|UFDC Home||myUFDC Home | Help|
This item has the following downloads:
DEPRESSION AND ILLNESS INTRUSIVENESS AS PREDICTORS OF QUALITY
OF LIFE AMONG IMPLANTABLE ATRIOVERTER DEFIBRILLATOR
REBECCA OWEN SOTILE
A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
UNIVERSITY OF FLORIDA
Rebecca O. Sotile
I would like to thank my mentor, Dr. Samuel F. Sears, for his constant guidance,
support, and understanding. I would also like to thank my first-year lab mates, Jason and
Robyn, for all of their advice, support, and, most of all, for their laughter. My
acknowledgments also go to Eva for her constant encouragement and willing assistance.
I would also like to thank my committee, Drs. Stephen Boggs, Dawn Bowers, and Robert
Glueckauf, for their general support as well as their specific suggestions and
contributions. My thanks also go to my boyfriend, Tom Horsman, for his love, courage,
and the countless positive things he has brought to my life. Also I thank my sister, Julia,
for being my best friend, my greatest source of comfort, and my most valuable point of
perspective. My utmost thanks go to my parents, Wayne and Mary Sotile, for their
incredible love and acceptance of who I am, and faith in the person I am becoming.
TABLE OF CONTENTS
A C K N O W L E D G M E N T S ......... .................................................................................... iii
L IST O F TA B L E S ......... ............................... ......... ... ....... ....... vi
ABSTRACT ........ .............. ............. .. ...... .......... .......... vii
1 INTRODUCTION............... .................... ............. ............. 1
A trial Fibrillation......................... ................................ .........2
Medical/Pharmacological Treatments for AF................... ..............3
D evice Therapies: The IAD ................... ................ .................4
Psychological Effects of Shock ............... ...............................6
Depression........... ...................................................... 9
Quality of Life................................. ....................... ...... 10
Illness Intrusiveness ..................................... ........................ .. 11
Relationship Between Illness Intrusiveness and Quality of Life.................. 13
A im s and Study Justification.......................................................... 14
Hypotheses ................... .................. .................. ... ......... 14
2 M ETH OD ................... ...........................................16
Participants ....................... .............. 16
A ssessm ent.............. ............... ............ ................. ... ......... 18
G eneric Quality of Life................... ....... ........ ..... ............. 18
Center for Epidemiological Studies Depression Scale.......................18
Illness Intrusiveness Rating Scale ............... ............................19
State-Trait Anxiety Inventory.................................................20
Pain and Intensity Ratings.................. .............. .. ........ ....... 20
D evice D ata................... .................................... ......... 20
D em graphic M easures........... ................. ...... .............. 21
Sample Descriptives ................. ................................. 22
Correlations and Collinearity Evaluation ................................... 23
Regression Analyses: Illness Intrusiveness.................. ...............23
Regression Analyses: Physical Quality of Life.............................25
Regression Analyses: Mental Quality of Life..................... ........26
4 D ISC U SSIO N ...................................................... .... ......... 28
Implications for the Experience of Shock ...................................29
C clinical Im plications ............................................. .............. ..30
Strength and Weaknesses of the Study ........... ...........................31
LIST OF REFERENCES................. ...................................... ..........33
BIOGRAPHICAL SKETCH ............................. ... .......................... 38
LIST OF TABLES
2-1 Patient Demographics and Relevant Medical Variables ......... .............17
3-1 M eans for Psychosocial M easures............. ..................................... 23
3-2 Correlations of Key Assessment Instruments ........... ......... ..........24
3-3 Regression Analysis: Illness Intrusiveness............................................25
3-4 Regression Analysis: Physical Quality of Life....................................26
3-5 Regression Analysis: Mental Quality of Life........................ .........27
Abstract of Thesis Presented to the Graduate School
Of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science
DEPRESSION AND ILLNESS INTRUSIVENESS AS PREDICTORS OF QUALITY
OF LIFE AMONG IMPLANTABLE ATRIOVERTER DEFIBRILLATOR
Rebecca Owen Sotile
Chair: Samuel F. Sears
Major Department: Clinical and Health Psychology
The Implantable Atrial Defibrillator (IAD) corrects atrial and ventricular
fibrillation via a high energy defibrillation shock. Because the application of shock is
aversive and atrial fibrillation (AF) is not an immediately life-threatening indication, the
inter-relationship of shock, AF symptoms, illness intrusiveness and quality of life
outcome will determine the potential value and future direction of IAD development.
The purpose of this study was to examine a biopsychosocial model of illness for illness
intrusiveness and quality of life in drug-refractory IAD patients. IAD adjustment was
evaluated in 96 patients enrolled in the Jewel AF-AF Only Study > 3 months follow up
(mean=19 months). Patients were mostly men (72%) and were 62+-12 years. A
questionnaire and national clinical database characterized patient demographics, AF
disease burden, atrial defibrillation therapy, and psychological distress. Within a
biopsychosocial design, multiple hierarchical regressions indicated depression as a
unique predictor of variance on illness intrusiveness scores, accounting for 11.4% of
variance. Illness intrusiveness and depression together predicted 11.1% of variance on
physical quality of life. Beta weights revealed that illness intrusiveness and age were the
only predictors of variance of physical quality of life. Regarding mental quality of life,
results indicated that 32.3% of variance was accounted for by depression and illness
intrusiveness together. Beta weights revealed that depression was the only unique
contributor of variance to mental health. Maladjustment to the physical aspects of
defibrillation may result from the presence of psychological distress. Psychological
symptoms such as depression and illness intrusiveness are largely responsible for AF
patients' declines in quality of life. Acceptance of IAD therapy may be facilitated by
successful treatment of psychological distress among IAD patients and multi-disciplinary
care that routinely addresses the psychological impact of AF and device treatment.
Cardiac arrhythmias are a prominent cause of death, hospitalizations, and
healthcare costs in the United States. Each year cardiac arrhythmias play a role in over
500,000 deaths and 724,000 hospitalizations, while also accounting for 11.9 billion
dollars spent annually on healthcare costs (American Heart Association, 2001). An
arrhythmia is characterized by abnormal electrical impulse conduction in the heart
(American Heart Association, 2001). A sustained rapid heartbeat (usually 160-280
beats/minute) is referred to as tachycardia. Tachycardia can begin in the atria or the
ventricles and is often accompanied by symptoms such as chest pain, fainting, and
dizziness. Prolonged tachycardia may result in fibrillation, which is an uncoordinated
movement of electrical impulses through the heart. These impulses cause the heart
chambers to twitch rapidly, resulting in inefficient blood flow to the rest of the body, and
have the potential to significantly affect mortality risk and quality of life (Allan &
The implantable atrioverter defibrillator (IAD) is a device that corrects fibrillation
in the atria. Correcting these irregular heartbeats requires a shock from the device,
similar to the shock received during external cardioversion. Shock can be an aversive
experience for patients, but the effects of untreated atrial fibrillation can be more
detrimental. Therefore, the degree of intrusion from the illness may be an important
index to understanding both patients' willingness to get shocked and the effects of having
been shocked. In this study, a biopsychosocial model including disease and treatment
variables as well as predictors of illness intrusiveness and quality of life in atrial
fibrillation patients who have been implanted with the IAD were examined.
