An Updated Review of Implantable Cardioverter/Defibrillators, Induced Anxiety, and Quality of Life

https://doi.org/10.1016/j.psc.2007.07.002Get rights and content

Despite overall favorable acceptance of implantable cardioverter-defibrillators (ICDs), patients may experience discharges as frightening and painful. The authors reviewed ICD-induced psychopathology in 2005. During the past 2 years the number of studies examining psychopathology and quality of life after ICD implantation has increased dramatically, warranting this update of that review. Variables assessed have included recipient age, gender, social support network, perception of control and predictability of shocks, and personality style. Now the picture of what is known is, if anything, cloudier than it was 2 years ago, with little definitive and much contradictory data emerging in most of these categories.

Section snippets

Age

In their original review, the authors reported that youth (age less than 50 years) was a risk factor for increased anxiety, reduced quality of life, and compromised adjustment to the device. They have found six additional studies, four of which refute this conclusion, and two of which concur with it, at least in part.

The first study to disagree found neither anxiety nor depression to be increased in 20 patients aged 9 to 19 years, despite worsened physical functioning [20]. These children and

Gender

Female gender has been thought to be an independent risk factor, although the literature is limited by the consistent finding that most study participants are male. Six studies update the understanding of this risk factor; like the studies of the effect of age, they either fail to achieve consensus or frankly contradict one another.

Thomas and colleagues [25] showed women reporting lower scores on the emotional subscale of the SF-36 than men. Two groups of investigators [26], [27] found women

Number and Frequency of Shocks

Most investigators in the authors' earlier review found that increasing numbers of ICD shocks corresponded to elevated rates of psychopathology [19], [25]. One such study of 167 ICD recipients revealed both increased depression and anxiety in those experiencing shock and also decreased adaptation to living with the device [15].

Although a representative early paper stated unequivocally that “multiple shocks were a clear precipitant for the psychiatric disorders” [30], more recent reports

Perception of Support and Family Response

In the authors' original review, excessive family anxiety and poor social support led to worse quality of life and emergent psychopathology. In a more recent review, Thomas and colleagues [25] reinforce this finding, stating “low anxiety, high social support and no shocks were predictive of the best quality of life.” It is not necessarily the recipient's own anxiety that is the problem. Eight of 12 patients voiced frustration with “overprotective” family members, with one reportedly moving away

Anger and Anxiety

The authors previously found that baseline state and traits of anger and anxiety may be higher in ICD recipients before implantation, with anxiety improving after implantation, and they noted that elevated anxiety predicts worse quality of life. ICD recipients commonly report anger and anxiety [15], [40]. Thirty-five ICD recipients scored higher on the Beck Anxiety Inventory than did controls, although not as high as patients who had a full-blown anxiety disorder [21]. The authors concluded

Optimism and Positive Health Expectations

Just as elevated anxiety can lead to pessimism, a fundamentally optimistic outlook can generate reduced anxiety and positive health expectations. Two recent trials address this possibility. The first, looking at 88 patients who had newly implanted ICDs, demonstrated that patients who had higher baseline positive health expectations, defined as “patient beliefs specifically related to the likelihood of a positive health outcome,” reported better general physical health at follow-up than patients

Psychoeducation

In the authors' original review, as now, there is consensus as to the importance of patient education. Recent researchers would all agree with Bourke and colleagues' [30] 1997 assertion that “appropriate interventions should begin with education as to the nature and purpose of the defibrillator.” Although several distinct approaches are advocated [28], [44], [45], commonalities include providing education about the nature of ICDs, including (1) their survival advantage over antiarrhythmic

New Directions

Since the authors' original review, several areas of inquiry have emerged. Stutts and colleagues [54] note “increasing attention given to psychological factors in cardiac disease subgroups is representative of a broader trend … in most chronic diseases.” These factors include the curious experience of feeling the ICD firing when it has not, called “phantom shock” and associated with depression and anxiety [36], [46]. The literature increasingly references ICD-induced posttraumatic stress

Summary

During the past 2 years the number of studies examining psychopathology and quality of life after ICD implantation has increased dramatically. Variables assessed have included recipient age, gender, and social support network. How recipients respond to having the device, particularly after experiencing firing, has been evaluated in light of new depression and anxiety disorder diagnoses as well as premorbid personality structure. Now the picture of what is known is, if anything, cloudier than it

References (58)

  • J. Lemon et al.

