Archives of Psychiatric Nursing 32 (2018) 235–241

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Correlations between stress, anxiety and depression and sociodemographic T

and clinical characteristics among outpatients with heart failure
⁎
Melissa Alves Cirelli , Marianna Sobral Lacerda, Camila Takao Lopes, Juliana de Lima Lopes,
Alba Lucia Bottura Leite de Barros
Paulista Nursing School, Federal University of São Paulo, 754 Napoleão de Barros St, 04024-002 São Paulo, SP, Brazil

A R T I C L E I N F O A B S T R A C T

Keywords: Aim
Anxiety To describe and investigate correlations among anxiety, stress and depression and identify their relationship
Stress psychological with sociodemographic and clinical characteristics of patients with heart failure.
Depression Methods: This is an analytical cross-sectional study. Sociodemographic and clinical characteristics were col-
Heart failure
lected, along with levels of anxiety, stress and depression from 309 outpatients.
Results: The mean levels of stress, anxiety and depression were correlated but low. Time since diagnosis, the
disease's functional class, family income, and smoking influenced stress. Functional class and Chagas disease
influenced anxiety and depression. Being unemployed and smoking influenced anxiety, while being a home-
owner influenced depression.
Conclusion: These findings should be considered when planning nursing interventions.

Introduction remodeling and contribute to HF clinical manifestations (Almeida,

Cardiovascular diseases are the main cause of morbidity and mor-
tality in Brazil and in the world (OPAS, 2016). In 2016, heart failure
(HF) accounted for 211,992 hospitalizations in Brazil (MS, 2016). More
than five million Americans are affected, while 10% of these cases are
in advanced stages of the disease (Dunlay & Roger, 2014; Heidenreich,
Albert, Allen, et al., 2013). The estimates for 2030 is that more than
eight million North-American individuals will be affected by HF
and > 23 million people will be affected by the disease worldwide
(Heidenreich et al., 2013; OMS, 2015).
Heart Failure imposes physical and functional limitations; various
medications along with behavior modification are required to properly
handle such limitations. Hospitalizations are recurrent when there is
decompensated heart failure, especially due to difficulties patients face
regarding treatment adherence, both in regard to the medication
scheme and non-medication therapy (York, Hassan, & Sheps, 2009).
Negative mood states such as stress, anxiety and depression emerge
in this context, leading to neurochemical alterations that increase
neural-hormonal sympathetic activity and inflammatory and im-
munological responses (Freedland, Carney, & Rich, 2011; Margis,
Picon, Cosner, & Silveira, 2003), which in turn lead to cardiac
Silveira, Viegas, & Godoy, 2009).
Stress, anxiety and depression influence morbidity and mortality,
increase the prevalence of a worse prognosis, promote the progression
of the disease's functional class (FC), increase length of hospitalization,
and also interfere in patient treatment adherence and quality of life
(Polikandrioti et al., 2015; Suzuki et al., 2014). However, the literature
shows that the investigation and management of psychological aspects
of patients with HF is not incorporated into clinical practice for many
reasons, including a lack of knowledge regarding the connection be-
tween psychological changes and physical outcomes (Moser, 2002).
Therefore, this study's objectives were: to describe and verify the
correlation among levels of stress, anxiety and depression among out-
patients with HF and to verify the relationship between these variables
and sociodemographic and clinical variables. The results can support
the planning of interventions intended to reduce the influence of these
variables on treatment adherence and progression of the disease, thus,
aiding in decreasing hospitalizations and related costs.
Material and method
This analytical cross-sectional study was conducted in a

Abbreviations: HF, heart failure; FC, functional class; BDI, Beck Depression Inventory; BAI, Beck Anxiety Inventory; PSS-10, Perceived Stress Scale; BMI, body mass index; AC, abdominal
circumference; SD, standard deviation; Min, minimum; Max, maximum; CDHU, Housing and Urban Development Company; MW, minimum wage; SE, standard error; RR, relative risk
⁎
Corresponding author.
E-mail addresses: melissa.cirelli@hsl.org.br (M.A. Cirelli), barros.alba@unifesp.br (A.L.B.L. de Barros).