Atrial fibrillation (AF) is the most common type of cardiac arrhythmia, occurring
in over 2 million Americans. AF refers to rapid contractions of the atria, or upper heart
chambers, and illicits an irregular response from the ventricles. This irregular rhythm
causes a reduction in blood flow, and increases the chances of formation of a blood clot
that could travel to the brain, causing stroke and possibly death (Luderitz & Jung, 2000).
Fifteen percent of all strokes are caused by AF (American Heart Association, 2001). The
prevalence of AF increases with age from less than 1% at 50 to 59 years to 9% at 80 to 89
years (Luderitz & Jung, 2000).
The majority of hospitalizations from cardiac arrhythmias are due to AF. Besides
increasing the risk of blood clots and stroke, the hemodynamic effects of AF may cause
decreased exercise tolerance and heart failure. Disorders that may result in atrial
fibrillation include: ischemic heart disease, rheumatic heart disease, hypertension, sick
sinus syndrome, cardiomyopathy, and other structural abnormalities. Atrial fibrillation
can be paroxysmal or sustained; however, the majority of patients have paroxysmal atrial
fibrillation, denoting a transient occurrence of AF (Lip, 2001). The initial impairment
caused by atrial fibrillation is less obvious than that caused by ventricular fibrillation, or
rapid contractions of the lower heart chambers, because atrial fibrillation only mildly
affects cardiac output. In fact, a patient may be unaware that he/she is in atrial fibrillation
because various medications can keep the heart rate normal during atrial fibrillation
(Allan & Scheidt, 1996). Approximately one-third of AF patients do not experience any
symptoms, while the other two-thirds may experience heart palpitations, fatigue,
dizziness, and presyncopal episodes (American Heart Association, 2001).
Although the physical symptoms of AF may not be immediately apparent,
significant psychological distress often accompanies this condition. The Ablate and Pace
Trial (Kay, Ellenbogen & Giudici, 1998) included a sample of highly symptomatic, drug-
refractory AF patients. Baseline assessment revealed significantly lower quality of life
among the AF patients as compared to patients with heart failure or a recent myocardial
infarction. This illustrates that AF patients may experience unique psychological issues
that are not as prominent for other cardiac populations. Because multiple studies have
illustrated that psychological intervention is effective in improving quality of life and
physical symptoms among various cardiac patient populations (Bennett & Carol, 1994;
Hill, Kelleher, & Shumaker, 1992; Linden, Stossel, & Maurice, 1996), this study suggests
that AF patients may receive similar benefit from psychological intervention.
Medical/Pharmacological Treatments for AF
The treatment of cardiac arrhythmias varies based on the rhythm's characteristics,
etiology, and the patient's experience of symptomotology. The most efficient way to
describe treatment options is to consider them on a scale of physical and mental
intrusiveness to the patient. The least severe, a non-life-threatening, and asymptomatic
paroxysmal arrhythmia, may be treated with simple behavioral interventions such as
dietary modifications and smoking cessation. A more severe symptomatic paroxysmal
arrhythmia, (e.g., ventricular tachycardia or atrial flutter), that results from a manageable
disease process may be treated with anti-arrhythmic medications such as beta-blockers
(Canobbio, Fassio, & Gasparini, 1986). In addition to suppressing premature
contractions that cause arrhythmias, beta-blockers also reduce heart rate, blood pressure,
and strength of cardiac contraction. Atrial fibrillation becomes more severe when the
episodes are sustained or paroxysmal, symptomatic, not drug-responsive, and/or life-
threatening. These may call for more invasive interventions such as catheter ablation of
conduction pathways, surgical ablation, or resection of conduction pathways (Canobbio
et al., 1986).
Although the treatment of AF varies widely, the majority of symptomatic
patients are successfully treated with dual chamber pacemaker therapy and/or
antiarrhythmic drugs. Most AF patients receive anticoagulants, such as aspirin or
warfarin, which help prevent the formation of blood clots. However, AF patients whose
symptoms are recurrent and require external cardioversion may benefit most from an
implantable device called the implantable atrioverter defibrillator (IAD; Lip, 2001). The
IAD alleviates symptoms but does not cure the underlying disorder. Currently, there are
no absolute indications for the implantation of an IAD; yet, the patients involved in
clinical trials using the IAD have paroxysmal atrial fibrillation that is symptomatic and
drug-refractory (Wellens, Lau, Luderiz, et al., 1998).
Device Therapies: The IAD
The technology of the IAD is similar to that of the implantable cardioverter
defibrillator (ICD), which terminates life-threatening ventricular arrythmias (Lip, 2001).
The ICD re-establishes normal sinus rhythm in response to ventricular fibrillation,
whereas the IAD is designed to re-establish normal sinus rhythm in individuals with atrial
arrythmias. The ICD gained FDA approval in 1985, and has been researched in
numerous trials since 1996 (Davidson, VanRiper, Harper & Wenk, 1994). In contrast,
the IAD is a much newer device, and IAD patients have not been extensively researched.
The IAD is similar to the size of a pacemaker, and consists of an atrioverter can
which is pectorally implanted, and three electrical leads which connect to three different
parts of the heart: the coronary sinus, the right atrium, and the right ventricle (Lip, 2001).
The IAD is capable of delivering two different types of shocks: a defibrillation shock for
the atrium, and a pacing discharge to the ventricle to prevent a bradyacardiac response
after defibrillation. The IAD can be programmed to shock automatically, or can be
activated by the patient or physician with a hand-held activator (Lip, 2001). A recent
trial illustrated that the Dual-Chamber ICD, which is essentially an ICD with atrial
therapies, is well-tolerated in drug-refractory symptomatic AF populations (Gold, Sulke,
Schwartzman, Mehra & Euler, 2001). The researchers found that the dual-chamber ICD
was successfully implanted in 99% of the sample (N = 146), and illustrated 98% survival
at 12-month follow-up. Additional results indicated that 99% of atrial arrhythmias
among this sample were correctly predicted by the device, and 87% of atrial arrhythmias
were successfully terminated. Perhaps even more critical, 7.6% of the sample required
ventricular shocks for VT/VF which would have been fatal (Gold et al., 2001). This
study suggests that patients with atrial fibrillation receive substantial physical benefit
from implantable defibrillation devices such as the IAD.
Although the IAD has been shown to provide relief from the physical symptoms
of AF, to date no study has examined the psychological implications of device therapy
for AF patients. An important difference between patients with atrial fibrillation and
patients with ventricular fibrillation is that atrial fibrillation does not present a threat of
immediate death, and a defibrillation charge from the IAD does not represent a life-
saving procedure as it does for ICD patients with life-threatening ventricular arrhythmias.
Therefore, the psychological stress associated with receiving a defibrillation shock may
be different for IAD patients, a concept that was examined in this study.
Psychological Effects of Shock
Although both the IAD and the ICD have demonstrated to be effective life-saving
devices (Gold et al., 2000), researchers continue to examine the issue of patient
adaptation to this therapy. Recent studies reveal that there is a strong fear component
associated with defibrillation, especially among patients receiving multiple shocks
(Murgatroyd & Camm, 1997; Sears, Todaro, Saia Lewis, Sotile, & Conti, 1999; Sears &
Conti, 2002). A recent major clinical trial, the CABG Patch Trial, examined the value of
prophylactic ICD implantation in patients undergoing coronary artery bypass graft
surgery versus no ICD after CABG surgery (Namerow, Firth, Heywood, Windle, Parides,
et al., 1999). Data indicated that the mental and physical quality of life outcomes for the
ICD patients were significantly worse compared to no-ICD patients. Further analyses
revealed that there were no differences in quality of life for non-shocked ICD patients vs.
no-ICD patients. These results indicated that the ICD group who had received shocks
was responsible for the significantly worse mental and physical quality of life outcome
scores between the groups.
