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RESEARCH PAPER Life Satisfaction and Positive Adjustment as Predictors of Emotional Distress in Men With Coronary Heart Disease Pilar Sanjua ´n A ´ ngeles Ruiz Ana Pe ´rez Published online: 12 December 2010 Ó Springer Science+Business Media B.V. 2010 Abstract This two-wave longitudinal study examines the ability of life satisfaction and adjustment strategies to predict anxious and depressive symptoms in coronary heart disease male patients. Studies have shown that most heart attack survivors report these symptoms, which may worsen the prognosis of the disease. At Time 1, immediately after the first cardiac episode, eighty-eight men reported their life satisfaction levels, adjustment strat- egies used, and anxious and depressive symptoms experienced. At Time 2, six months later, sixty-three of those patients reported only their anxious and depressive symptoms again. The results showed that, after controlling for demographic variables, anxious and depressive symptoms at Time 1 were predicted by positive adjustment and life satisfaction. At Time 2, after controlling for both demographic variables and Time 1-emotional symptoms, none of the psychological variables predicted anxious symptoms, while depressive symptoms were only predicted by life satisfaction. It is concluded that an adequate level of life satisfaction may help to decrease emotional distress, both short and long term, while the use of positive adjustment strategies is especially important imme- diately after diagnosis. Keywords Coronary heart disease Anxiety Depression Life satisfaction Adjustment to illness Coping strategies 1 Introduction Coronary heart disease (CHD) is the first worldwide cause of death, representing 12.6% of the global death rate. The World Health Organization (WHO) has estimated that 7 million people die from CHD each year (WHO 2007). Although the total number of men and women who die from CHD is similar; in the Mediterranean countries the proportion of P. Sanjua ´n (&) A ´ . Ruiz A. Pe ´rez School of Psychology, Universidad Nacional de Educacio ´n a Distancia (UNED), C/Juan del Rosal, 10–Ciudad Universitaria, 28040 Madrid, Spain e-mail: [email protected] 123 J Happiness Stud (2011) 12:1035–1047 DOI 10.1007/s10902-010-9243-5

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RESEARCH PAPER

Life Satisfaction and Positive Adjustment as Predictorsof Emotional Distress in Men With Coronary HeartDisease

Pilar Sanjuan • Angeles Ruiz • Ana Perez

Published online: 12 December 2010� Springer Science+Business Media B.V. 2010

Abstract This two-wave longitudinal study examines the ability of life satisfaction and

adjustment strategies to predict anxious and depressive symptoms in coronary heart disease

male patients. Studies have shown that most heart attack survivors report these symptoms,

which may worsen the prognosis of the disease. At Time 1, immediately after the first

cardiac episode, eighty-eight men reported their life satisfaction levels, adjustment strat-

egies used, and anxious and depressive symptoms experienced. At Time 2, six months

later, sixty-three of those patients reported only their anxious and depressive symptoms

again. The results showed that, after controlling for demographic variables, anxious and

depressive symptoms at Time 1 were predicted by positive adjustment and life satisfaction.

At Time 2, after controlling for both demographic variables and Time 1-emotional

symptoms, none of the psychological variables predicted anxious symptoms, while

depressive symptoms were only predicted by life satisfaction. It is concluded that an

adequate level of life satisfaction may help to decrease emotional distress, both short and

long term, while the use of positive adjustment strategies is especially important imme-

diately after diagnosis.

Keywords Coronary heart disease � Anxiety � Depression � Life satisfaction � Adjustment

to illness � Coping strategies

1 Introduction

Coronary heart disease (CHD) is the first worldwide cause of death, representing 12.6% of

the global death rate. The World Health Organization (WHO) has estimated that 7 million

people die from CHD each year (WHO 2007). Although the total number of men and

women who die from CHD is similar; in the Mediterranean countries the proportion of

P. Sanjuan (&) � A. Ruiz � A. PerezSchool of Psychology, Universidad Nacional de Educacion a Distancia (UNED),C/Juan del Rosal, 10–Ciudad Universitaria, 28040 Madrid, Spaine-mail: [email protected]

123

J Happiness Stud (2011) 12:1035–1047DOI 10.1007/s10902-010-9243-5

deaths among men is higher than among women. In particular, in Spain, the number of men

who die from CHD is three times higher than that of women (WHO 2008).

