Prevalence of Depression, Anxiety and Stress and Their Associated Factors among Cardiac Patients in Jazan, Saudi Arabia

Mohammed Ali Madkhali¹, Atheer Y. Hakami², Mohammad A. Jareebi³, Alhassan H. Hobani⁴, Halimah A. Sumayli⁵, Khawlah A. Abbas⁶, Hanadi F. Abueishah⁷, Ghalia H. Hakami⁸, Amal J. Alfaifi⁹, Khalid Y. Haroobi¹⁰, Bayan H. Hakami¹¹, Weaam A. Najmi¹², Yasser A. Sultan¹³ and Luai Alhazmi¹⁴

¹Department of Internal Medicine, Division of Hematology and Oncology, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia

²Department of Medical Rehabilitation, Jazan Health Cluster, Ministry of Health, Jazan, Saudi Arabia

^3-7,10-14Faculty of Medicine, Jazan University, Jazan, Saudi Arabia

⁸Department of Intensive Care Unit, Jazan General Hospital, Ministry of Health, Jazan, Saudi Arabia

⁹Department of Family Medicine, Jazan Health Cluster, Ministry of Health, Jazan, Saudi Arabia

Objectives: Cardiovascular diseases pose life-threatening health conditions. The presence of depression and anxiety has been associated with increased rates of hospitalization and elevated mortality risks. This study aims to assess the prevalence of depression, anxiety and stress, along with their determinants, among cardiac patients in the Jazan region, Saudi Arabia. Methods: A cross-sectional study was conducted among all individuals seeking care at Prince Mohammed Bin Nasir Hospital, Jazan, from July 2023 to June 2024. The questionnaire, adapted from the literature, comprised sections addressing sociodemographic particulars, health-related information and the standardized Depression, Anxiety and Stress Scale-21 (DASS-21). SPSS v 26 was used for data analysis. Results: A total of 327 patients participated in our study, revealing a prevalence of 47%, 73% and 50% for depression, anxiety and stress, respectively. Stressful life events (95% CI for depression: 1.0 to 6.7; 95% CI for anxiety: 0.68 to 6.6; 95% CI for stress: 4.3 to 11) and the presence of chronic diseases were significantly associated with higher risks of depression, anxiety and stress. Female gender (95% CI: -8.2 to -0.20, p value: 0.04) and smoking (95% CI: 0.91 to 7.1, p value: 0.011) were predictors of higher anxiety, while a sedentary lifestyle (95% CI: 0.09 to 5.5, P value: 0.043) was associated with an increased risk of depression. Social support was linked to a greater risk of stress (95% CI: 2.8 to 11, P value: 0.001). Effective control over heart diseases was associated with lower risks of depression, anxiety and stress. Conclusion: Our findings underscore an alarming prevalence of depression, anxiety and stress among cardiovascular disease patients, with key predictors identified as stress, lifestyle, the presence of chronic diseases and social support. Thus, attention should be directed towards interventions that may enhance mental health in cardiac patients, ultimately improving their quality of life.

Key Words Cardiovascular diseases, depression, anxiety, stress, prevalence, jazan region, saudi arabia, mental health

Cardiovascular diseases stand as a prevalent and life-threatening chronic ailment, consistently maintaining their position as the leading global cause of mortality [1]. Notably, ischemic heart disease accounts for 15.9% of total global deaths [2], with recent WHO data reporting a staggering 17.7 million deaths attributed to cardiovascular diseases [3]. This category encompasses a broad spectrum of vascular, structural and valvular cardiac anomalies, spanning from acute coronary syndrome to chronic hypertension, chronic and valvular insufficiency and congenital disorders [4,5].

The realm of mental health within cardiac patients reveals noteworthy figures, with global prevalence rates of 31.3% for depression, 32.9% for anxiety and 57.7% for stress [6]. An Iranian study disclosed proportions of 38.6% for anxiety, 41% for stress and 38.6% for depression symptoms [7], while Jordanian research indicated a depression prevalence of 45.1% [8]. Depression, a prominent psychiatric disorder among heart patients, is characterized by feelings of sadness, loss of interest in pleasurable activities, social withdrawal, questioning the meaning of life, reduced interest in intimacy, lowered tolerance threshold and suicidal ideation [9].