The Antiarrhythmics Versus Implantable Defibrillators (AVID) trial represents
the first major comparison of self-perceived quality of life among ICD patients and
antiarrhythmic drug (AAD) therapy patients. AVID researchers concluded that ICD and
AAD therapy have similar effects on self-perceived quality of life among patients with
ventricular arrhythmias. Although all patients had poor baseline quality of life, a
significant finding was that adverse symptoms were associated with major impairment in
quality of life, regardless of the type of therapy and sporadic shocks received from the
ICD. Specifically, adverse symptoms among AAD patients were associated with
reductions in physical functioning, and both physical functioning and mental well-being
in ICD patients (Schron, Exner, Yao et al., 2002). The AVID study illustrated that
frequent ICD shocks (>5) were associated with increased psychological distress and
lower quality of life. Additionally, the study demonstrated that ICD patients receiving at
least one shock in the first year of follow-up had significant declines in physical
functioning and mental well-being, along with increased patient concerns. This effect of
shock was present independently of other markers of disease severity (Schron et al.,
2002). Such research highlights the fact that shock can be a frightening experience for
ICD patients, and has implications for clinical interventions with IAD patients.
The Canadian Implantable Defibrillator Study (CIDS) (Irvine, Dorian, Baker,
O'Brien, Roberts, Gent, Newman, & Connolly, 2002) yielded similar results regarding
the negative effects of shock. In a longitudinal quality of life comparison between
shocked vs. non-shocked ICD patients, researchers concluded that non-shocked patients
experienced improved quality of life at 2, 6, and 12 months follow-up. More specifically,
patients receiving 5 or more shocks within the first year of device implantation
experienced significant declines in generic quality of life (Irvine et al., 2002). These
results imply the existence of a "shock threshold," or maximum number of shocks that
can be tolerated before patients' quality of life is significantly compromised.
Conversely, a number of studies have illustrated that shock is not a unique
contributor to decreased psychological well-being. Several investigators have examined
patients with ICDs and compared them to patients with permanent pacemakers on generic
measures of quality of life. Very few consistent differences were demonstrated between
these two populations. For example, Duru and colleagues (2001) found no differences in
generic quality of life score, anxiety or depression when comparing ICD patients with
and without shock experience and pacemaker patients. ICD patients with a shock history
were more likely to report limitations in leisure activities and anxiety about the ICD, but
they also viewed the ICD as a "life extender." However, this study did not use a disease-
specific quality of life measure, and therefore measurement may have been too gross to
determine a difference between groups. Herbst, Goodman, Feldstein, and Reilly (1999)
recently compared the quality of life and psychological distress of four patient groups:
ICD only (n = 24) vs. ICD + anti-arrhythmic drug (n = 25) vs. anti-arrhythmic drug only
(n = 35) vs. a general cardiac sample (n = 73). Quality of life was assessed via the SF-36
and three supplementary scales examining sleep, marital and family functioning, and
sexual problems. Comparisons were made between ICD groups and drug groups.
Results indicated that there were no significant differences on the 11 quality of life
scales, even after controlling for age, gender, disease severity, and duration of treatment.
Yet, significant differences were found in drug groups vs. no drug groups, such that the
drug treated group consistently reported greater impairment in physical functioning,
vitality, emotional, and sleep functioning, as well as psychological distress. Overall,
these results suggest that quality of life was maintained in ICD treated groups, while anti-
arrhythmic drug therapy was associated with diminished quality of life and increased
Although study results vary, it is important to recognize that ICD-related fears are
universal and may be the most pervasive psychosocial adjustment challenge ICD patients
face. Psychological theory suggests that symptoms of fear and anxiety can result from a
classical conditioning paradigm in which certain stimuli or behaviors are coincidentally
paired with an ICD shock and are thereby avoided in the future (Sears & Conti, 2002).
Due to fear of present and/or future discharges, some patients increasingly limit their
range of activities and inadvertently diminish the benefits of the ICD in terms of quality
of life (Sears & Conti, 2002). Collectively, these data implicate that the experience of
shock is often strongly associated with psychological distress and diminished quality of
life (Sears et al., 1999). The experience of shock may be different for IAD patients, who
have the option of administering the shocks manually, and thus eliminate receiving an
unexpected defibrillation charge that may lead to fear or anxiety. Atrial shocks are
unpleasant and possibly frequent; subsequently IAD patients are likely to view shock as
negatively as ICD patients do, and to experience similar symptoms of psychological
Depression has been identified as a significant characteristic related to health
outcomes among various cardiac populations (Frasure-Smith, Lesperance, & Talajic,
1995). Among ICD patients, prevalence rates of depressive symptomatology range from
24% to 87% at various follow-up intervals (Hegel, Griegal, Black & Goulden, 1997;
Konstam, Colbum & Butts, 1995; Sears et al., 1999). Early research highlights
correlations between declines in physical ability/functioning and the development of
depression in ICD patients (Pycha, Gulledge, Hutzler, Kadri, & Maloney, 1986). More
recently, similar findings within the ICD patient population indicate that depression and
mood disturbance post-implant may increase the likelihood of an arrhythmia requiring a
shock from the device (Dunbar, Kimble, Jenkins, et al., 1999). Sears and colleagues
(1999) postulate that depression among device patients may result from the patient's
perceived lack of control over the defibrillation charges. These symptoms may
eventually lead patients to have increased negative beliefs and hopelessness about their
current and future health status. This negative view of the future is often reflected by a
reduction in mental quality of life. Although many IAD patients maintain control over
when a defibrillation charge is administered, a single charge may not always correct an
atrial arrhythmia. Thus, it is often necessary for IAD patients to experience multiple
shocks, contributing to psychological distress (Irvine et al., 2002; Schron et al., 2002).
Further, the after-effects of receiving a painful shock are likely similar for ICD and IAD
patients. Due to the prevalence of depression among ICD patients and the relationship
between shock, depression, and quality of life, this study predicts that depression among
IAD patients will present similarly to ICD patients.
Quality of Life
To date the largest study examining quality of life among symptomatic AF
patients found that both disease specific and generic quality of life were significantly
lower for AF patients than for healthy controls (Dorian, Jung, Newman et al., 2000). AF
patients scored significantly lower on all scales of the SF-36 except for the Bodily Pain
scale. However, much of the current research regarding quality of life among patients
with defibrillators has focused on ICD patients. Although ICD patients primarily report
desirable quality of life, it is well established that psychosocial distress contributes to a
reduction in quality of life (Heller, Ormont, Lidagoster et al., 1998; Luderitz, Jung,
Deister & Manz, 1996; Pycha et al., 1986; Sears et al., 1999, 2000). Among the most
common patient complaints regarding quality of life are social isolation, psychological
distress, and physical complaints (Heller et al., 1998; Luderitz et al., 1996; Pycha et al.,
1986; Sears et al., 1999). Poorer quality of life is more prevalent among patients who
receive shocks from the ICD as compared to patients who have not received shocks from
the ICD (Dunbar et al., 1999; Heller et al., 1998; Herbst et al., 1999; Kohn, Petrucci,
Baessler, Soto & Movsovitz, 2000; Reid, Nagy & McKinley, 1999; Sears et al., 1999).