Given these figures, much research is needed to identify all the variables that influence

the progression of these diseases. Over the last decades, health psychology has shown that

psychosocial factors have an important effect on development and progression of chronic

diseases such as CHD (Baum et al. 2001; Krantz and McCeney 2002; Schneiderman et al.

2001). In particular, many empirical studies have been conducted to increase knowledge on

adaptation or adjustment processes to chronic disease (Stanton et al. 2001, 2002, 2007;

Watson and Homwood 2008).

Specifically, in the case of CHD, it is known that the experience of a first-time cardiac

episode is a highly stressful event that poses different threats, of which the most relevant is

the threat to life. Uncertainty about its development is another factor likely to trigger stress

reactions. Once this first phase is overcome, patients have to face new situations stemming

from having become chronically ill. Thus, changing habits such as diet or exercise are

required. Moreover, the disease may imply some physical limitations; it may also interfere

with the achievement of significant goals. Therefore, the patient must go through an

adjustment period during which symptoms of emotional distress such as anxiety or

depression may appear. In fact, two-thirds of heart attack survivors report symptoms of

depression (Gravely-Witte et al. 2007) and the prevalence of major depression in this group

is higher than in the general population (Carney et al. 2002). Studies have reported that

symptoms of anxiety are also common in patients with cardiovascular diseases (Goodwin

et al. 2009).

The development of anxiety and depression has effects on different systems, such as the

increases in sympathetic nervous system activity and the level of stress-related hormones

possibly affecting the cardiovascular system and, therefore, worsening the disease prog-

nosis (Gallo et al. 2004; Rozanski and Kubzansky 2005). It is important to detect and treat

these symptoms, since even minimal symptoms of depression have been reported to

increase mortality risk after a myocardial infarction (Bush et al. 2001). Depression also

doubles the risk of a new cardiac episode after surgery for coronary artery bypass (Blu-

menthal et al. 2003). Likewise, patients with high anxiety have been reported five times

more likely to experience complications or even death after a myocardial infarction (Moser

and Dracup 1996).

From the positive psychology perspective, which focuses on the study of positive

experience and psychological functioning (Seligman 2002; Seligman and Csikszentmihalyi

2000), there is currently a growing interest in researching, in connection with health

psychology, how some positive phenomena may influence the etiology, progression and

disease management (Aspinwall and Tedeschi 2010).

Research on adaptation processes, which has been conducted mainly in health psy-

chology, and more recently in conjunction with positive psychology, has shown that

effective adjustment to disease includes the use of certain coping strategies, the perception

of control over the disease, the belief in the ability to cope with it, and positive attitudes

and expectations about its development (Carver et al. 1993; Stanton et al. 2001, 2007).

With respect to coping strategies, it is well established that when situations are con-

trollable (when something can be done to change the situation) the best strategy is active

coping (Anderson 1996; Carver et al. 1993; Stanton et al. 2007). The direct confrontation

of the problems not only increases the possibility of solving them, but it is also associated

with decreased emotional distress.

When problems are uncontrollable, the most effective coping strategies to reduce

emotional distress are acceptance of the problem, positive reappraisal of the situation (e.g.,

1036 P. Sanjuan et al.

123

considering it as an opportunity to change unhealthy habits, deepening relationships,

assessing really important things, etc.) and the use of the sense of humour. In the case of

uncontrollable situations, the denial of the disease, the avoidance of facing it, and the focus

on negative emotions are related to the development of emotional distress (Anderson 1996;

Carver et al. 1993; Garnefski et al. 2009; Litman and Lunsford 2009).

It is necessary to consider that the experience of the disease includes controllable

aspects (basically those related to the treatment, like changes in diet and exercise), but also

involves other aspects that can not be changed (fundamentally those related to the fact of

becoming chronically ill and the limitations this may involve). Therefore, an appropriate

adjustment will require the use of both types of strategies.