Significantly, depression substantially affects cardiovascular patients' behavioral and psychological capacities to engage in health-enhancing behaviors mitigating cardiac risks, including exercise, adherence to a diet and medication compliance [10,11]. Moreover, these patients tend to partake in activities exacerbating their cardiac condition, such as smoking, alcohol misuse, social isolation and suboptimal response to cardiac rehabilitation [12].

Simultaneously, anxiety can manifest as a response to cardiac discomfort, resulting in symptoms like heart palpitations, high blood pressure, muscle tension, sweating, a flushed face, a sense of impending danger, difficulty focusing and disruptions in sleep [13,14]. Repeated hospitalizations amplify patient stress, collectively impacting their quality of life [15]. Both depression and, to a lesser extent, anxiety correlate with adverse clinical outcomes in heart disease patients, leading to increased hospitalization rates and heightened mortality [16-18]. affecting cardiac rehabilitation crucial to improving patient outcomes [19]. Therefore, the objective of our study was to assess the prevalence of depression, anxiety and stress, alongside their associated determinants, among cardiac patients within the Jazan region of Saudi Arabia.

Study Design and Settings

A cross-sectional study was conducted in the cardiac outpatient department (OPD) of Prince Mohammed bin Nasir Hospital (PMBN) in the Jazan region of Saudi Arabia. In the first half of 2022, the Heart Center at PMBN performed over 1,400 catheterization and cardiac procedures, including diagnostic catheterizations, electrical cardiac interventions and open-heart surgeries. The centre also provided training to senior cardiology fellows. Furthermore, 6,819 patients were admitted to the emergency department and 1,241 patients were admitted to the adult cardiac department to treat various heart conditions [20]. For our study, we enrolled patients aged 18 and above who visited the cardiac outpatient department at PMBN on specific outpatient days from September 2022 to April 2023. Exclusions were made for patients with cognitive impairment, those on medications that could affect results and those unable to participate in surveys.

Sample Size and Data Collection Tools

The sample size was calculated using the statistical equation: initial sample size = [(z²×p×q)]/d². To align with the study's objectives and scientific literature, an interview-based structured questionnaire with closed-ended items was developed. Consultant cardiologists, an internist and a family medicine specialist conducted a comprehensive review of the questionnaire's face and content validity. Following necessary revisions, expert approval and translation into Arabic, the mentioned specialists further reviewed the questionnaire. A total of 327 participants were included.

A pilot study was conducted with 20 randomly selected patients and feedback from this pilot study was carefully analyzed, leading to iterative modifications to enhance the questionnaire's clarity, pertinence and efficacy.

The questionnaire comprised three sections. The first part contained socio-demographic attributes, including variables such as age, gender, marital status, educational attainment, nationality, employment status and monthly income level. The second section covered health-related particulars, encompassing aspects such as sedentary lifestyle, parenthood, living alone, familial support, stressful life events, heart disease management, duration of heart disease, familiarity with health applications and their accessibility, tobacco and alcohol consumption habits, presence of chronic diseases and their numbers.

The final section introduced the Depression, Anxiety and Stress Scale-21 (DASS-21), originally developed by Lovibond and Lovibond [21]. The DASS-21 is a self-administered evaluative tool featuring three distinct subscales, each assessed on a four-point Likert scale (ranging from 0, "Strongly Disagree," to 3, "Totally Agree"). Each of the three subscales within the DASS-21 comprises seven items, collectively assessing emotional states related to depression, anxiety and stress.

The Arabic version of the DASS-21 [22] was employed, demonstrating commendable reliability coefficients of 0.76 for depression, 0.75 for anxiety and 0.77 for stress. In the context of this study, the internal consistency reliability of the depression subscale was 0.85, 0.81 for anxiety and 0.87 for stress.

Ethical Approval

Approval was secured from the ethical committee of Jazan University (Reference No. 2288), following the principles outlined in the 1964 Helsinki Declaration and its subsequent amendments. Informed consent was obtained from all participants, ensuring the confidentiality of their information, which is strictly maintained for scientific purposes.

