Anxiety, depression, resilience and self-esteem in individuals with cardiovascular diseases 1

ABSTRACT Objectives: to analyze the relationship between anxiety and depression symptoms, resilience and self-esteem with sociodemographic and clinical characteristics; correlate resilience and self-esteem with age and duration of the disease; check associations between anxiety and depression with measures of resilience and self-esteem among individuals with cardiovascular diseases. Method: correlational study conducted in a large university hospital in the interior of the state of São Paulo, Brazil. The population was composed of adult inpatients with cardiovascular diseases. A non-probabilistic consecutive sample was composed of 120 patients. Variables of interest were assessed using the Hospital Anxiety and Depression Scale, Resilience Scale, and Rosenberg Self-Esteem Scale. Results: anxiety and depression symptoms were present in 32.5% and 17.5% of the patients, respectively, and were associated with the female sex (p = 0.002; p = 0.022). Manifestations of depression were associated with the presence of comorbidities (p = 0.020). More resilient patients did not present depression symptoms (p < 0.001) and anxious women were more resilient (p = 0.042). The highest scores regarding self-esteem were present in patients with anxiety and depression. Men presented higher resilience and lower self-esteem compared to women. Conclusion: patients with anxiety and depression were less resilient but presented higher self-esteem.

however, has been paid to the identification of these characteristics in hospital settings.
A literature review identified studies assessing resilience in patients with congenital cardiovascular diseases (8)(9) and congestive heart failure (10) . There are few studies addressing resilience in this population using scales validated in Brazil, especially resilience related to self-esteem, anxiety or depression. These results can support the strengthening of multidisciplinary strategies focusing on increased resilience and emotional skills to help patients cope with stress arising from heart disease.
Therefore, this study's objectives were: 1) analyze potential associations between anxiety and depression with sociodemographic and clinical characteristics; 2) verify association between measures of resilience  the Hospital Anxiety and Depression Scale (HADS) (11) ; Resilience Scale (5,12) ; and the Rosenberg Self-esteem Scale (RSES) (13) .
HADS is easy to use and can be quickly applied.
It can be either self-reported or completed by an interviewer. HADS has 14 items; seven items assess anxiety (HADS-A) and seven assess depression (HADS-D). Each item has four possible answers on a scale from 0 to 3, with a total score of 21 points for each subscale; the higher the score, the higher the presence of anxiety (HADS-A) or depression (HADS-D) symptoms (11) . doing things against one's own will but keeping interest focused on things that matter (12) . This scale's scores range from 25 to 175 points; high scores indicate high resilience (12) .
RSES (13) is composed of 10 items with four alternates for answers: 1 strongly agree, 2 agree, 3 disagree, 4 strongly disagree. A measure of self-esteem is obtained by summing up the scores obtained in the scale's items, then recoding five items with reverse scores. The sum of these scores may range from 10 to 40; higher scores indicate higher self-esteem (13) .
Data collection was initiated a census of patients of the hospitalization ward to confirm heart disease.
After receiving clarification regarding the study and consenting to take part in the study, participants signed free and informed consent forms and the interview was then verbally applied by an interviewer.
Measures of position (mean and median) and variability (standard deviation) were used.
Qualitative data were associated by applying the

Results
Of the 120 individuals with cardiovascular diseases,   There was no association of clinical variables

Discussion
This study's results show that 32.5% and 17.5% of the patients presented anxiety and depression symptoms, respectively. Other studies report similar percentages (14)(15) , highlighting that the presence of these symptoms may increase the risk of morbidity and mortality, delay hospital discharge, lead to readmission or functional decline, hinder self-care and the adoption of changes necessary to modify one's lifestyle, resulting in non-adherence to treatment (14,16) .
Women presented more anxiety and depression symptoms than men, a fact that may be related to women's greater exposure to stressful factors, such as a low socioeconomic level, lack of energy, overload of roles, psychological issues, and low self-esteem. The lower prevalence of these symptoms among men may be explained by a difficulty in reaching a diagnosis, as men tend to deny depression symptoms and compensate with attitudes and behaviors such as anger, aggressiveness, antisocial behavior, excessive consumption of alcohol and hostility (17) . Other studies also identified positive associations between anxiety and depression for the female sex (15,17) .
Depression is the main cause of incapacity measured by HADS (14) .
Various studies indicate the impact negative impact of depression on patients with heart disease (14)(15)(16)19) .
One in every five patients presented high levels of depression three months after an episode of myocardial infarction; this mood disorder is associated with increased risk of new cardiovascular event or death (19) .
Other studies provide evidence that depression can raise the level of mortality among patients with coronary diseases (15,20) .
The mechanism behind the association of depression with cardiovascular diseases is still unclear, but it is known that it is bi-directional and multi-causal, involving the integration of various central and peripheral processes, causing changes in the immunological system (21) , increased platelet count, inflammation, abnormal heart rate, high catecholamine levels, and endothelial dysfunction (16) . Psychological factors, such as an inability to cope with a chronic disease that presents a high mortality rate and abrupt changes in lifestyle, may also aggravate the condition (16) .

Individuals identified by HADS as having
anxiety and depression symptoms were less resilient than those who did not present symptoms. This association corroborates one German study including 186 patients with congestive heart failure and 372 controls, which verified that resilience is predominantly associated with psychological variables rather than with the severity of disease. The results show that resilience was lower among patients with depression and alexithymia (10) . one's personality (6) .
In regard to sex, this study reveals that men are more resilient than women, a finding that supports the results of a study conducted with individuals with chronic kidney disease (7) . This result may be related to the fact that women more frequently use coping strategies patients after surgical correction of tetralogy of Fallot (9) and in Korea with individuals with congenital heart disease (8) .
Therefore, the nursing team and other health professionals should devise efficient ways to sustain and promote the development of these positive characteristics in the population to improve coping strategies and prepare patients for the unpredictable task of living with a chronic disease.
The scores obtained on the Rosenberg Selfesteem Scale reveal that the feelings people hold about themselves concerning their worth, capacity, importance, and success were moderate (mean score = 20.31 points).
Women presented higher self-esteem scores when compared to men (p = 0.031). High level of self-esteem was found in a Brazilian study addressing patients with coronary diseases, though no significant difference was found between men and women (23) .
A meta-analysis of 80 studies reports that low selfesteem is a predictor factor for depression, regardless of sex or age (24) . The highest scores for self-esteem in this study were obtained by patients who presented symptoms of anxiety, thereby not corroborating the results reported in the literature (24) .
Evidence shows that the relationship between depression and self-esteem is more robust that the relationship between anxiety and self-esteem, a fact that may be related to the cognitive vulnerabilities specific to each situation. When depressed, individuals make constant negative assessments of themselves, of the world, of future prospects, and when anxious one anticipates physical or psychological threats (24) .
Further studies are needed to verify whether there is an association between anxiety and self-esteem, controlling for variables that may interfere in the process.
Other studies confirm that high self-esteem may be associated with a lower frequency of coronary