggest some stability in prevalence of post-implantation anxiety throughout five years of follow-up.10,20,26,27

Assessment of panic disorder (PD) within days of placement identified a prevalence of 5.9%.9 Similar prevalence rates of 5% were noted at seven and a half months post-implant.29 However, estimates were comparatively higher (19.4%) among recipients at three and a half years post-implant.30 The assessment of PD as detailed by these studies was carried out using structured/semi-structured interviews, including the SCID and DIPS.31,32

There has been some consideration of the correlation of post-implantation anxiety and patient characteristics.  For example, significantly higher anxiety scores have been noted among female recipients (6) and amongst individuals who smoke and use psychotropic medication.17 Age has been both negatively and positively correlated with anxiety amongst this population.21,28,30

Features of the device implantation may be implicated in the prevalence of anxiety.  Three studies22,25,33 investigated the relationship between time since implant and anxiety.  However, although one study33 suggested anxiety decreases over time, two studies22,25 reported no such relationship.  It has been suggested the severity of post-implant physical symptoms associated with heart failure, as classified by the New York Heart Association, may be associated with anxiety.34

Patients fulfilling criteria for an anxiety disorder are often preoccupied with anxiogenic predictions of imminent ICD firing, fear of device malfunction, death, feelings of loss of control 34 and, as such, constantly self-monitor for signs of an impending shock (30).  Additionally, high scores on the Anxiety Severity Index were related to the perceived predictability of a shock, interference of activities due to worrying about shock, and time spent worrying about shock.27

Depression

The prevalence of depression ranged from 5-38%.12,15,19 Six studies examining the prevalence of depression prior to ICD placement10-14,16 reported pre-implant prevalence of 23-35.8%11,14 with an estimate that 20.8% had mild, 5.7% moderate, and 9.4% severe depression.14

The prevalence of depression was assessed at varying time-points post-implantation with estimates ranging from 5-38%.21,35 Within three-months of implantation, the prevalence of depression varied from 11-20%.9,16,20 At approximately seven and a half months post-implant 15% experienced major depression.29 The remaining studies, monitoring depression at least one-year post-implant, reported prevalence between 5% and 38%.22-25,27,35-38

Six studies addressing the prevalence of depression featured more than one follow-up period9,10,12,19,20,27 ranging from one-month10,19 to two years post-implant9,12,20,27 with a maximum of four follow-ups.10,19 The reviewed studies suggest depression amongst recipients of ICDs is a stable trait.9,10,12,19,20,27 Neither of two prospective studies noted a significant difference in the prevalence of depression at pre- and post-implantation.10,12

The specific presence of major depressive disorder was examined by two of the included studies and ranged from 8.6% to 15%.9,29 At nine to eighteen months follow-up one of these studies noted that 7.4% could be classified as having major depressive disorder.9

Post-implant depression has been linked to patient characteristics.  For example, women were reported to be more likely to experience depression.25 Persistent depression was suggested to be associated with older age by one study.16 However, similar research suggests that age may be negatively correlated with depression.21 Marital status and highest level of education are also suggested to be associated with depression among this population.24 Additional factors associated with depression include poor social support and poor physical functioning.24

Iatrogenic factors inherent in the ICD may increase the likelihood of depression including the receipt of one or more shocks,24 as well as fear of ICD firing.27 Clinical factors such as having CRT, heart failure, in particular NYHA classes III/IV, and previous CABG, in addition to the use of diuretics and psychotropic medicines are suggested to be associated with persistent depression, type D behaviour pattern and high ICD concerns within this population.16 Time since implant may significantly predict depression independent of ejection fraction status,24,33 with significant differences in depression based on follow-up lowest in one to five years, but increasing thereafter.6 However, such an influence is not universally reported.25

Shocks

The administration of therapeutic shocks for the correction of potentially fatal arrhythmias occurs in 4.2 to 90% of ICD recipients.16,17,29 However, such figures may be influenced by time since implantation.39 When the population prevalence of shock for the overall sample of studies was calculated, this was approximately 29%.  The number of shocks received by an individual ranged from one to over ten, with one study37 reporting that 17.1% had received upwards of ten shocks.  Shock storms, typically classed as three or more shocks within a 24 hour period, were reported by five studies and were experienced by 2.2% to 11% of ICD recipients.15,16,20,22,36

It has been purported that ICD shocks25 and the number of shocks received28,40 may be correlates of psychological distress.  Nineteen studies investigated the relationship between shocks and distress with one study20 noting that almost two-thirds of participants experiencing shocks had clinical anxiety.  Further, individuals with a specific anxiety disorder have been shown to experience significantly more shocks per year compared to their non-anxious counterparts.30 Time since implantation could be influential in determining emotional reaction.  For example, ICD recipients shocked within a year post-implantation are more likely to experience anxiety at one-year follow-up compared to their non-shocked peers.10 The receipt of shocks likely leads to concerns about the device,17 and corresponding anxiety related to shocks as displayed in one-third of recipients.39

The receipt of just one shock may be sufficient to cause a person to experience symptoms akin to depression.38 Furthermore, people experiencing two or more shocks within a month have been suggested to be significantly more depressed than those receiving less than four a year.6 The number of shocks received and duration since last shock are significantly associated with depression in a positive and negative direction respectively.6 However, recent research has suggested that shock was not associated with depression16,19,36 nor anxiety.19,36

Discussion

The ICD is a life-saving device with the ability to reduce the occurrence of potentially fatal arrhythmias.  Nevertheless, it has been speculated that the ICD and its therapeutic mode is associated with poor psychosocial outcomes.  The present review sought to clarify the nature of the relationship between the ICD and the experience of shocks with psychological distress.