Some variables such as perception of control over the disease, the belief in the ability to

cope with it, and positive attitudes and expectations about its development, not only allow

the control of emotional distress resulting from adjustment to illness, but also facilitate

recovery (Gallo et al. 2004; Stanton et al. 2007). In this sense, research has shown that

optimistic expectations were an important predictor for both progression of heart disease

(Matthews et al. 2004), and recovery after a cardiovascular event or surgery (Scheier et al.

1989). Studies have also shown that positive expectancies predicted both improved patient

health 6 months after a heart transplant (Leedham et al. 1995), and recovery from a

myocardial infarction (Agarwal et al. 1995).

Life satisfaction is a key issue in positive psychology, and one of the positive factors

which are currently receiving more attention. Life satisfaction is the subjective assessment

that people make regarding their own lives (Diener 2000). It is the cognitive component of

subjective well-being, which also includes an affective component (high positive affect and

low negative affect). Life satisfaction maintains an inverse relationship with emotional

distress (Kuppens et al. 2008; Schimmack et al. 2004) and a direct one with positive

emotions (Kuppens et al. 2008) and the use of positive adjustment strategies (Dubey and

Agarwal 2007).

Over the past decade, most studies of different subjective well-being components had

focused on their determinants (Diener 2000), but in recent years the interest in the rela-

tionships between these components and physical health has increased, with some findings

that suggest that life satisfaction protect against illness (Veenhoven 2008), predict lowered

risk of all mortality causes (Xu and Roberts 2010), and is associated with reduced car-

diovascular mortality in healthy populations (Chida and Steptoe 2008).

There are very few studies analyzing the impact of life satisfaction level in the

development of emotional distress symptoms in cardiac patients, but the data seem to

suggest that it may play a protective role. Thus, one study found that among people who

had low life satisfaction levels along with low levels of positive affect and psychological

well-being, the prevalence of coronary heart disease was higher (Keyes 2004). In a pre-

vious cross-sectional study, we found that life satisfaction was indirectly related to

symptoms of anxiety and depression in a sample of men who had just suffered an episode

of coronary heart disease for the first time, and that this relationship was partially mediated

by use of adjustment strategies (Ruiz et al., in press).

Given that life satisfaction is a relatively stable and pervasive feature (Diener et al.

2002), it would be expected that its possible protective effect would be prolonged after the

cardiac event. Therefore, in the current study we wanted to analyze, from a longitudinal

perspective, the effects that life satisfaction and adjustment strategies had on reported

emotional distress (anxious and depressive symptoms) of cardiac patients at two different

times, immediately after the first cardiac episode, and 6 months later, when patients had

returned to their everyday activities.

Predictors of Emotional Distress in Men with CHD 1037

123

The conceptualization of the adjustment to illness that we employed was that proposed

by Watson and Homwood (2008), which is an integrative approach, since it proposes a

global consideration of all those aspects that have been separately shown to be relevant to

illness adjustment. Thus, those aspects that have been considered as effective adjustment

(such as active coping strategies, positive reappraisal, sense of humour and optimistic

attitudes about the disease) are included altogether in what is termed here as positive

adjustment. While those aspects that have been considered as ineffective adjustment (such

as perceived lack of control, denial, delegation of control in others, and focusing on

negative emotions) are included altogether in what is here called negative adjustment.

This approach also provides a measure which, in addition evaluating all these aspects, is

short and has excellent reliability. Therefore, it allows the examination of relevant specific

responses in relation to adjustment to chronic illness and avoids lengthy protocols.

As was expected from this perspective, some studies, carried out on chronic patients,

have supported that the predominant use of negative adjustment and the low use of positive

adjustment is associated with poorer functioning and higher emotional distress symptoms,

such as anxiety or depression (Ruiz et al., in press; Ferrrero et al. 1994; Watson and

Homwood 2008).

According to the evidence and suggestions presented above, we expected that, at Time

1, life satisfaction would be directly related to positive adjustment, and indirectly related to

negative adjustment, and anxious and depressive symptoms. In the same way, we also

hypothesized that positive adjustment would maintain an inverse relationship with anxious

and depressive symptoms, while we expected a direct relationship between negative

adjustment and anxious and depressive symptoms.