Because shock has been established as a negative experience (Namerow et al., 1999;
Sears et al., 1999; Sears & Conti, 2002), it may be hypothesized that patients receiving
shocks will also experience higher levels of illness intrusiveness as compared to patients
who have received no shocks, which has been shown in previous research (Schron et al.,
2002; Irvine et al., 2002). Therefore, this study examined the relationship between
factors affecting illness intrusiveness and subsequent quality of life within a
biopsychosocial model that accounted for both psychological and medical data.
The construct of illness intrusiveness is described as lifestyle disruptions,
resulting from an illness and/or its treatment, that hinder participation in valued activities
and interests (Devins et al., 1983). Because illness intrusiveness limits participation in
valued activities, it may in t urn decrease psychosocial well-being as it lowers an
individual's exposure to positively-valued interactions. Illness intrusiveness may cause
further psychosocial decline by reducing an individual's personal control over both
positive and negative outcomes in important situations, especially among patients with
chronic conditions (Devins et al., 1993).
Studies indicate varying degrees of illness intrusiveness across treatment
modalities and illnesses (Devins et al., 1993). Among chronic illness populations, a
number of illness-related factors contribute to the construct of illness intrusiveness,
including disease factors, such as pain and disability, and treatment factors such as time
required for treatment and mode of treatment (Devins, 1994). Illness intrusiveness
among chronic illness populations has been shown to have a significant and unique
relationship to several psychological variables, including positive and negative mood, life
satisfaction, and depression, and is further influenced by psychological and social
characteristics such as social support and coping resources (Binik, Devins & Orme, 1989;
Devins, 1994). Devins' (1994) model hypothesizes that factors of an individual's disease
and treatment psychosocially impact quality of life through their relationship with illness
intrusiveness. The model also accounts for direct effects of psychological and social
factors on both illness intrusiveness and quality of life.
Research on illness intrusiveness among AF patients found that symptomatic AF
patients had significantly higher illness intrusiveness than same-aged non-AF patients
(Dorian et al., 2002). Consistent with Devins' model, this study also found lower quality
of life on several SF-36 scales among AF patients as compared to angioplasty,
myocardial infarction and congestive heart failure patients, even when controlling for
physical impairment (Dorian et al., 2002). Despite AF patients experiencing a variety of
physical symptoms, these data suggest that psychological distress is an equally limiting
aspect of the condition. The influence of psychological constructs such as illness
intrusiveness on quality of life often overpowers the influence of AF's unique physical
limitations, and emphasizes the importance of psychological intervention in conjunction
with standard medical care for AF patients. In this regard, illness intrusiveness emerges
as an important target for multidisciplinary interventions.
Relationship Between Illness Intrusiveness and Quality of Life
The Devins (1994) model stems from research involving the role of illness
intrusiveness in quality of life among End-Stage Renal Disease patients, and has
indicated that perceived illness intrusiveness was significantly correlated with three
quality of life measures including satisfaction/happiness, pessimism/illness-related
concerns, and depression/distress (See Figure 1; Devins, Mandin, Hons et al., 1990).
Specifically, higher levels of perceived illness intrusiveness were significantly correlated
with decreased life satisfaction and happiness, increased pessimism and illness-related
concerns, and increased depression and distress. These results remained stable over time,
even after controlling for response style and background variables (Devins et al., 1990).
Similarly, an additional study with rheumatoid arthritis patients revealed a statistically
significant relationship between illness intrusiveness and physical disability, such that
after controlling for physical disability, illness intrusiveness maintained a unique,
significant relationship with depression (Devins, Edworthy, Guthrie et al., 1992). These
data illustrate the role of illness intrusiveness as a mediator of the psychosocial impact of
chronic illness, although no study to date has examined this potentially valuable construct
in IAD patients. The current study will examine illness intrusiveness among IAD
patients using analyses influenced by Devins' (1994) model.
Psychological & Social
Figure 1. Hypothesized relations among illness intrusiveness, its determinants, and
quality of life in AF patients (Devins, 1994).
Aims and Study Justification
The purpose of this study was to test a biopsychosocial model of illness
intrusiveness and quality of life in a sample of drug-refractory IAD patients. Using
hierarchical multiple regression analyses controlling for demographic and biomedical
data, this study explored predictors of illness intrusiveness and physical and mental
quality of life. This model was adapted to identify areas of possible psychological
intervention among IAD patients.
The following hypotheses were investigated in this study:
1. It was hypothesized that CES-D ratings of depression would be significantly
associated with Illness Intrusiveness Rating Scale scores among IAD patients, while
controlling for demographics, number of shocks, and biomedical variables.
2. It was hypothesized that Illness Intrusiveness Rating Scale scores would significantly
predict variance in the Physical Functioning Scale of the SF-36 Quality of life Measure
among IAD patients, while controlling for demographics, number of shocks, biomedical
variables, and psychological variables.
3. It was hypothesized that CES-D ratings of depression would significantly predict
variance in the Mental Scale of the SF-36 Quality of life Measure among IAD patients,
while controlling for demographics, number of shocks, biomedical variables, and
The participants (N = 96) were recruited from an ongoing multi-site FDA study
spanning 23 lAD-implanting facilities. Participants were recruited by the research
coordinator at each implanting facility. Each participant had undergone a full medical
workup prior to recruitment.
In order for a patient to qualify for inclusion in the study, he/she must have had
lone AF, indicating AF was his/her only major heart condition. All participants were also
drug-refractory, defined as having tried and failed at least one anti-arrhythmic drug
within the year prior to the study. Participants must have had at least one AF episode
lasting 48 hours. At the time of the study, all subjects were taking an anti-coagulant such
Particpant exclusion criteria included documented risk of sudden death from
ventricular fibrillation, which would indicate implantation of a traditional ICD. Table 1
provides a summary of the demographic and medical characteristics of the study sample.
Table 1. Patient Demographics and Relevant Medical Variables
Mean (SD) or %
Total Manual Shock Automatic Shock
(N = 96) (n = 42) (n = 35)
Age 62.2 (11.8) 59.8 (12.1) 64.3 (10.9)
Gender (% Male) 72% 64% 80%
Marital Status (% Married) 83.3% 83.3% 82.9%
Ejection Fraction (N= 54) 52.1 (15.8) 56 (15.1) 45.3 (15.6)
Pre-Implant Cardioversions 2.2 (2.1) 2.2 (2.1) 2.1 (2)
Pre-Implant AF episodes 9.1 (13) 8.4 (12.3) 12.5 (20.7)
AF Symptom Score 15.6(8.49) 14.4 (8.2) 18.2 (9.2)
Years Since Implant 1.6 (.87) 1.6 (.84) 1.6 (.81)
Detected AF Episodes 176 (337) 167 (306) 191 (337)
Total Atrial Shocks 12.8 (18.4) 13 (21.1) 12.5 (14.9)
Manual Shock/month 0.93 (2.7) 1.4 (3.5) 0.46 (1.3)
Automatic Shock/month 0.22 (.76) 0.0 (0.0) .57 (1.2)
Atrial Shock Energy (J) 15.2 (7.8) 15 (7.9) 15.9 (7.9)
Note: 18 patients did not receive any shocks or received both manual and automatic shocks, and therefore
were not included in the statistical analyses
Generic Quality of Life
The Medical Outcomes Study Short-Form 36 Health Survey (SF-36; Ware, Snow,
Kosinski & Gandek, 1993) was used to measure quality of life. This is a widely used and
well-validated generic measure of health-related quality of life, and was shown to be the
most effective measure for evaluating quality of life among pacemaker patients in a
recent comparison study (Stofmeel, Post, Kelder et al., 2000). Because of its widespread
application to cardiac patients and its role in validating other measures of cardiac illness,
the SF-36 has become the standard measure of quality of life among cardiac populations
(Stofmeel, et al., 2001; Hamilton & Haennel, 2000). Items included in the SF-36 were
constructed by Ware and colleagues (1993), who used a sample of over 20,000 U.S.