https://doi.org/10.1016/j.apnu.2017.11.008
Received 9 May 2017; Received in revised form 25 October 2017; Accepted 2 November 2017
0883-9417/ © 2017 Elsevier Inc. All rights reserved.
M.A. Cirelli et al.
myocardiopathy outpatient clinic of a large university hospital in the
city of São Paulo, SP, Brazil, from April 2014 to August 2015. This
outpatient clinic schedules medical appointments weekly according to
the hospital's referrals.
The sample consisted of patients with HF and Z statistics were used
to compute the study's three main scales: Beck Depression Inventory
(BDI), Beck Anxiety Inventory (BAI), and the Perceives Stress Scale
(PSS-10). Variance of the scales was calculated in a pilot sample of 30
patients and was 81.02, 118.33, and 45.64, respectively. Considering
that the total scores of BDI and BAI range from zero to 63 and the PPS
total score ranges from zero to 40, a maximum acceptable error
of ± 2% of the total score in each of the scales and a confidence in-
terval of 95%, the total sample was established with 309 patients.
Inclusion criteria were: patients with a medical diagnosis of HF,
functional classes I and II, cared for in the aforementioned outpatient
clinic, older than 18 years old, with at least four years of schooling.
Exclusion criteria were: visual impairment that impeded filling out the
self-reported instrument.
The primary researcher, a Cardiology specialist nurse with nine
years' experience in the field, made weekly visits to the outpatient clinic
and approached patients while they waited for their medical appoint-
ments. She clarified the study's objectives and asked those who con-
sented to sign free and informed consent forms. The participants were
then interviewed based on a script developed by the researchers ad-
dressing gender, age, ethnicity, occupation, housing types, religion,
family income, education, HF FC, time since diagnosis, comorbidities,
and type of myocardiopathy. The patients' medical charts were also
consulted whenever needed.
The researcher checked the patients' weight and height prior to the
medical appointment. Those using a wheelchair or who were unable to
stand, due to an amputation of a lower limb, e.g., self-reported their
information or the information was pulled from their medical charts.
Body mass index (BMI) was obtained by dividing weight (kg) by
squared height (m2). The classification recommended by the World
Health Organization was used (WHO, 2000): underweight < 18.5;
normal range: 18.5 to 24.9; overweight: 25 to29.9; obese class I: 30 to
34.9; obese class II: 35 to 39.9; and obese class III: ≥ 40.The patients'
abdominal circumference (AC) was checked by the researcher with a
metric tape placed under their clothing at the navel height, without
tightening the tape or leaving any slackness. Measures above 80 cm
were considered abdominal obesity among women and above 94 cm
among men (Simão et al., 2013).
The BDI was used to assess depressive symptoms. It is composed of
21 items, with four alternatives that describe behavioral, cognitive,
affective and somatic manifestations and correspond to the severity of
depressive symptoms. Its total score ranges from zero to 63 and refers to
symptoms experienced in the last week. Scores were categorized as
follows: scores from zero to 14 reveal no symptoms of depression;
scores from 15 to 19 reveal no symptoms of dysphoria; scores equal to
20 or higher reveal depression symptoms. The instrument's Portuguese
version had an internal consistency equal to 0.81 in a sample of stu-
dents and equal to 0.88 for a sample of patients with depressive
symptoms (Gorenstein & Andrade, 1996).
The BAI was used to assess anxiety levels. It was developed to assess
symptoms characteristic of anxiety and to differentiate them from de-
pression (Beck, Brown, Epstein, & Steer, 1998). The scale has 21 items
that reflect somatic, cognitive and affective manifestations that are
characteristic of anxiety, in order to verify the extent to which these
symptoms have affected the study's participants in the last week. A four-
point Likert scale is used, upon which zero corresponds to no symptoms
and 4 corresponds to the presence of severe symptoms; the total score
ranges from zero to 63.
Anxiety is classified as follows: Normal – score from 0 to 9; Mild to
Moderate – scores from 10 to 18; Moderate to Severe – scores from 19 to