Statistical Analysis

Data were extracted into an Excel sheet, thoroughly cleaned and subsequently imported into R software version 4.2.2. Descriptive statistics, including medians and interquartile ranges for continuous variables, along with frequencies and percentages for categorical variables, were employed. The chi-square test and Fisher's exact test were utilized to identify variables associated with depression, anxiety and stress. Patients without heart conditions were excluded from the analysis. Furthermore, a multiple linear regression analysis was conducted to assess predictors of depression, anxiety and stress. Variables that exhibited a statistically significant relationship at the bivariate analysis level were included in the multiple analysis. A p-value less than 0.05 was deemed significant in all analyses.

Participant Information

A total of 327 individuals participated in the study. Among them, the majority 147(45%) were aged 60 years and above. Most participants were male 223(68.2%), married 255(78%) and of Saudi nationality 298(91.1%). Approximately 124(37.9%) of the participants were both illiterate and unemployed. Moreover, 181(55.4%) reported an income level of less than 5000 SAR. The study revealed significant associations; specifically, depression was associated with nationality (p-value: 0.011), while anxiety showed associations with gender (p-value: 0.027), level of education (p-value: 0.010), employment (p-value: 0.020) and heart disease (p-value: 0.020). Stress did not exhibit associations with any sociodemographic predictors (Table 1).

Table 1: Sociodemographic characteristics of the study participants (n = 327)

Health-Rrelated Information

The majority of participants reported having children (87%), leading stressful lives (70%), maintaining sedentary lifestyles (59%), receiving family support (86%) and having heart disease (91%). The majority also indicated not living alone (82%). Most participants stated having cardiovascular disease for less than 3 years (45%), with a significant portion maintaining good control (81%). A substantial 75% of patients claimed awareness of health applications, with only 15% having never heard of them. Approximately 42% were aware but had never used them; however, 61% had access. Seventy-six percent of patients reported having a chronic disease, with the majority (37%) having only two diseases. Hypertension (57%), diabetes mellitus (48%) and arthritis (45%) were the most prevalent chronic conditions. Notably, only 31% of participants reported smoking, while 99% did not consume alcohol. Table 2

Table 2: Health-related data of the study participants (n = 327)

Prevalence of Depression, Anxiety and Stress

Depression was categorized as "moderate," "severe," or "extremely severe" among heart disease patients for 47% of participants, while anxiety and stress were reported in 73% and 50% of cases, respectively. The mean depression score among heart disease patients was 6.8±5.5, with the anxiety and stress mean scores being 8.6±5.5 and 9.5±6.1, respectively. The total DASS score was 24.4±15.5 (Table 3).

Table 3: DASS level among the heart disease patients

Predictors of Depression, Anxiety and Stress

Concerning depression, individuals experiencing a stressful life had a significantly higher risk, with a 3.9-fold increase (95% CI: 1.0 to 6.7, p-value: 0.008). Moreover, those leading a sedentary lifestyle showed a 2.8 times higher risk (95% CI: 0.09 to 5.5, p-value: 0.043) of developing depression. Additionally, patients with chronic diseases had a 4.9 times higher risk (95% CI: 0.70 to 9.0, p-value: 0.022) of experiencing depression.

Regarding anxiety, males exhibited a 4.2-fold lower risk than females (95% CI: -8.2 to -0.20, p-value: 0.04). Conversely, being a smoker was linked to a 4-fold higher risk (95% CI: 0.91 to 7.1, p-value: 0.011) of anxiety compared to nonsmokers. Furthermore, individuals facing stressful life situations were 3.6 times more likely (95% CI: 0.68 to 6.6, p-value: 0.016) to suffer from anxiety, while those with chronic diseases had a 4.5 times higher risk (95% CI: 0.11 to 8.9, p-value: 0.045) of developing anxiety.

Concerning stress, individuals facing stressful life situations exhibited a 7.6-fold higher risk (95% CI: 4.3 to 11, p-value: <0.001). Interestingly, having family support was associated with a 7.2 times higher risk (95% CI: 2.8 to 11, p-value: 0.001) compared to patients without support. Additionally, individuals with chronic diseases showed a 5.2 times higher risk (95% CI: 0.47 to 10, p-value: 0.032) of experiencing stress.

Among patients with heart disease, those who effectively controlled their condition had significantly lower risks of depression, anxiety and stress. Specifically, they had a 6.7 times lower risk for stress, a 5.9 times lower risk for depression and a 3.8 times lower risk for anxiety than those with poorly controlled heart disease (Table 4).