Given that experiencing a cardiac episode is a highly stressful event because it poses a

serious threat to life, which decreases as time passes, we also thought that patients would

report fewer anxious and depressive symptoms at Time 2 than at Time 1. Moreover, we

also expected that these residual anxious and depressive symptoms at Time 2 could be

predicted by life satisfaction, and positive and negative adjustment at Time 1.

2 Method

2.1 Participants

One hundred and nine men who had just suffered an episode of coronary heart disease for

the first time (myocardial infarction or angina pectoris) were interviewed. Of these 109

patients, 21 were excluded, 3 for having a previous psychiatric history, 4 for having other

serious illnesses and 14 for not sending questionnaires in the time required. Thus, the

sample at Time 1 was finally composed of 88 patients whose mean age was 55.35

(SD = 10.29), ranging from 34 to 77. Among these participants at Time 1, 42% had

finished elementary school, 43.20% had finished high school, and 14.80% were holders of

a university degree; 68.20% were in employment before the cardiac episode; and 92.05%

lived with their family (partner, children and/or other relatives).

Of the 88 participants at Time 1, only 63 answered the questionnaires at Time 2,

6 months after the cardiac episode. The mean age of the sample at Time 2 was 55.38

(SD = 8.65), ranging from 38 to 70. Among Time 2 participants, 33.3% had finished

elementary school, 49.20% had finished high school, and 17.50% were holders of a uni-

versity degree; 74.60% were in employment before the cardiac episode; and 96.80% lived

with their family.

1038 P. Sanjuan et al.

123

During the 6 months between Times 1 and 2, there were no new coronary episodes

among these 63 patients. Participants who completed both phases of the study were

compared with those who did not complete Time 2 questionnaires on demographic and

psychological variables analyzed. There were no significant differences in these variables

between the groups (all ps [ 0.20).

2.2 Procedure

Patients for this two-wave longitudinal study were recruited from different hospitals in

central Spain immediately after being diagnosed by specialists at the Cardiology Units.

Patients who chose to participate in the study were interviewed in order to collect socio-

demographic data and discard psychiatric disorders and other diseases. After this interview,

two envelopes were delivered to patients; one contained the questionnaires that they had to

fill in, and another, which included the address, to send the completed questionnaires to.

Patients were asked to reply within a period not exceeding 15 days once they are dis-

charged from hospital, which happened between 4 and 7 days after the occurrence of the

cardiac event.

The criterion of not exceeding 15 days was required to ensure that all participants reported

their psychological state at the same stage of adjustment period, specifically, immediately

after the heart episode. In this way, elapsed time between the occurrence of cardiac event and

the completion of the questionnaires at Time 1 ranged from 14 to 22 days.

All participants at Time 1 were telephoned 5 months and 3 weeks after their hospital

admission to inform them that if they wanted to continue participating then other ques-

tionnaires would be mailed to them, which they had to complete and forward within

15 days. Twenty-five patients did not respond within the requested time, so that the sample

at Time 2 was reduced to 63 patients.

All patients participated voluntarily and signed informed consent form to the data

obtained was used for research purposes.

2.3 Instruments

The following variables were measured:

2.3.1 Anxious and Depressive Symptoms

We used the Hospital Anxiety and Depression Scale (HADS; Zigmond and Snaith 1983;

Spanish version: Rueda 2004). This scale is a 14-item measure that evaluates anxious (7

items) and depressive (7 items) symptoms. Respondents were asked to report the frequency

of current symptoms on 4-point Likert-type scales ranging from ‘‘0’’ (‘‘Never’’) to ‘‘3’’

(‘‘Always’’) with varying scoring instructions. Anxious and depressive symptoms scores

were computed by averaging items of anxious or depressive symptoms, respectively.

Therefore, total scores ranged from 0 to 3, with higher scores indicating a greater fre-

quency of anxious or depressive symptoms.

This is a short scale, but with excellent psychometric properties and for that reason it

has been widely used for screening and research purposes in patients with CHD (Martin

et al. 2008). In our study alpha coefficients were, at Time 1, 0.80 and 0.72 for anxious and

depressive symptoms, respectively, and, at Time 2, 0.67 and 0.55 for anxious and

depressive symptoms, respectively.