residents to assess perceptions of 40 mental and physical health concepts in the Medical
Outcome Study (MOS). The SF-36 contains scales to measure the eight most salient
concepts represented by this survey: Physical Functioning, Physical Role, Bodily Pain,
General Health, Vitality, Social Functioning, Emotional Role, and Mental Health. To
avoid inflating experiment-wise error, the current study examined scores on only three
scales of the SF-36: Physical Functioning, Mental Health, and Social Functioning.
Center for Epidemiological Studies Depression Scale
Depression was measured using the Center for Epidemiological Studies -
Depression Scale (CES-D), a 20-item self-report measure of depressive symptomatology
(Radloff, 1977). Participants are asked how frequently over the past week they have
experienced various depressive symptoms, and responses range from 0 (less than one
day) to 3 (5-7 days). Total scores range from 0 to 60, and a standard cut-off score of 16
indicates clinically significant depressive symptoms (Radloff, 1977). The CES-D reflects
the number and duration of depressive symptoms. The CES-D has a high internal
reliability coefficient of .85, and has been reported as a more generally useful self-report
measure of depression than the Beck Depression Inventory, the MMPI Depression Scale,
and the Zung Self Rating Scale of Depression (Turk & Okifuji, 1994).
Illness Intrusivenss Rating Scale
The Illness Intrusiveness Rating Scale (IIRS; Devins, Orme &Costello, 1988) is a
19-item self-report measure that asks respondents to rate how much their illness and
consequent treatment interferes with each of 13 life domains. Ratings occur along a 7-
point Likert scale, ranging from 1 (Not Very Much) to 7 (Very Much). The domains
pertain to health, recreation, diet, work, financial situation, self-expression, family
relations, relations with spouse, sex life, social relations, religious expression and
community involvement. A total intrusiveness score and a score for each of the 13
domains can be calculated. Total scores range from 13 (where the illness is not intrusive)
to 91 (where the illness is extremely intrusive in all domains). Exploratory and
confirmatory factor analyses across eight different patient groups have revealed three
underlying factors comprising the scale (Relationships and Personal Development,
Intimacy, and Instrumental Life Domains). Recent research indicates that the total IIRS
score may be preferable for use in basic analyses (Devins et al., 2001). The IIRS has
been shown to have adequate to high internal consistency, reliability, and validity
(Devins et al., 1993). Coefficient alpha ranges from 0.80 to 0.95 have been found across
diagnoses (Devins et al., 2001).
State-Trait Anxiety Inventory
The STAI is a 40-item self-report questionnaire designed to measure both state
and trait anxiety (Speilberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). For the
purposes of this study, only the 20-item trait scale of this questionnaire was administered.
Trait anxiety is defined as a relatively enduring personality characteristic, or more
specifically, as anxiety proneness. The internal reliability of both the state and trait
anxiety scales has been shown to be uniformly high across samples of adults ranging
from .89 to .96. Test-retest reliability coefficients for multiple samples of college
students ranged from .73 to .86, with test-retest validity specifically for the trait scale
being reported at .73 for males and .77 for females. Concurrent validity between the
STAI and IPAT Anxiety Scale and the Taylor Manifest Anxiety Scale ranged from .83 to
.73 (Spielberger et al., 1983).
Pain and Intensity Ratings
Subjective ratings of pain and intensity were taken from the Patient Acceptance
Scale (PAS), which provides statements about the pain and intensity of a defibrillation
charge, and provides responses ranging from Strongly Disagree to Strongly Agree (Burns
et al., 2002).
Information was collected to address several aspects of patients' IAD history.
The device data included number of years since device implantation at the time of survey,
number of treated episodes, and number of manual and automatic shocks received per
This measure was developed to assess: marital status, age, religion, ethnicity,
education level, employment status, number of doctor visits, exercise habits, smoking
habits and alcohol consumption.
This study used baseline data for quality of life measures only. All other data was
collected at the follow-up in the closest proximity to the survey data (M = 4.7 months
since last device interrogation, SD = 2.8 months).
Illness intrusiveness scores for this sample ranged from 13 to 73 (M= 27; SD =
14). Additional descriptive data was gained by using t-tests to compare this sample with
the group of End Stage Renal Disease patients upon which Devins' (1994) original work
was based. The IAD sample's mean illness intrusiveness rating was significantly lower
than a published mean for patients receiving hemodialysis ( < .001), but not
significantly different from a published mean for patients of successful renal
transplantation (p = .504; Devins, 1994). In the present sample, 42% had illness
intrusiveness scores above cut-off scores for an AF-only sample, but sample differences
were insignificant. Results also indicate that IAD recipients may experience levels of
illness intrusiveness similar to those experienced by transplant recipients. Thus, the IAD
may be considered analogous to a lifesaving "organ" which is capable of prolonging and
Additional descriptive data was computed using t-tests. CES-D scores (M =
11.1; SD = 8.5; n = 81) were significantly different from healthy normals (M = 9.3; SD =
8.6; p < 0.05), although these differences are likely not clinically significant (Radloff,
1977). Regarding anxiety levels, the STAI scores of this sample (M = 33.9; SD = 10.8; n
= 88) were not significantly different from scores of healthy normals (healthy males, M =
34.9; SD = 9.9; healthy females, M = 34.8; SD = 9.2) (Speilberger, Gorsuch,
Lushene, Vagg & Jacobs, 1983). Mean total symptom score (16.0) and mean AF
symptom number (8.2) was also calculated. Means for all participants in this study are
located in Table 2.
Table 2. Means for Psychosocial Measures
M SD n Min. Max.
Depression (CES-D) 11.07 8.57 81 0 35
Trait Anxiety (STAI) 33.99 10.8 88 20 70
Illness Intrusiveness (IIRS) 27.00 14.4 93 13 73
Quality of life (SF-36)
Physical 67.01 25.5 82 15 100
Mental 72.76 17.7 84 16 100
Total Symptom Score 15.95 8.50 82 1 41
Total Symptom Number 8.16 3.37 83 1 12
Correlations and Collinearity Evaluation
Correlations were run among several of the independent and dependent variables
to determine the inter-correlations between variables. These results are presented in
Table 3. Although there were significant correlations between some psychosocial
variables, none exceeded r >.7, which is a cut-off to determine multicollinearity
(Kleinbaum, Kupper, Muller & Nizam, 1998). Therefore, all variables were included in
the planned analyses.
Regression Analyses: Illness Intrusiveness
A three-step multiple hierarchical regression analysis was conducted to examine
the relationships between demographic, shock, and symptom variables, along with patient
ratings of pain and discomfort, and the psychological construct of illness intrusiveness as
the dependent variable. Specifically, number of shocks and AF symptom score were
included as disease-specific factors that may influence illness intrusiveness. Significance
was set at alpha = .05.