Table 4: Risk factors for depression, anxiety and stress among cardiac patients in Jazan (N = 297)

Heart disease patients are susceptible to psychological distress. Therefore, we aimed to estimate the prevalence of anxiety, depression and stress among cardiovascular disease patients attending the Heart Center at Prince Mohammed bin Nasser Hospital and identify potential predictors.

Our findings revealed associations between gender, educational level, employment and heart disease with anxiety, consistent with well-established predictors proven by prior research [22,23]. Intriguingly, depression was associated with nationality, with Saudi patients exhibiting a higher association than non-Saudi patients, potentially attributed to cultural influences impacting mental health discussions and help-seeking behavior. Further investigation is needed to unravel the underlying factors, including awareness of depressive symptoms and treatment-seeking behavior.

The prevalence of anxiety (73%), depression (47%) and stress (50%) among cardiovascular Saudi patients in this study appears notably higher than the global prevalence among cardiac patients [6], where anxiety was 32.9%, depression was 31.3% and stress was 57.7%. It surpasses rates in other Middle Eastern countries, as demonstrated by an Iranian study reporting 38.6% for anxiety, 41% for stress and 38.6% for depression symptoms [7] and a Jordanian study indicating a depression prevalence of 45.1% [8]. This higher prevalence may be linked to social stigma, interpersonal dilemmas and limited accessibility to mental health services and information, as reported in a qualitative study [24].

Depression's association with a sedentary lifestyle aligns with prior research [25,26]. Numerous studies emphasize the positive impact of regular exercise in reducing depression risk and enhancing overall well-being [27]. Implementing educational programs and promoting physical activity may enhance outcomes and reduce depression risk among heart disease patients.

Our study identified an increased risk of depression, anxiety and stress among individuals with chronic diseases, consistent with the literature [28]. Chronic diseases impact mental health through physiological mechanisms, lifestyle limitations and psychological distress related to managing the condition [29,30]. Holistic chronic disease management should integrate mental health assessments and interventions. The study reaffirms the established link between stress and mental health conditions [31,32]. Psycho-social vulnerabilities were identified as better predictors of depression in cardiac patients than demographic and disease-related variables [33]. Considering the personal life experiences of cardiac patients when treating depression and incorporating stress management techniques, such as mindfulness and relaxation, is crucial [34].

The finding that males exhibited a lower risk of anxiety compared to females aligns with literature suggesting gender differences in anxiety disorder prevalence [22,23]. While the reasons for this discrepancy are complex, hormonal and genetic factors may contribute to varying vulnerability between genders [35].

Our findings also established a connection between smoking and anxiety, consistent with previous research [36]. Nicotine and other components of tobacco smoke are implicated in influencing brain neurotransmitter systems, contributing to anxiety and related mood disorders [37]. Consequently, smoking cessation programs are imperative to mitigate heightened anxiety risk [38].

Effective cardiovascular disease management can positively influence mental health outcomes, recognizing the bidirectional relationship between cardiovascular health and mental well-being [39]. The biological linkage of depression to cardiovascular disease through inflammation underscores the potential for treating cardiovascular diseases to alleviate the severity of depression symptoms [40], though further investigations are needed for confirmation.

Interestingly, our study indicated a counterintuitive association between family support and heightened stress risk, contrasting some literature that underscores the protective role of social support against stress [41]. The social support-stress relationship is influenced by individual factors, relationship quality and cultural context, warranting careful consideration. Notably, a study suggests that culturally inappropriate forms of social support might inadvertently exacerbate stress [42].

One of the key limitations of our study is the cross-sectional design, which inherently restricts the ability to establish causal relationships between variables. While our study provides valuable associations, we cannot infer causality and this limits the conclusions we can draw about the temporal sequence of events or effects.

The study revealed an alarming prevalence of depression, anxiety and stress among cardiovascular disease patients in the Jazan region of Saudi Arabia. It emphasizes the crucial need to consider multiple factors, including stress, lifestyle, chronic diseases and social support, to comprehend and enhance these individuals' mental health and well-being. Given the complex interplay between mental and physical health, clinicians should adopt a multifactorial approach, taking into account factors such as stress, lifestyle, chronic diseases and social support when evaluating mental well-being

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