29; and Severe – scores from 30 to 63. The scale's psychometric prop-
erties were assessed in samples of clinical and non-clinical psychiatric
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Archives of Psychiatric Nursing 32 (2018) 235–241
patients. In samples of clinical and non-clinical patients, Cronbach's
alpha ranged from 0.75 to 0.95 and from 0.71 to 0.92, respectively.
The PSS-10 (Reis, Hino, & Añez, 2010)was used to verify the extent
to which individuals perceived stressors in everyday life. The scale is
composed of ten questions that correlate events from the last 30 days.
Zero corresponds to “never”, 1 to “almost never”, 2 to “sometimes”,
three to “almost always” and four to “always”. Six out of the ten items
are considered negative aspects (1, 2, 3, 6, 9, and 10) and four are
considered positive aspects (4, 5, 7, and 8); questions with positive
connotations should be inversely scored. The total score ranges from
zero to 40; the higher the score, the greater is one's perception of stress.
The scale was tested in adults and elderly individuals, showing relia-
bility and validity, with internal consistency coefficients equal to 0.86
(Reis et al., 2010) and 0.83 (Luft, Sanches, Mazo, & Andrade, 2007),
respectively.
To describe the sample, absolute (n) and relative (%) frequencies
were used for the qualitative variables, while the mean, standard de-
viation (SD), minimum (Min) and maximum (Max)values were used for
the quantitative variables (Beck et al., 1998).
Spearman's correlations were used to relate the scales with quanti-
tative variables. The following r values were considered in order to
classify strength of correlation: 00–0.19 (very weak); 0.20–0.39 (weak);
0.40–0.59 (moderate); 0.60–0.79 (strong); 0.80–1.0 (very strong). The
associations between scales and qualitative variables were measured
using either the t-test or Mann-Whitney test. The associations between
scales and variables or more categories were performed using tests of
hypotheses, ANOVA or Kruskal-Wallis. For the associations with sig-
nificant differences, multiple comparisons were performed using the
non-parametric Tukey test. All the analyses were performed using R
Team software and the level of significance adopted was 0.05.
Finally, three linear regression models were developed to associate
each of the scales –stress (linear normal), anxiety and depression (ne-
gative linear binomial) –jointly with factors. The variables considered
eligible for the models were all those with statistical significance in the
bivariate analyses with at least one of the variables (anxiety, stress or
depression). The final variables were then selected through the back-
ward method with alpha equal to 0.05.
The project was approved by the Institutional Review Board (CAAE
No. 554.195/2014). Before admitting the participants, all patients re-
ceived clarification regarding the study's objectives, were assured of
confidentially and informed they were free to withdraw from the study
at any time, and signed free and informed consent forms.
Results
A total of 309 patients with HF, aged 53.0 ± 13.59 years old, were
included. Most were male, Caucasian, married, homeowners, Catholic,
had a family income three times the minimum wage, were not eco-
nomically active, and had four to seven years of education. Table 1
presents the patients' sociodemographic and clinical characteristics.
The means concerning stress, anxiety and depression were
16.14 ± 7.03 (minimum zero, maximum 35); 8.57 ± 8.62 (minimum
zero, maximum 48); and 10.87 ± 8.75 (minimum zero, maximum 44),
respectively.
Positive and significant correlations were found among levels of
stress, anxiety and depression. The correlations between stress and
depression (r = 0.49) and between stress and anxiety (r = 0.47) were
moderate, while the correlation between anxiety and depression was
moderate to high (r = 0.63) (p < 0.001).
Table 2 shows that being a woman was significantly associated with
higher levels of stress and anxiety. Being Afro-descendant and evan-
gelical were associated with higher levels of stress and depression,
while being a Caucasian and spiritist was associated with higher levels
of anxiety.
Having a family income less than one minimum wage was asso-
ciated with higher levels of stress, anxiety and depression. Living in a
M.A. Cirelli et al. Archives of Psychiatric Nursing 32 (2018) 235–241

