Somatic and cognitive-affective depressive symptoms among patients with heart disease: differences by sex and age

OBJECTIVE: this study investigated the association of somatic and cognitive-affective symptoms with sex and age, among patients hospitalized with heart disease. METHOD: this study was a secondary analysis of two previous observational studies totaling 531 patients with heart disease, hospitalized from 2005 to 2011 in two public hospitals in Ribeirão Preto, state of São Paulo, Brazil. Somatic and cognitive-affective symptoms were assessed using the subscales of the Beck Depression Inventory - I (BDI-I). RESULTS: of 531 participants, 62.7% were male, with a mean age 57.3 years (SD= 13.0) for males and 56.2 years (SD= 12.1) for females. Analyses of variance showed an effect of sex (p<0.001 for somatic and p=0.005 for cognitive-affective symptoms), but no effect of age. Women presented with higher mean values than men in both BDI-I subscales: 7.1 (4.5) vs. 5.4 (4.3) for somatic, and 8.3 (7.9) vs. 6.7 (7.2) for cognitive-affective symptoms. There were no differences by age for somatic (p=0.84) or cognitive-affective symptoms (p=0.84). CONCLUSION: women hospitalized with heart disease had more somatic and cognitive-affective symptoms than men. We found no association of somatic and cognitive-affective symptoms with age. Future research for these patients could reveal whether these differences according to sex continue throughout the rehabilitation process.


Introduction
Cardiomyopathies are the main cause of morbidity and mortality in the world (1) . Despite the significant advances in treatment and control of cardiomyopathies, they still represent a highly relevant health problem in the world today. The World Health Organization (WHO) estimates that the global mortality due to cardiomyopathies will increase from 17.1 million in 2004 to 23.4 million in 2030, with a larger relative increase in countries of low and medium income (1) . Emotional issues in person with cardiomyopathy have been studied, including studies of depression in patients in Brazil (2)(3) and other countries (4)(5) .
Depression symptoms are present in one out of five persons with coronary artery disease (CAD) and in one out three persons with congestive heart failure (CHF).
However, the majority of these cases are not recognized or treated appropriately. Depression is considered a risk factor for developing cardiovascular disease, as well as a predictor of worse outcomes among persons with established cardiomyopathy (6) .
Age and sex are two factors that have been studied as moderators of depression symptoms in persons with cardiomyopathy. Females tend to have a two to three times higher probability of being diagnosed with major depressive disorder (MDD) than males (7) , and present higher scores than males in selfreport measures of depression symptoms (2,8) . For age, studies have shown that there is a higher prevalence of depression symptoms among adults 35 to 50 years of age, with a decline in prevalence for 65 years and older (2,7,(9)(10) .
Researchers have also pointed out differences between men and women diagnosed with MDD regarding perception of depressive symptoms as measured by the Beck Depression Inventory (BDI-I and BDI-II) (8,11) . Women tended to present higher frequency of depression symptoms than men, as well as higher rates of anxiety disorders and somatic symptoms, such as fatigue, sleep disorders, and lack of appetite (12) . Among patients with cardiomyopathy, especially the ones with CAD, the presence of anxiety has been observed in various studies (12)(13) . Given the frequency of reports of depression as well as other symptoms associated with cardiomyopathy, it is of interest to determine whether the differences between men and women exist when examining the specific symptom clusters of depression.
Despite the research on depression and cardiomyopathy, little has been examined on whether differences exist in the presence or absence of specific depressive symptoms in this population. Specifically, we have not found studies that investigated the role of sex and age in the presence of somatic and cognitive-affective symptoms among persons with cardiomyopathy. This study aimed to investigate the association of somatic and cognitive-affective symptoms with sex and age among patients hospitalized with heart disease in two public hospitals in the state of São Paulo, Brazil. Given the previous research, we hypothesized that women would report more symptoms in each symptom cluster than men and that those who were older who report higher levels of each symptom than those who were younger. The results will help clinicians to understand the somatic and cognitive-affective symptoms profile of patients with established cardiomyopathy, by providing information that can be used in their treatment and care, and can assist in the mental and psychosocial rehabilitation of those patients.

Setting and study design
This study is a secondary analysis of data from two observational studies, which will be described below.