    Avoidance behaviors in patients with implantable cardioverter defibrillators

    Heart Lung

    (2004)
  • S.F. Sears et al.

    Psychological aspects of cardiac devices and recalls in patients with implantable cardioverter defibrillators

    Am J Cardiol

    (2006)
  • J.P. DiMarco

    Implantable cardioverter-defibrillators

    N Engl J Med

    (2003)
  • A.J. Moss et al.

    Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators

    N Engl J Med

    (1996)

  • A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. The Antiarrhythmics Versus Implantable Defibrillators (AVID) Investigators

    N Engl J Med

    (1997)
  • S.J. Connolly et al.

    Canadian Implantable Defibrillator Study (CIDS): a randomized trial of the implantable cardioverter defibrillator against amiodarone

    Circulation

    (2000)
  • K.H. Kuck et al.

    Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest: the Cardiac Arrest Study Hamburg (CASH)

    Circulation

    (2000)
  • F. Bokhari et al.

    Long-term comparison of the implantable cardioverter defibrillator versus amiodarone: eleven-year follow-up of a subset of patients in the Canadian Implantable Defibrillator Study (CIDS)

    Circulation

    (2004)
  • G.H. Bardy et al.

    Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure

    N Engl J Med

    (2005)
  • U.S. Food and Drug Administration Center for Devices and Radiological Health. Available at:...
  • B. Luderitz et al.

    Patient acceptance of the implantable cardioverter defibrillator in ventricular tachyarrhythmias

    Pacing Clin Electrophysiol

    (1993)
  • A.S. Eads et al.

    Supportive communication with implantable cardioverter defibrillator patients: seven principles to facilitate psychosocial adjustment

    J Cardiopulm Rehabil

    (2000)
  • E.A. Kuhl et al.

    Measurement of patient fears about implantable cardioverter defibrillator shock: an initial evaluation of the Florida Shock Anxiety Scale

    Pacing Clin Electrophysiol

    (2006)
  • H.C. Kamphuis et al.

    Implantable cardioverter defibrillator recipients: quality of life in recipients with and without ICD shock delivery: a prospective study

    Europace

    (2003)
  • P.B. Namerow et al.

    Quality-of-life six months after CABG surgery in patients randomized to ICD versus no ICD therapy: findings from the CABG Patch Trial

    Pacing Clin Electrophysiol

    (1999)
  • S.E. Sears et al.

    Understanding implantable cardioverter defibrillator shocks and storms: medical and psychosocial considerations for research and clinical care

    Clin Cardiol

    (2003)
  • A.K. Bilge et al.

    Depression and anxiety status of patients with implantable cardioverter defibrillator and precipitating factors

    Pacing Clin Electrophysiol

    (2006)
  • M.J. Yarnoz et al.

    Why cardioverter-defibrillator implantation might not be the best idea for your elderly patient

    Am J Geriatr Cardiol

    (2006)
  • G.A. Hamilton et al.

    The effects of age on quality of life in implantable cardioverter defibrillator recipients

    J Clin Nurs

    (2004)

    • Cited by (83)

    • Cardiac stereotactic ablative radiotherapy for refractory ventricular arrhythmias: A radical alternative? A narrative review of rationale and cardiological aspects

      2021, Journal of Medical Imaging and Radiation Sciences

    • Moderators of the effect of psychological interventions on depression and anxiety in cardiac surgery patients: A systematic review and meta-analysis

      2015, Behaviour Research and Therapy

    • Quality of life and psychological co-morbidities in children and adolescents with cardiac pacemakers and implanted defibrillators: A cohort study in Eastern Germany

      2020, Cardiology in the Young

    • Radiotherapy for non-cancer diseases: benefits and long-term risks

      2024, International Journal of Radiation Biology

    • The experience of patients with an implantable cardioverter-defibrillator: A systematic review and meta-synthesis of qualitative studies

      2022, European Journal of Cardiovascular Nursing

    • Overview of Biofluids and Flow Sensing Techniques Applied in Clinical Practice

      2022, Sensors
    View all citing articles on Scopus
    View full text
    Copyright © 2007 Elsevier Inc. All rights reserved.