Table 1 Table 4 shows that having a diagnosis of HF between two and five
Sociodemographic and clinical characterization of outpatients with heart failure years increases the level of stress compared to having a diagnosis for
(n = 309). São Paulo, Brazil. 2014 and 2015.
more than five years. Functional class II increases the level of stress by
Variable Mean (SD) Minimum–maximum 1.66 points, on average, while having a family income of up to three
times the minimum wage increases stress by 2.6 points compared to
Age 53,00 (13,59) 18–84 having a family income from three to seven times the minimum wage.
Time since diagnosis of heart failure 6,99 0–51
In contrast, being a former smoker decreases the level of stress by 1.72
n % point, on average, compared to those who do not have such an ante-
Male 192 62.14 cedent.
Ethnicity
Caucasian 166 53.60
As shown in Tables 5 and 6, FC II increased levels of anxiety by 55%
Mixed race 72 23.40 and by 29% one's level of depression. Having Chagas disease increased
Afro-descendant 60 19.50 anxiety levels by 44% and depression by 41%. Not having a job or being
Others 11 3.50 on sick leave increased one's anxiety level by 60% compared to being
Marital status
retired. Being a former smoker decreased anxiety levels by 22% and
Married 167 54.05
Single 65 21.04 being a homeowner decreased depression by the same percentage, 22%.
Divorced 35 11.33
Widowed 24 7.77 Discussion
Lives with a partner 18 5.83
Housing
Owned 213 68.93
The literature shows that one's mood should be taken into account
Rented 66 21.36 in the investigation and routine management of patients with HF in
Borrowed 30 9.71 order to promote a greater impact on clinical outcomes and quality of
Religion life than what currently is obtained through the management of tradi-
Catholic 174 56.31
tional risk factors and treatment (Moser, 2002). Stress, anxiety and
Evangelical 73 23.62
Spiritist 15 4.85 depression consist of negative mood states (Davey et al., 2016) and play
Others 46 14.89 an important role among modifiable cardiovascular risk factors. These
Family income (times minimum wage) factors compromise one's adherence to a healthy lifestyle, treatment
Less than one time 35 11.33 adherence, and interfere in one's level of knowledge or orientation
1 to 3 times 174 56.31
From to 3 to 5 times 60 19.42
concerning aspects that increase the risk of morbidities and mortality
From 5 to 7times 23 7.44 (Simão et al., 2013).
From 7 to 9 times 11 3.56 Therefore, this study's aim was to investigate levels of anxiety, stress
> 9 times 6 1.94 and depression among outpatients with HF, how these conditions in-
Schooling (in years)
teract, and their relationship with the sociodemographic and clinical
4 to 7 121 39.16
8 to 10 55 17.80 characteristics of individuals. After developing the linear regression
11 to 14 93 30.10 models, we verified that FC II was related to the three mood states;
15 years or more 40 12.94 being a former smoker was related to stress and anxiety; having Chagas
Functional class disease was related to anxiety and depression; having a HF diagnosis for
I 172 55.66
II 136 44.01
two to five years; and having a family income less than three minimum
Body mass index wages were related to stress; while not having a job or being on sick
Normal 106 34.30 leave were related to anxiety; and being a homeowner was related to
Overweight 113 36.60 depression.
Obese I 61 19.70
The sociodemographic characteristics of the study sample, with a
Comorbidities
Hypertension 212 68.61 predominance of Caucasian men with a low family income and low
Former smoking 137 44.34 educational level, were similar to those reported by other studies ad-
Coronary insufficiency 102 33.01 dressing patients with HF (Albuquerque et al., 2015; Lima, Ferreira,
Diabetes mellitus 92 29.80 Parente, & Neto Rios, 2015; Almeida, Teixeira, Barichello, & Barbosa,
Ischemic cardiomyopathy 86 27.80
Hypertrophic cardiomyopathy 69 22.30
2013and data provided by the Brazilian Institute of Geography and
Former alcoholism 53 17.10 Statistics concerning a predominance of Catholics (IBGE, 2010).
Alcoholism 34 11.00 In regard to age, most studies report individuals older than 60 years
Smoking 22 7.10 old, on average (Albuquerque et al., 2015; de Castro Graciano, do Lago,
Júnior, & Marcos, 2015; Lima et al., 2015; Nogueira, Rassi, & Corrêa,
2010), though two Brazilian studies addressing outpatients with HF
rented home was associated with higher levels of stress, while living in
reported individuals younger than 60 years of age (Dantas, Pelegrino, &
a borrowed home (or a home bought through the Brazilian Housing and
Garbin, 2007; Pelegrino, Dantas, & Clark, 2011a, 2011b). Epidemiolo-
Urban Development Company) was associated with higher levels of
gical studies conducted outside Brazil reveal that individuals older than
anxiety and depression. Being unemployed or on sick leave was also
65 years old are the ones more frequently affected by HF. In the United
associated with higher levels of stress (Table 2).
States and Europe, this condition accounts for 80% of deaths among
Patients with HF FC II had higher levels of stress, anxiety and de-
individuals older than 65 years of age (Bui, Horwich, & Fonarow,
pression. Patients with obesity class III, former alcoholics and former
2011).
smokers had higher levels of stress. Chagas disease was correlated with
Low scores concerning stress, anxiety and depression were found
higher levels of anxiety and depression (Table 3). We found, after
among outpatients, while high levels of these variables were reported
multiple comparisons (non-parametric Tukey test) performed with
by studies addressing inpatients with HF(Gorayeb, Facchini, &
variables with more than three categories, lower levels of stress and
Schimidt, 2012; Polikandrioti et al., 2015). It is believed that the clin-
anxiety among those living in their own homes compared to individuals
ical compensation of outpatients (Functional classes I and II) may have
living in a rented home (p = 0.028 and p = 0.027, respectively). In-
influenced their responses to the questionnaires, which assessings of
dividuals with BMI obesity class III had higher levels of stress than
anxiety and depression in the last week and stress in the last month. In
underweight individuals (p = 0.022).
fact, as corroborated by these results, the literature shows that stress,