Data collection and instruments
The data for this study came from two previous studies involving patients hospitalized with heart disease in two public hospitals in the state of São Paulo, Brazil, and which collected the Beck Depression Inventory -I (BDI-I) .
The first study was performed to culturally adapt and evaluate the psychometric properties of the Antonovsky's sense of coherence questionnaire to the Portuguese language (14) . The data was collected from a single university hospital that serves individuals through the public system of healthcare in Brazil.
Individuals could be included in the study if they had a diagnosis of cardiac disease confirmed by clinical, laboratory or radiologic exam, did not have psychiatric conditions (such as dementia, clinical depression or schizophrenia), and were hospitalized for diagnostic or therapeutic purposes due to cardiomyopathies, whether the first or a repeated hospitalization for the diagnosis. The second study was performed to study the association between depressive symptoms and age and sex, in persons with acute coronary syndrome (including acute myocardial ischemia and unstable angina) hospitalized for their first cardiac event (2) . Data were collected from the same university hospital as the first study with additional participants from a second hospital (non-teaching institution), also within the public system of healthcare, with a similar Regarding the age, in the first study (14) , individuals could be included if they were 18 years or older, and in the second study (2) were included 21 years or older individuals. In this present study, the results are regarding all patients were age 18 or older.

Somatic and cognitive-affective symptoms
Both studies collected information on somatic and cognitive-affective symptoms via the subscales of the BDI-I (15) using the adapted version to Portuguese language (16) .

The BDI-I is an inventory composed of 21 items,
where each item describes a specific behavioral manifestation of depression. Each item has four choices of self-assessment statements, which are scored 0 to 3, with higher scores indicating increasing symptom severity. Respondents are instructed to describe the way they have been feeling during the past week. Higher sum of scores suggest higher depression symptoms (15) .
Based on one review of existing factor models and item content (17) and studies with cardiac patients (8,18) , The significance level was set to α=0.05. informed consent, since it was a secondary analysis of data already available from previously approved studies. Table 1 shows the participants' demographic and clinical characteristics. When compared to women, men had slightly higher mean years of education and higher family income (both statistically significant with p<0.001), but were similar in mean age (p=0.30). A higher proportion of men were married or living with a partner (p<0.001) and were employed (p<0.001) than women.

Results
Men and women differed in diagnosis at hospital admission, with a higher proportion of men having coronary artery disease and higher proportion of women having heart failure. Men had lower proportions of arterial hypertension (p=0.01), dyslipidemia (p<0.001), and diabetes (p=0.01) than women, but were not different in obesity (p=0.93) and cerebral vascular accident (p=0.83).  Table 2 presents the results of the ANOVA. For both subscales, there was an effect of sex, but no effect of age or the interaction between age and sex.    Figure 1 depicts the mean of the two BDI-I subscales by age and sex. We plotted the data of each subscale in order to show the relative severity of the symptoms for each age and sex group. Note that males seem to have the same level of symptoms regardless of age group for both, somatic and cognitive-affective subscales. Females presented higher values than males for all age groups, but seemed to have higher values at middle age (45-49.5 years) and older age (75 or more), although age group was not statistically significant. Figure 1 -Mean of the BDI-I somatic and cognitiveaffective symptoms by age and sex

Discussion
We found that somatic and cognitive-affective symptoms were different for the groups of men and women, but not different for age groups.
In the literature, studies that used the BDI-I in populations with cardiac diseases did not report the somatic and cognitive-affective subscales separately and, therefore, a direct comparison with our study is not possible. However, when taken as a single total score, the BDI-I showed differences between males and females in depressive symptoms for various studies (11,(19)(20)(21) and our general findings are consistent with the literature. reported more symptoms of depression overall and somatic complaints when compared to men (19) . Somatic complaints that were different between males and females included headache, dizziness, back pain, nausea, muscle pain, hot and cold flashes, and feeling lump on throat. Other researchers also studied people with major depressive disorder (MDD) and found a higher likelihood that females would present with somatic depression than males (11) . Fatigue and change in appetite were significantly different between men and women (11) .
In our study, age group was not a statistically significant factor in the presence of cognitive-affective or somatic symptoms. Again, we found no studies that examined cognitive-affective symptoms separately.
However, while not statistically significant, we did see a trend where an increase of somatic and cognitiveaffective symptoms was seen for those at younger age (especially middle age) when compared to older age.
A similar pattern has been observed in the people with depression in the general population (7,(9)(10) . Note in Figure   1 that women had higher means for both subscales of the BDI-I, but there were only seven women in that group and two of them had high-value symptoms, inflating the mean of the entire group.
Some possible causes of differences in depressive symptoms between men and women have been discussed in the literature (22)(23) , including a study in the Brazilian population (24) .

Conclusion
Using the subscales of the BDI-I in people with cardiomyopathy sampled from two public hospitals in the state of São Paulo, Brazil, we found that women had, on average, higher levels of somatic and cognitiveaffective symptoms than men. Age was not statistically associated with the subscales of BDI-I. Although women in the age group of 45-54.9 years showed a higher mean in both subscales, the interaction of age and sex was not statistically significant.
Treatment of patients with cardiomyopathy should include the assessment of depressive symptoms and special care should be taken to assess depression in women, so that depressive symptoms are identified early and appropriate treatment is initiated.