The existing literature reveals confusing and often contradictory conclusions regarding the true extent of psychological difficulties associated with ICD implantation.  It appears a high proportion of people with ICDs display some form of psychopathology post-implantation.  Both anxiety and depression appear to be common post-implantation with estimates of up to two-thirds, and two-fifths of patients, respectively, experiencing such problems and research suggesting significant chronicity of such difficulties.9,10,19,20,27 However, the paucity of prospective studies available limits the extent to which it can be determined whether the ICD and its associated shocks cause these adverse outcomes.  Based on the available research it is not possible to confidently conclude whether people receiving shocks are at an increased risk of developing anxiety or depression, or whether such difficulties are directly due to their ICD firing.  Any confidence in the literature is confounded by the adoption of multifarious methodology including study design, time of recruitment and assessment, assessment measures utilised, and criteria used.

The current paper aimed to identify factors associated with the prevalence of anxiety and depression in post-implant ICD patients.  It has been suggested that gender and age may influence the development of psychopathology, which is not unreasonable due to the stress, limitations in activities of daily living and socialisation experienced by many.41 Additionally, among younger recipients maladjustment to the device may be related to body image issues occurring as a result of scarring, or concerns about childbearing.19,42 Furthermore, fear and worry about the device, and the implications that a device shock may have for oneself or another are noted to be the most distressing aspects of treatment for many.39 However, no clear conclusions can be drawn regarding whether factors such as gender, age or time since implant have an impact on the subsequent development of psychopathology.  Similarly, although the association between the experience of shocks and anxiety and depression was mostly positively correlated, contradictory findings were reported.19,36 Based on the included studies it is not possible to confidently limn the factors that increase the likelihood of experiencing either anxiety or depression as a result of ICD firing.

The number of shocks experienced by participants varied significantly between studies yet the reason underlying this is not clear.  For example, demographic and clinical factors were often not accounted for within the statistical analyses.  A limited amount of research suggests that emotional factors such as anger, mental stress and anxiety may influence the occurrence of arrhythmias and subsequent ICD firing.43-46 However, although intriguing, this remains a tentative suggestion since such factors were not sufficiently addressed by the included studies to permit the declaration of a meaningful conclusion in this regard.

Recommendations

Recognition of the high prevalence of emotional distress amongst people with ICDs supports previous recommendations of the need for patients’ care by multidisciplinary teams to be psychologically informed including the availability of access to specialist psychological services for appropriate assessment and management.5 This could include the provision of pre-implantation assessment to help identify the presence of any ICD-related misconceptions likely to affect subsequent adjustment to the device and provide an opportunity for patients to discuss any concerns or distress.  There is increasing evidence that such cognitively oriented interventions have value within the ICD population enhancing patient wellbeing and leading to minimising use of healthcare resources.12

The variety of research methods used within this area precludes the assimilation of data, the ability to meaningfully compare studies, and assert findings with confidence.  For example, the majority of the reviewed studies examining the relationship between certain emotional states and ICD firing used a retrospective design and thus limit any confidence in the findings of these investigations.  Prospective studies, recruiting patients prior to the receipt of the device, would allow patient levels of anxiety pre- and post-implantation, to be monitored and control for other potentially confounding variables.  The identification of such factors would allow for the development of interventions to specifically target and improve the psychological well-being of such vulnerable populations.

Summary

The present paper presents a description of the literature investigating the prevalence of psychological difficulties following ICD implantation.

Conflict of interest

None declared.

Key messages

  • ICDs are associated with a multitude of psychosocial issues, many of which are a result of ICD placement and subsequent firing.
  • ICD shocks and number of shocks received may be correlates of psychological distress.
  • It is unclear whether factors such as time since implant have an impact on the development of anxiety or depression post-implantation.
  • Patients should be assessed pre- and post-implantation, which may assist subsequent adjustment to the device.

References

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PS1021 Photo

Authors

Deirdre Holly, BHF Assistant Psychologist

John Sharp, BHF Principal Clinical Psychologist

Corresponding author
Deirdre Holly, BHF Assistant Psychologist, Cardiac Psychology Service, The Lister Centre, Crosshouse Hospital, Kilmarnock, KA2 0BE

Citation

Holly D, Sharp J.  The psychological impact of the implantable cardioverter defibrillator: A systematic review.  Arrhythmia Watch 2011;Issue 17 (Oct)

Published on: September 28, 2011

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