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M.A. Cirelli et al. Archives of Psychiatric Nursing 32 (2018) 235–241

Table 2
Significant associations among sociodemographic variables and levels of stress, anxiety and depression among outpatients with heart failure. São Paulo, Brazil. 2014–2015.

Variables Depression (mean) p-Value Anxiety (mean) p-Value Stress (mean) p-Value
Depression Anxiety Stress

Gender
Female (n = 117) 11.85 0.324 10.73 0.002 17.53 0,012
Male (n = 192) 10.28 7.26 15.29
Ethnicity
Caucasian (n = 165) 10.91 < 0.0001 9.08 < 0.0001 16.05 < 0,0001
Afro-descendant (n = 60) 11.03 8.45 16.55
Mixed race (n = 72) 10.97 8.17 16.24
Other (n = 11) 8.55 4.91 14.27
Occupation
Retired 10.47 7.42 15.01
Autonomous/micro entrepreneur/trader/ 7.95 5.89 15.26
Entrepreneur/unemployed/ 13.91 0.046 12 0.002 17.7 0,129
On sick leave/employed 10.12 8.1 16.27
Religion
Catholic (n = 174) 10.33 8.32 15.74
Spiritist (n = 15) 9.87 < 0.0001 9.73 < 0.0001 15.60 < 0,0001
Evangelical (n = 73) 11.79 8.88 17.18
Other (n = 46) 11.5 8.13 15.93
Type of housing
Owned (n = 213) 9.74 7.69 15.53
Borrowed/CDHU (n = 30) 14.67 < 0.0001 11.80 0.024 16.00 0,035
Rented (n = 66) 12.8 9.97 18.15
Family income
< 1 MW (n = 35) 13.80 9.54 18.60
1 to 3 MW (n = 174) 11.58 9.29 16.95
3 to 5 MW (n = 60) 7.98 0.007 6.77 0.013 13.12 < 0,0001
5 to 7 MW (n = 23) 10.7 8.52 16.43
7 to 9 MW (n = 11) 6.82 5.09 11.45
> 9 MW (n = 6) 10.33 6.83 15.83

CDHU: Housing and Urban Development Company, MW: minimum wage.

anxiety and depression symptoms among individuals with HF may vary
according to functional class (Suzuki et al., 2014; Soares, Toledo,
Santos, Lima, & Galdeano, 2008; Saldaña, Amaya, Rodriguez, &
Bolaños, 2011).
The correlations existing among stress, anxiety and depression
among patients with HF is strengthened by activation of the same
physical-pathological mechanism. Both HF and psychological aspects
activate the neural-hormonal axis (Graeff, 2007; Merz, Elboudwarej, &
Mehta, 2015; Nasser et al., 2016). A recent study seeking to clarify the
nature of the relationships among negative mood states using a model
with healthy twins verified that stress had a causal relationship with
both depression and anxiety, while depression had a causal relationship

Table 3
Significant associations between clinical variables and levels of stress, anxiety and depression among outpatients with heart failure (n = 309). São Paulo, Brazil. 2014–2015.

Variables Depression (mean) p-Value Anxiety (mean) p-value Stress (mean) p-value
Depression Anxiety Stress

Functional class
I (n = 173) 9.47 < 0.00010 6.9 < 0.0001 15.28 0.027
II (n = 136) 12.67 10.71 17.25
Former alcoholic
Yes (n = 53) 9.34 0.132 7.11 0.095 14.26 0.034
No (n = 275) 11.19 8.88 16.52
Chagas disease
Yes (n = 45) 13.91 0.010 11.76 0.002 17.20 0.330
No (n = 264) 10.36 8.03 15.95
Cardiomyopathies
Ischemic (n = 86) 10.52 7.80 16.37
Hypertrophic (n = 69) 8.91 7.06 14.90
Chagasic (n = 45) 13.82 11.98 17.62
Dilated (n = 42) 9.40 8.33 15.33
Alcoholic (n = 21) 11.86 0.021 6.95 0.036 16.38 0.075
Peripartum (n = 14) 16.64 14.00 20.86
Other (n = 24) 10.12 8.17 14.12
Undefined (n = 4) 8.50 4.50 19.75
Not reported (n = 4) 16.00 11.50 14.75
Body mass index 0.167 0.648 0.041
Low weight (n = 4) 3.25 3.50 8.50
Normal (n = 106) 11.92 8.71 16.08
Overweight (n = 113) 10.24 8.12 16.26
Obese class I (n = 61) 10.36 8.84 16.00
Obese class II (n = 19) 10.68 9.74 15.53
Obese class III (n = 6) 15.33 11.67 23.33

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Table 4 decompensated HF or refractory arrhythmia among individuals hospi-