Table 3. Correlations of Key Assessment Instruments
CES-D IIRS Physical Mental
Physical -.298* -.263*
Mental -.604** -.275* .300**
** Correlation is significant at the 0.01 level (2-tailed).
* Correlation is significant at the 0.05 level (2-tailed).
On the first step of the analysis, sex and age were insignificant predictors of
illness intrusiveness (F change (2, 52) = 1.847, = .168), accounting for 6.6% of the
variance. Number of manual and automatic atrial shocks, AF symptom score, and patient
ratings of pain and discomfort were entered on the second step of the analysis. These
factors contributed 18.3% of variance, although this variance was not significant (F
change (5, 47) = 2.295, p = .060). On step three, CES-D scores were entered,
significantly predicting 11.4% of variance in illness intrusiveness scores (F change (1,
46) = 8.202, p = .006). Specifically, higher depression was associated with higher illness
intrusiveness. The overall model was significant (F (8, 54)= 3.279, p= .005), and
accounted for 36.3% of variance in illness intrusiveness.
Table 4. Regression Analysis: Illness Intrusiveness.
Model R Square F Change dfl df2 Sig
1 .066 1.847 2 52 .168
2 .183 2.295 5 47 .060
3 .114 8.202 1 46 .006
Regression Analyses: Physical Quality of Life
A three-step multiple hierarchical regression analysis examined demographics,
baseline physical quality of life scores, number of atrial shocks, and psychological
variables (depression and illness intrusiveness) with post physical quality of life as the
dependent variable. Pain and discomfort were excluded since they failed to contribute
significant variance to illness intrusiveness in the presence of depression (F change (5,
47) = 2.295, p= .060). In step one of the analysis, baseline physical quality of life
scores, age and sex were not significant predictors of post physical quality of life (F
change (3, 64) = 1.634, = .190). Step two of the analysis included number of total atrial
shocks, which also failed to contribute significant variance (F change (1, 63) = .608, p =
.439). Psychological variables (depression and illness intrusiveness) were entered on the
third step of the analysis; they significantly added 12.0% of the variance (F change (2,
61)= 4.575, = .014). Specifically, higher age and higher illness intrusiveness predicted
lower post physical quality of life. Therefore, illness intrusiveness uniquely predicted
post physical quality of life above and beyond a host of demographic, biomedical, and
psychological variables. The overall model significantly accounted for 20.0% of variance
in post physical quality of life (F (6, 67) = 2.542, p = .029).
Table 5. Regression Analysis: Physical Quality of Life.
Model R Square F Change dfl df2 Sig
1 .071 1.634 3 64 .190
2 .009 .608 1 63 .439
3 .120 4.575 2 61 .014
Regression Analyses: Mental Quality of Life
The last three-step multiple hierarchical regression was conducted to examine
demographic, baseline mental quality of life scores, total atrial shocks and psychological
variables (depression and illness intrusiveness), with post mental quality of life as the
dependent variable. On step one, baseline mental quality of life, sex, and age did not
contribute significant variance in post mental quality of life (F change (3, 64) = .814, p =
.491). Step two included total atrial shocks, which also failed to explain significant
variance in post mental quality of life (F change (1, 63) = .029, p = .865). Depression
and illness intrusiveness were entered on the third step of the analysis, and significantly
predicted post mental quality of life (F change (2, 61) = 15.412, p < .001), contributing
32.3% of the variance. Specifically, higher depression was associated with lower post
mental quality of life. The overall model accounted for 36% of variance in post mental
quality of life (F (6, 67) = 5.729, p < .001). As stated earlier, multicollinearity statistics
were calculated to ensure that these results were not influenced by the correlation
between depression and mental quality of life. The tolerance value (.774) indicates an
acceptable correlation level (Kleinbaum et al., 1998). Therefore, depression uniquely
predicted mental quality of life within this biopsychosocial model, but no demographic or
disease-specific variables were significant predictors of mental quality of life. The
overall model accounted for 36.0% of variance in post mental quality of life.
Table 6. Regression Analysis: Mental Quality of Life.
Model R Square F Change dfl df2 SigF
1 .037 .814 3 64 .491
2 .000 .029 1 63 .865
3 .323 15.412 2 61 .000
The current study investigated the utility of Devins' (1994) biopsychosocial
model regarding the relationships between psychological variables and their influence on
physical and mental quality of life within a sample of IAD patients. It was hypothesized
that the psychological constructs of depression and illness intrusiveness would impact
physical and mental quality of life above and beyond the influence of demographic,
biomedical and disease-related variables. A series of three-step multiple hierarchical
regression analyses indicated that the hypotheses regarding the impact of depression on
illness intrusiveness and mental quality of life, and the impact of illness intrusiveness on
physical quality of life were supported.
Previous research in similar populations has established that depression and
illness intrusiveness are related constructs (Hegel et al., 1997; Konstam et al., 1995; Sears
et al., 1999). This study extends the literature to include IAD patients, who have been
shown to have unique psychological distress associated with their condition (Kay et al.,
1998). A decline in physical abilities that hinders participation in valued activities is an
integral part of Devins (1983) definition of illness intrusiveness. IAD patients whose
illness causes a decline from previous functioning may subsequently develop depression,
and view their illness as more intrusive. The correlation between illness intrusiveness
and physical quality of life is consistent with Devins' (1983) theory that the construct of
illness intrusiveness is a disruption of lifestyle that hinders participation in valued
activities. Patients whose functioning is significantly limited due to their illness will
most likely report a reduction in the quality of their physical abilities. Additionally, the
correlation and predictive relationship between the psychological construct of depression
and mental quality of life is consistent with Devins' (1983) biopsychosocial model. With
regard to the relationships between disease, treatment, and psychological factors, this
sample of IAD patients rated illness intrusiveness and quality of life similarly to the End-
Stage Renal Disease patients comprising Devins' original sample.
Implications for the Experience of Shock
Collectively, these results suggest that shock is not the factor most responsible for
reducing quality of life among IAD patients as it has been illustrated to be among ICD
patients (Namerow et al., 1999; Schron et al., 2002; Irvine et al., 2002). This discrepancy
may result from differences in perceived lack of control between these two populations.
IAD patients have the option of delivering the defibrillation charge manually, whereas all
shocks received by ICD patients are automatically received with little warning. Since AF
is not a life-threatening condition, IAD patients also have the option of avoiding the
defibrillation charge and experiencing the AF episode. In this way, IAD patients are able
to mentally separate the act of shock from other physical aspects of their illness. Even
IAD patients who receive automatic shocks can receive advanced warning and therefore
maintain a sense of control. Further, a defibrillation charge for IAD patients does not
indicate a life-threatening arrhythmia as it does for ICD patients, suggesting that ICD
patients may have a more emotional response to shock.
Most of the literature in this area indicates that, overall, shock is a physically
aversive experience (Murgatroyd & Camm, 1997; Sears et al., 1999; Sears & Conti,
2002; Namerow et al., 1999; Schron et al., 2002). Pauli and colleagues' (1999) research
clarified and disputed this idea by distinguishing the psychological effects of shock from
the physical effects. The present study, in conjunction with the work of Pauli and
colleagues (1999), indicates that IAD recipients will benefit from being psychologically
prepared for the emotional impact of defibrillation. Results suggest that IAD therapy is
well accepted, but may be hindered by psychological factors such as depression.