Predictors of Emotional Distress in Men with CHD 1039

123

2.3.2 Adjustment to Illness Strategies

To measure adjustment to illness, we used the Mental Adjustment to Cancer Scale (MAC;

Watson et al. 1988; Spanish version: Ferrrero et al. 1994). This measure, which has

recently been labeled as the Positive and Negative Adjustment Scales (PNAS; Watson and

Homwood 2008), is a 33-item questionnaire that assesses the frequency of use of strategies

of positive and negative adjustment to illness through scales of 4-point Likert-type, with

‘‘1’’ meaning ‘‘nothing’’ and ‘‘4’’ ‘‘very much’’. The Positive Adjustment Subscale (PA)

includes 17 items that assess positive attitudes to illness and different actions to face it, like

active coping, positive reappraisal and sense of humour. The Negative Adjustment Sub-

scale (NA) consists of the 16 remaining items, which assess the perceived lack of control

over the disease, the passive delegation of control in others, the denial of illness, and focus

on negative feelings. Positive and Negative Adjustment scores were computed by aver-

aging items of positive and negative adjustment items, respectively. Therefore, total scores

ranged from 1 to 4, with higher scores indicating greater use of positive or negative

adjustment strategies.

This scale has often been used to assess the adjustment of patients with either cancer or

coronary heart disease, proving to have excellent psychometric properties (Ferrrero et al.

1994; Watson and Homwood 2008). In the current sample alpha coefficients were 0.75 and

0.76 for positive and negative adjustment, respectively.

2.3.3 Life Satisfaction

We used the Life Satisfaction subscale of the Quality of Life Questionnaire (Ruiz and Baca

1993), which includes 10 items designed to measure the degree of perceived satisfaction

with different life aspects like work, income, personality, lifestyle, or achieved goals.

Patients were asked to report their degree of agreement on scales of 5-point Likert-type,

with ‘‘1’’ meaning ‘‘nothing’’ and ‘‘4’’ ‘‘very much’’. The total score was computed by

averaging all items. Therefore, total score ranged from 1 to 4, with higher scores indicating

greater life satisfaction.

This scale has mainly been used to assess the life quality of people with health problems

(diabetes, cancer, heart disease, etc.), and it has demonstrated excellent reliability and

validity (Badia et al. 2002). Cronbach’s alpha coefficient in this patient sample was 0.89.

2.4 Statistical Analysis

Correlations were calculated to check hypothesized relationships among all analyzed

variables. In addition, criterion proposed by Cohen (1988) was followed to assess the

intensity or power of these correlations.

In order to assess possible differences between anxious and depressive symptoms

between times 1 and 2 a repeated measures ANOVA was carried out.

Several hierarchical multiple regression analyses were conducted to determine the

extent to which all predictor variables explain emotional symptoms. When cross-sectional

data were considered (that is, when Time 1 anxious or depressive symptoms were the

criterion variables) demographic variables, such as age, educational level, occupational

status (employed/unemployed) and coexistence type (living alone/living with family) were

entered simultaneously into the equation on Step 1; positive and negative adjustment, and

life satisfaction were also entered simultaneously on Step 2.

1040 P. Sanjuan et al.

123

In longitudinal analysis (that is, when Time 2 anxious or depressive symptoms were the

criterion variables), on a prior step to those described above, anxious or depressive

symptoms at Time 1 were entered into the equation to control for the effect that these

symptoms could have on Time 2-symptoms.

Prior to conducting the regression analyses, and in order to avoid potential problems

with overlap between variables, multicollinearity tests were conducted.

3 Results

Descriptive statistics and correlations for all Time 1 and 2 variables are presented in

Table 1.

Repeated measures ANOVA showed that anxious and depressive symptoms at Time 2

were lower than at Time 1 [Fs(1,61) = 187.99 and 31.68, respectively, p \ 0.001]. Posthoc analyses were carried out to determine whether frequency of anxious and depressive

symptoms differed in each of the two periods evaluated. In this way, we found that

symptoms of anxiety predominated over those of depression at Time 1, while the opposite

was true at Time 2 [F(1,87) = 4.15, p \ 0.04, and F(1,62) = 5.28, p \ 0.02,

respectively].