Linear regression for the stress levels of outpatients with heart failure (n = 309). São talized due to HF, regardless of age, sex, FC, natriuretic peptide levels,
Paulo, SP, Brazil. 2014 and 2015.
implantable devices, kidney disorders, or left ventricular dysfunction
Estimate SE Confidence interval p-Value (Suzuki et al., 2014).
95% Smoking is related to different negative mental health outcomes,
while smoking cessation is associated with improved mental health
Lower Upper (Skov-Ettrup, Nordestgaard, Petersen, & Tolstrup, 2017). In this study,
limit limit
being a former smoker was associated with decreased levels of stress
Intercept 11.59 0.24 11.12 12.06 < 0.0001 and anxiety. Considering the potential causal relationships between
Time since diagnosis 2.40 0.17 2.08 2.73 0.0336 these factors found in the literature, a systematic review reports that
2–5 years smoking is associated with depression and subsequent anxiety. A
Time since 0.93 0.15 0.63 1.23 0.3724
smoking control study conducted with smokers with heart disease re-
diagnosis > 5 years
Functional class II 1.66 0.12 1.43 1.89 0.0393 veals that, when these individuals attempt to quit smoking, they may
Former smoker − 1.72 0.12 −1.95 − 1.49 0.0322 also experience significant emotional symptoms. Thus, behavioral
Family income of up 3 times 2.60 0.14 2.34 2.87 0.0051 modifications affect treatment and psychological support is necessary to
the MW
help these patients control anxiety and stress during smoking cessation
Family income from 3 to 7 − 0.96 0.27 −1.49 − 0.43 0.5988
times the MW (Costa et al., 2006).
Therefore, interventions intended to promote the cessation of
MW: minimum wage; SE: standard error; RR: relative risk. smoking can positively impact depression and anxiety levels but not
necessarily influence levels of stress. Likewise, interventions intended
Table 5 to decrease anxiety and depression levels can contribute to smoking
Negative binomial regression, considering the levels of anxiety among outpatients with cessation.
heart failure (n = 309). São Paulo, SP, Brazil. 2014 and 2015. Studies have sought to establish a relationship between depression
Estimate SE RR Confidence p
and Chagas disease through psycho-immunological phenomena. Both
interval 95% depression and Chagas disease are characterized by the activation of the
immunological system with changes in inflammatory markers.
Lower Upper Depression is accompanied by the activation of a cascade of in-
limit limit
flammatory responses that play an important role in its physio-
Intercept 1.32 0.21 3.74 2.47 5.67 < 0.0001 pathology. Chagas disease, in turn, is characterized by inflammatory
HF functional class 0.44 0.12 1.55 1.23 1.95 0.0002 foci in myocardial tissues and neurocognitive alterations. These chronic
Chagas disease 0.37 0.16 1.44 1.06 1.98 0.0215 stressors suggest a relationship between cardiac disease and depression
Former smoker −0.25 0.11 0.78 0.62 0.97 0.0263
(Ritz, Alberte, Almeida, & Guarieto, 2008; Silva, Lima, Costa, & Gomes,
Autonomous/micro- 0.03 0.26 1.03 0.61 1.72 0.9192
entrepreneur/ 2015). Additionally, Chagas disease is incurable and linked to poverty,
trader/ so that those with the disease may suffer stigmatization and margin-
businessperson alization, as the population usually has poor knowledge of the disease
Unemployed/sick leave 0.47 0.16 1.60 1.17 2.20 0.0034 (Magnani, Oliveira, & Gontijo, 2007; Ritz et al., 2008).