Depression and illness intrusiveness are related among IAD patients, lending support to
early research among ICD patients that highlights correlations between declines in
physical ability and the development of depression (Hegel et al., 1997; Konstam et al.,
1995). Most patients who are provided with appropriate cognitive-behavioral
interventions should adapt well to receiving an IAD, and will likely not experience
clinically significant levels of depression, illness intrusiveness, or reduced quality of life
(Kohn et al., 2000).
Clinically, this study highlights the need for healthcare providers to recognize,
acknowledge, and refer psychological treatment for symptoms of distress among IAD
patients in an attempt to reduce illness intrusiveness and optimize quality of life. The
majority of these patients do not experience clinically significant depression or illness
intrusiveness, but those who do will likely also experience reductions in physical and
mental quality of life. Clinicians should be educated about the effects that psychological
factors have on quality of life, and subsequently pay routine attention to both general and
disease-specific quality of life among IAD patients. Since AF is a non-life-threatening
condition, IAD patients can experience improved quality of life through various levels of
psychosocial intervention, such as in-patient psychological consultation, support groups
with other patients, and individual psychotherapy. This process will be facilitated by the
integration of psychologists as essential parts of IAD patient treatment teams, and by
future research exploring additional aspects of defibrillation, including a comparison
between the patient's subjective experience of shock and the objective shock data
recorded by the device
Strengths and Weaknesses of the Study
The current study has specific strengths and weaknesses to take into account when
interpreting this data. The comprehensive biopsychosocial design including both
objective medical information and subjective psychological testing data provide a more
complete view of the outcomes of interest than previous work with the IAD designed to
establish its efficacy (Gold, et al., 2001). Further, the effects of shocks were well
examined in the current data set and did not indicate the cumulative, detrimental effects
that one might expect. A weakness of the study includes the highly selected sample
utilized. Patients in this study were volunteers who were drug-refractory and failed at
least one anti-arrhythmic drug. Therefore, the results cannot be generalized to all patients
with AF. The willingness to participate as a subject in this trial certainly selects for some
personality variables that cannot be fully understood. The study also included baseline
medical variables but did not include baseline psychosocial variables other than quality of
life. In fact, because FDA investigators did not expect the significance of psychological
factors at the beginning of the study, the remaining psychosocial factors are measured at
only a single point in time. Therefore, we are unable to determine the course of patient
acceptance from the current data.
LIST OF REFERENCES
American Heart Association. (2001). About sudden death and cardiac arrest. In 2001
Heart and Stroke Statistical Update [On-line]. Available:
www.americanheart.org/statistics/aboutsdca.html. Last accessed 1/15/03.
Allan, R. & Scheidt, S. (1996). Heart & Mind: The Practice of Cardiac
Psychology.Washington: American Psychological Association.
Bennett, P. & Carroll, D. (1994) Cognitive-behavioral interventions in cardiac
rehabilitation. Journal of Psychosomatic Research, 38(3), 169-182.
Binik, Y.M., Devins, G.M. & Orme, C.M. (1989). Psychological stress and coping in
end-stage renal disease. In: Neufeld, R.W.J. (Ed.), Advances in the Investigation
of Psychological Stress. New York, NY: Wiley, 305-342.
Burns, J.L., Sears, S.F., Sotile, R., Schwartzman, D.S., Hoyt, R.H., Alvarez, L. &
Ujhelyi, M.R. (2002). Do patients accept implantable atrial defibrillation therapy?
Results from the Patient Atrial Shock Survey of Acceptance and Tolerance Study
(PASSAT Study). (In Press).
Canobbio, L., Fassio, T. & Gasparini, G. (1986). Cardiac arrhythmia: Possible
complication from treatment with cisplatin. Tumori, 72(2), 201-204.
Davidson, T., VanRiper, S., Harper, P., & Wenk, A. (1994). Implantable
cardioverter defibibrillators: A guide for clinicians. Heart & Lung, 23, 205-215.
Devins, G.M (1994). Illness intrusiveness and the psychosocial impact of lifestyle
disruptions in chronic life-threatening disease. Advances in Renal Replacement
Therapy, 1, 251-263.
Devins, G. M., Binik, Y. M., Hutchinson, T. A., Hollomby, D.J., Barre, P.E. &
Guttmann, R.D. (1983). The emotional impact of end-stage renal disease:
Importance of patients' perceptions of intrusiveness and control. International
Journal of Psychiatry in Medicine. 13. 327-343.
Devins, G.M., Dion, R., Pelletier, L.G., Shapiro, C.M., Abbey, S., Raiz, L.R., Binik
Y.M., McGowan, P., Kutner, N.G., Beanlands, H. & Edworthy, S.M. (2001).
Structure of lifestyle disruptions in chronic disease: A confirmatory factor
analysis of the illness intrusiveness ratings scale. Medical Care, 39(10), 1097-
Devins, G.M., Edworthy, S.M., Guthrie, N.G. & Martin, L. (1992). Illness intrusivenes
in rheumatoid arthritis: Differential impact on depressive symptoms over the adult
lifespan. Journal of Rheumatology, 19, 709-715.
Devins, G. M., Edworthy, S. M. & Seland, T. P. (1993). Differences in
illness intrusiveness across rheumatoid arthritis, end-stage renal disease, and
multiple sclerosis. Journal of Nervous & Mental Disease, 181, 377-381.
Devins, G.M., Mandin, H., Hons, R.B., Burgess, E.D., Klassen, J., Taub, K., Schorr, S.,
Letourneau, P.K. & Buckle, S. (1990). Illness intrusiveness and quality of life in
end-stage renal disease: Comparison and stability across treatment modalities.
Health Psychology, 9(2), 117-142.
Devins, G.M., Orme, C.M. & Costello, C.G. (1988). Measuring depressive symptoms
in illness populations: Psychometric properties of the Center for Epidemiologic
Studies Depression (CES-D) scale. Psychology & Health, 2, 139-156.
Dorian, P., Jung, W., Newman, D., Paquette, M., Wood, K., Ayers, G.M., Camm, J.,
Akhtar, M. & Luderitz, B. (2000). The impairment of health-related quality of life
in patients with intermittent atrial fibrillation: Implications for the assessment of
investigational therapy. Journal of the American College of Cardiology, 36(4),
Dunbar, S. B., Kimble, L. P., Jenkins, L. S., Hawthorne, M., Dudley, W., Slemmons, M.,
& Langberg, J. L. (1999). Association of mood disturbance and arrhythmia events
in patients after cardioverter defibrillator implantation. Depression and Anxiety,
Duru, F., Barton, M., Luscher, T.F. & Candinas, R. (2001). Endothelin and cardiac
arrhythmias: Do endothelin antagonists have a therapeutic potential as
antiarrhythmic drugs? Cardiovascular Research, 49(2), 272-280.
Frasure-Smith, N., Lesperance, F., & Talajic, M. (1995). The impact of negative
emotions on prognosis following myocardial infarction: Is it more than
depression? Health Psychology, 14(5), 388-398.
Gold, M.R., Brockman, R., Peters, R.W., Olsovsky, M.R. & Shorofsky, S.R. (2000).