Correlations revealed that life satisfaction was inversely and significantly related to

anxious and depressive symptoms at both Time 1 and 2, and directly and significantly

associated with positive adjustment. These correlations ranged from moderate (with Time

2-anxious symptoms: -0.27) to strong (with the other variables: from -0.37 to -0.71). In

turn, positive adjustment was inversely and significantly related to Time 1 anxious

symptoms, and Time 1 and 2 depressive symptoms. These correlations were all strong

(from -0.41 to -0.49). The correlations between negative adjustment and other variables

did not reach statistical significance in any case.

Table 1 Correlations and descriptive statistics for all Time 1 and Time 2 variables

1 2 3 4 5 6 7

1. Anxious symptoms-1 –

2. Depressive symtoms-1 0.5** –

3. Positive adjustment -0.41** -0.49** –

4. Negative adjustment 0.14 0.18 -0.25* –

5. Life satisfaction -0.37** -0.66** 0.49** -0.19 –

6. Anxious symptoms-2 0.91** 0.23 -0.24 0.17 -0.27* –

7. Depressive symtoms-2 0.47** 0.87** -0.46** 0.14 -0.71** 0.34* –

Mean 1.09a 0.97a 2.73 2.18 3.56 0.64 0.77

1.07b 0.92b

SD 0.59a 0.56a 0.46 0.49 0.87 0.39 0.39

0.54b 0.46b

n-Time 1 = 88; n-Time 2 = 63a mean or standard deviations at Time 1 of 88 patientsb mean or standard deviation at Time 1 of 63 patients who remained at Time 2

* p \ 0.05 ** p \ 0.001

Predictors of Emotional Distress in Men with CHD 1041

123

In relation to each of the regression analyses carried out, all the tolerance indices were

greater than 1-R2 (specifically all [ 0.41), and therefore none of the variables had to be

removed or aggregated in the analyses.

Results of hierarchical multiple regression analyses for Time-1 symptoms can be seen in

Table 2.

In relation to Time 1-anxious symptoms, on step 1, when demographic variables were

simultaneously introduced, only age was a significant predictor. However, when psycho-

logical variables were introduced into the equation, the significance of age was lost. Thus,

on step 2, only positive adjustment and life satisfaction were significant predictors.

In regard to Time 1-depressive symptoms, none of the demographic variables were

significant predictors. However, on step 2, when psychological variables were introduced,

age, and occupational status became significant predictors. Moreover, as in the previous

case, positive adjustment and life satisfaction were significant predictors.

Therefore, at Time 1, patients who were more satisfied with their lives and those who

used more positive adjustment strategies reported fewer anxious and depressive symptoms.

Furthermore, in the case of depressive symptoms, younger patients and those unemployed

reported fewer symptoms.

Results of hierarchical multiple regression analyses for Time-2 symptoms can be seen in

Table 3.

After controlling for Time 1-anxious symptoms, Time 2-anxious symptoms were only

predicted by age, with older patients reporting fewer anxious symptoms. While Time 2-

depressive symptoms, after controlling Time 1-depressive symptoms were only predicted

by life satisfaction, with patients more satisfied with their lives reporting fewer

symptoms.

Table 2 Hierarchical regression analysis to predict Time 1-emotional symptoms (Anxiety or depression)

Predictors Anxiety Depression

b t b t

Step 1

Age -0.25 -1.98* 0.08 0.64

Educational level 0.05 0.42 -0.10 -0.94

Occupational status 0.13 1.02 -0.20 -1.55

Coexistence type 0.01 0.12 -0.12 -1.07

Model R2 = 0.05, F(4,83) = 1.15 Model R2 = 0.04, F(4,83) = 0.98

Step 2

Age -0.16 -1.36 0.22 2.26*

Educational level 0.10 1.01 -0.01 -0.12

Occupational status 0.12 1.04 -0.19 -2.01*

Coexistence type 0.08 0.76 -0.03 -0.38

Negative adjustment 0.08 0.72 -0.01 -0.09

Positive adjustment -0.24 -2.06* -0.27 -2.84**

Life satisfaction -0.25 -2.15* -0.54 -5.81***

Model R2 = 0.24, F(7,80) = 3.67** Model R2 = 0.52, F(7,80) = 12.16***

* p \ 0.05 ** p \ 0.01 *** p \ 0.001

1042 P. Sanjuan et al.

123

4 Discussion

The main goal of the current study was to analyze the effects that life satisfaction and

adjustment strategies had on reported emotional distress (anxious and depressive symp-

toms) of cardiac patients on two occasions, immediately after the first cardiac episode, and

6 months later, when patients had returned to their everyday activities.