Employed 0.22 0.14 1.24 0.95 1.63 0.1092
Despite the progressive nature of HF and associated conditions such
HF: heart failure; SE: standard error; RR: relative risk. as fatigue, sleep disorders, and worse quality of life and resulting
emotional disorders (Fini & da Cruz, 2009; Soares et al., 2008), in this
Table 6
study, more recent diagnoses were related to higher levels of stress. The
Negative binomial regression considering the levels of depression among outpatients with literature, however, did not show any relationship between time since
heart failure (n = 309). São Paulo, SP, Brazil. 2014 and 2015. diagnosis and psychological changes. Thus, we believe that the
knowledge and skills acquired over time enabled individuals to acquire
Estimates SE RR Confidence interval p-Value
competent coping strategies to deal with stress.
95%
The literature shows that people in poor socioeconomic conditions,
Lower Upper having low income, facing poverty and unemployment are subject to a
limit limit longer duration of mental disorders and events that generate stress
(Coutinho, Matijasevich, Scazufca, & Menezes, 2014; Gomes, Miguel, &
Intercept 2.10 0.19 8.17 5.61 11.91 < 0.0001
HF functional class 0.25 0.10 1.29 1.06 1.57 0.0113 Miasso, 2013). Financial hardship can lead to stress, as it impedes ac-
Chagas disease 0.35 0.14 1.41 1.08 1.85 0.0117 cess to health resources (Tucker-Seeley, Harley, Stoddard, & Sorensen,
Housing: 0.17 0.19 1.19 0.82 1.71 0.3562 2013). In regard to the individuals' purchasing power, low income
borrowed/ hinders one's access to medication and appropriate foods (Kind et al.,
CDHU
homeowner − 0.25 0.12 0.78 0.61 0.99 0.0389
2014; Pelegrino et al., 2011a, 2011b) and increases the risk of hospi-
talization. Thus, levels of stress, anxiety and depression can increase
HF: heart failure; SE: standard error; RR: relative risk, CDHU: Housing and Urban due to financial concerns, as well as concerns related to housing. A
Development Company. previous study reports that housing conditions (classified either as poor,
moderate or good) and urban agglomeration are positively correlated
with anxiety (Davey et al., 2016). Depressive symptoms found among with common mental disorders (Ludemir & Filho, 2002). Also, the
556 American outpatients with HF functional class III/IV were in- prevalence of common mental disorders increases as the number of
dependent predictors of anxiety (Dekker et al., 2014). items one has at home decreases (Coutinho et al., 2014).
Thus, it is believed that interventions intended to decrease stress can Such data coincide with this study's results and those reported in the
also be effective in decreasing depression and anxiety (Davey et al., literature; that is, insufficient income leads to stress and other disorders
2016), while interventions intended to decrease depression can influ- such as anxiety, depression and a sense of insecurity (Rocha, Almeida,
ence anxiety levels (Dekker et al., 2014). Additionally, they can impact Araújo, & Júnior, 2010). These findings are corroborated by the Bra-
other important clinical outcomes: associated depression and anxiety zilian literature reporting that being on sick leave (Tucker-Seeley et al.,
are independent predictors of death and readmission due to 2013) or unemployed (Rocha et al., 2010) is positively related to