Aucte hemodynamic effects of right ventricular pacing site and pacing mode in
patients with congestive heart failure secondary to either ischemic or idiopathic
dilated cardiomyopathy. The American Journal of Cardiology, 85(9), 1106-1109.
Gold, M.R, Sulke, N., Schwartzman, D.S., Mehra, R. & Euler, D.E. (2001). Clinical
experiences with a dual-chamber implantable cardioverter defibrillator to treat
atrial tachyarrhythmias. Journal of Cardiovascular Electrophysiology, 12, 1247-
Hamilton, D.M. & Haennel, R.G. (2000). Validity and reliability of the 6-minute walk
test in a cardiac rehabilitation population. Journal of Cardiopulmonary
Rehabilitation, 20(3), 156-164.
Hegel, M.T., Griegal, L.E., Black, C. & Goulden, L. (1997). Anxiety and depression in
patients receiving implanted cardioverter defibrillators: A longitudinal
investigation. International Journal of Psychiatry in Medicine, 27, 57-69.
Heller, S. S., Ormont, M. A., Lidagoster, L., Sciacca, R. R., & Steinberg, J. S. (1998)
Psychosocial outcome after ICD implantation: A current perspective. Pacing and
Clinical Electrophysiology, 21, 1207-1215.
Herbst, J. H., Goodman, M., Feldstein, S., & Reilly, J. M. (1999). Health-related quality
of life assessment of patients with life-threatening ventricular arrhythmias. PACE
Hill, D.R., Kelleher, K. & Shumaker, S.A. (1992). Psychosocial interventions in adult
patients with coronary heart disease and cancer. General Hospital Psychiatry, 14S,
Irvine, J., Dorian, P., Baker, B., O'Brien, B.J., Roberts, R., Gent, M., Newman, D. &
Connolly, S.J. (2002). Quality of life in the Canadian Implantable Defibrillator
Study (CIDS). American Heart Journal, 144(2), 282-289.
Kay, G. N., Ellenbogen, K. A. & Giudici, M. (1998). The Ablate and Pace Trial: A
prospective study of catheter ablation of the AV conduction system and
permanent pacemaker implantation for treatment of atrial fibrillation. Journal of
Interventions in Cardiac Electrophysiology, 2, 121-135.
Kleinbaum, D.G., Kupper, L.L., Muller, K.E. & Nizam, A. (1998). Applied Regression
Analysis and Other Multivariable Methods. CA: Brooks/Cole Publishing
Kohn, C. S., Petrucci, R. J., Baessler, C., Soto, D. M., & Movsovitz, C. (2000). The effect
of psychological intervention on patients' long term adjustment to the ICD: A
prospective study. PACE, 23, 450-456.
Konstam, V., Colburn, C. & Butts, L. (1995). Psychosocial adaptation of automatic
implantable cardioverter defibrillator recipients Implications for the
rehabilitation counselor. Journal of Applied Rehabilitation Counseling, 26, 19-22.
Linden, W., Stossel, C. & Maurice, J. (1996). Psychosocial interventions for patients with
coronary artery disease. Archives of Internal Medicine, 156, 745-752.
Lip, G.Y.H. (2001). Atrial Fibrillation in Clinical Practice. London: Martin Dunitz.
Luderitz, B. & Jung, W. (2000). Quality of life in patients with atrial fibrillation.
Archives of Internal Medicine, 160, 1749 1757.
Luderitz, B., Jung, W., Deister, A., & Manz, M. (1996). Chapter 18: Quality of life in
multiprogrammable implantable cardioverter-defibrillator recipients. In S.
Saskena & B. Luderitz (Eds.), Interventional electrophysiology: A textbook (2nd
ed.). Armonk, NY: Futura Publishing, 305-313.
Murgatroyd, F.D. & Camm, A.J. (1997). Nonpharmacological Management of Atrial
Fibrillation. NY: Futura Pub. Co.
Namerow, P.B., Firth, B.R. & Heywood, G.M. (1999). Quality of life six months after
CABG surgery in patients randomized to ICD versus no ICD therapy: Findings
from the CABG Patch Trial. Pacing and Clinical Electrophysiology, 22, 1305
Pauli, P., Wiedemann, G., Dengler, W., Benninghoff, G.B. & Kuhlkamp, V. (1999).
Anxiety in patients with an automatic implantable cardioverter defibrillator: What
differentiates them from panic patients? Psychosomatic Medicine, 61, 69-76.
Pycha, C., Gulledge, A. D., Hutzler, J., Kadri, N., & Maloney, J. (1986). Psychosocial
responses to the implantable defibrillator: Preliminary observations.
Psychosomatics, 12, 841-845.
Radloff, L.S. (1977). The CES-D Scale: A self-report depression scale for research in the
general population. Applied Psychological Measures, 1(3), 85-401.
Reid, S. S., Nagy, S., & McKinley, S. (1999). Outcomes, problems, and quality of life
with the implantable cardioverter defibrillator. Australian Journal of Advanced
Nursing, 16(4), 14-19.
Schron, E.B., Exner, D.V., Yao, Q., Jenkins, L.S., Steinberg, J.S., Cook, J.R., Kutalek,
S.P., Friedman, P.L., Bubien, R.S., Page, R.L. & Powell, J. (2002). Quality of life
in the antiarrhythmnics versus implantable defibrillators trial: Impact of therapy
and influence of adverse symptoms and defibrillator shocks. Circulation, 105(5),
Sears, S.F. & Conti, J.B. (2002). Current views on the quality of life and psychological
functioning of implantable cardioverter defibrillator patients. Heart, 87, 488-493.
Sears, S.F., Todaro, J.F., Saia Lewis, T., Sotile, W.M. & Conti, J.B. (1999). Examining
the psychosocial impact of the implantable cardioverter defibrillator: A literature
review. Clinical Cardiology, 22, 481-489.
Spielberger, C.D., Gorsuch, R.L., Lushene, R., Vagg, P.R. & Jacobs, G.A. (1983).
Manual for the State-Trait Anxiety Inventory (Self-Evaluation Questionnaire:
Form Y). Palo Alto: Consulting Psychologist Press, Inc.
Stofmeel, M. A., Post, M. W. & Kelder, J. C. (2000). Quality of life of pacemaker
patients. Pacing and Clinical Electrophysiology, 23, 946-952.
Turk, D. C. & Okifuji, A. (1994). Detecting depression in chronic pain patients:
Adequacy of self-report. Behavior Research and Therapy, 32, 9-16.
Ware, J.E., Snow, K., Kosinski, M. & Gandek, B. (1993). SF-36 Health Survey: Manual
and Interpretation Guide. Boston: Nimrod Press.
Wellens, H.J., Lau, C.P., Luderitz, B., Akhtar, M., Waldo, A.L., Camm, A.J.,
Timmermans, C., Tse, H.F., Jung, W., Jordaens, L. & Ayers, G. (1998).
Atrioverter: An implantable device for the treatment of atrial fibrillation.
Circulation, 98(16), 1651-1656.
Rebecca Owen Sotile was born in Winston-Salem, NC on January 1st, 1979, to
Wayne and Mary Sotile. She has one younger sister, Julia, with whom she remains very
close. She received a Bachelor of Arts in psychology from the University of North
Carolina at Chapel Hill in 2001. She is currently living in Gainesville, FL, pursuing her
Ph.D. in clinical and health psychology at the University of Florida Health Science
Center. Her future plans include mastery of clinical and research skills with a focus on