Cross-sectional analyses at Time 1 showed that, after controlling for demographic

variables, and despite the fact that some of them were significant predictors of depressive

symptoms, life satisfaction and positive adjustment remained significant predictors of both

anxious and depressive symptoms. In this way, patients who were more satisfied with their

lives and those who used more positive adjustment strategies reported fewer anxious and

depressive symptoms. Positive adjustment predicted both anxiety and depressive symp-

toms with similar strength. However, life satisfaction was a more powerful predictor in the

case of depressive symptoms.

From a longitudinal perspective, and after controlling for symptoms at Time 1, only age

could predict Time 2-anxious symptoms, with older patients reporting fewer symptoms.

With respect to Time 2-depressive symptoms, patients more satisfied with their lives

reported fewer symptoms.

Taking all the results as a whole, some conclusions can be derived. Firstly, not only do

these data confirm the beneficial effect of life satisfaction on the development of depressive

symptoms just after the cardiac event (Ruiz et al., in press), but also they indicate, for the

Table 3 Hierarchical regression analysis to predict Time 2-emotional symptoms (Anxiety or depression)

Predictors Anxiety Depression

b t b t

Step 1

Time 1- symptoms 0.91 17.12*** 0.87 13.78***

Model R2 = 0.83, F(1,61) = 293.11*** Model R2 = 0.76, F(1,61) = 190.0***

Step 2

Time 1- symptoms 0.89 14.95*** 0.87 13.13***

Age -0.13 -2.09* -0.04 -0.61

Educational level -0.001 -0.02 -0.05 -0.71

Occupational status 0.01 0.19 0.09 1.29

Coexistence type -0.09 -1.59 0.06 0.89

Model R2 = 0.84, F(5,57) = 62.86*** Model R2 = 0.76, F(5,57) = 38.10***

Step 3

Time 1- symptoms 0.94 15.34*** 0.73 7.12***

Age -0.15 -2.74*** -0.02 -0.23

Educational level 0.02 0.32 -0.02 -0.37

Occupational status 0.02 0.39 0.11 1.51

Coexistence type -0.05 -0.81 0.12 1.53

Negative adjustment 0.12 1.22 0.04 0.61

Positive adjustment 0.05 1.39 0.07 0.81

Life satisfaction 0.08 1.33 -0.23 -2.39**

Model R2 = 0.88, F(8,54) = 49.82*** Model R2 = 0.79, F(8,54) = 25.77***

* p \ 0.05 ** p \ 0.01 *** p \ 0.001

Predictors of Emotional Distress in Men with CHD 1043

123

first time, that this beneficial effect is maintained over the next months. As has been

previously noted, life satisfaction is a more global and pervasive feature and therefore can

predict symptoms after 6 months. These findings reinforce the idea that life satisfaction

protects against emotional distress when people are faced with difficult situations, such as

heart disease.

Secondly, the data also suggest that positive adjustment strategies are relevant variables

in reducing the emotional impact resulting from disease onset. However, these strategies

are insufficient by themselves to cushion the emotional symptoms resulting from the

consequences of the disease in the longer term.

In this regard, it should be noted that the demands resulting from the disease are

different depending on the time period considered. Thus, in the onset of illness, emotional

distress would result from the threat to life, the uncertainty about disease development, the

fear of relapse or the occurrence of new episodes. However, 6 months after the onset of

disease, emotional distress is possibly derived from other factors, since people are likely to

have learned that they can live with the disease, but may also know what it means to be

chronically ill. In this sense, the illness involves permanent changes to lifestyle, it can

hinder the achievement of some goals, and it can also limit certain activities (Garnefski

et al. 2009). That is, the disease implies changes and limitations that may cause life to be

valued as less pleasant.