239
M.A. Cirelli et al.
common mental disorders. Another study presents a positive relation-
ship when it compares unemployed individuals, regardless of profession
(Gomes et al., 2013). Self-rated health is better among employed in-
dividuals than among unemployed ones (Kind et al., 2014).
Having a job or not is closely linked to the findings presented so far
and a positive relationship was identified in this study between being
unemployed or on sick leave and levels of anxiety and depression. The
fact an individual has income accruing from work and that a relation-
ship is established with society when one has a job contributes to de-
creased levels of anxiety. This relationship, however, can be inverted;
i.e., a lack of satisfaction at work may be associated with higher levels
of stress and anxiety. The job market and organizational pressures may
lead to psychological distress, due to competitiveness or personal and
work relationships, contributing to anxiety (OMS, 2010).
The results of this study should be considered in light of the fol-
lowing limitations: due to its cross-sectional nature, this study does not
allow for the establishment of causal relationships among variables;
because the setting where data were collected is common with other
patients, the presence of other patients may have interfered in the
participants' level of concentration; and the fact data were collected in a
single center also compromises the generalization of data.
Conclusion
Levels of anxiety, stress, and depression among outpatients with HF
are low, correlate to each other and are associated with both socio-
demographic and clinical variables. These characteristics should be
taken into account when planning educational interventions for these
patients.
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