In this way, it could be suggested that the specific strategies and attitudes that constitute

what is termed as positive adjustment are effective only for reducing emotional distress

resulting from the specific initial demands, but they would be insufficient to decrease

emotional distress at later stages when people have already become aware that demands

will continue for long periods of time. In this case, only the satisfaction with life, which is a

general frame of reference, can mitigate the emotional distress derived from the perpetual

demands of a chronic disease.

In relation to these different demands, it would have to be said that initial emotional

impact is much stronger than 6 months later, which is corroborated by the significant

reduction of anxious and depressive symptoms at Time 2. In this sense, it should also be

noted that symptoms of anxiety predominate over those of depression at Time 1, while the

opposite is true at Time 2. These results are consistent taking into account both the

different demands of illness depending on periods evaluated, and the distinctive features of

anxiety and depression jointly. Thus, at Time 1, the salient features are the perception of

threat and danger, and uncertainty, which are the distinctive characteristics of anxiety.

While at Time 2 the features that dominate are the perception of loss, feelings of inade-

quacy and hopelessness, which are the distinctive characteristics of depression (Clark and

Watson 1991).

In the current study, at Time 1, all psychological predictors jointly considered increased

the percentage of accounted variance by 19% for anxious symptoms, while the same

predictors increased this percentage by 48% for depressive symptoms. Moreover, at Time

2, none of these variables could significantly predict anxious symptoms, whereas life

satisfaction still predicted depressive symptoms after controlling Time 1-depressive

symptoms. These results suggest that although some personal factors can alleviate anxious

symptoms at the onset of the disease, the powerful features of the situation may have, in

this case, more strength to explain the emergence of these symptoms. However, personal

features evaluated here have an important impact on the development of depressive

symptoms.

Unlike other studies (Anderson 1996; Carver et al. 1993; Stanton et al. 2007; Ruiz et al.,

in press), our results showed that the use of negative adjustment strategies was not related

1044 P. Sanjuan et al.

123

to symptoms in either of the two times of evaluation. Moreover, negative adjustment was

not a significant predictor, neither when it was regarded as an isolated predictor (corre-

lations), nor when it was considered together with other predictors (regression analysis). If

these results are confirmed by further studies, then it would strengthen the idea, in line with

what modern positive psychology advocates, that intervention must be aimed not only at

reducing or eliminating the negative characteristics, but also at enhancing the positive ones

(Sin and Lyubomirsky 2009).

In this way, and as noted above, the presence of anxious and depressive symptoms

worsens the prognosis of the disease, and therefore, the intervention, not only to reduce

these symptoms, but on all those aspects that have an effect on symptoms, is very

important for the development of the disease. In relation to positive adjustment, our results

further suggest that the intervention is especially relevant just after a cardiac episode and

certain changes are required. Regarding life satisfaction, it would be very interesting to

promote programs to enhance this positive characteristic of human functioning since this

feature has a protective role in difficult times. In this way, genetic factors account for 50%

approximately of the variance in life satisfaction, but the remaining percentage reflects

factors under the individual’s control (Lyubomirsky et al. 2005).

Although the effects of demographic variables did not overshadow those of the psy-

chological variables studied here, we want to briefly comment on some of the implications

that these effects could have. The analyses showed that when the cardiac event has just

happened, depressive symptoms are increased when patients were in employment (before

the cardiac episode). However, 6 months later, when patients have already returned to their

everyday activities, occupational status is no longer a significant predictor. These data

might suggest that part of the patients’ emotional distress resulted from temporary inability

to carry out their work.

Future studies should confirm whether inability to work due to disease increases

emotional distress, and whether or not the degree of job satisfaction is a significant factor

in said emotional distress.

This study was subject to some limitations that deserve mention. First, it is necessary for

the results to be corroborated in other samples that include women, which also allow us to

check possible differences between men and women. Second, only self-reports have been

used. Future studies should include more objective measures which may clarify whether

the possible protective role of life satisfaction has an impact not only on emotional distress,

but also on both disease development and recovery. Despite these main limitations, this

study provides new and interesting data about different effects of life satisfaction and

adjustment on emotional distress in men with coronary heart disease.

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