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Quality of Life, Depressed Mood, and Self-Esteem in Adolescents With

Heart Disease
MIRI COHEN, PHD, DANIELA MANSOOR, PHD, HAYA LANGUT, RN, BA, AND AVRAHAM LORBER, MD
Objective: To assess health-related quality of life (HRQoL), depressed mood, and self-esteem in adolescents with heart disease and
compare them with age-matched healthy adolescents (control group). Methods: Ninety adolescents (aged 12 to 18 years with
congenital or acquired heart disease) and 87 controls completed the HRQoL (TAAQOL-CHD), Center for Epidemiologic Studies
Depression scale, and Rosenberg self-esteem questionnaires. Relevant medical details were collected. The patients and their parents
were asked to rate their perceived severity of heart disease. Results: Adolescents with severe heart disease reported higher levels
of depressed mood and lower self-esteem than did adolescents with moderate and mild heart disease and age-matched healthy
controls. Adolescents with severe heart disease also reported worse HRQoL than those with moderate and mild disease. According
to the multiple regression analysis, 44% of variance of HRQoL was explained by the study variables. Disease severity alone
explained 11% of the variance, but when entered with the other study variables, depressed mood, self-esteem, and adolescents’
perceived severity of disease were the only significant contributors to the explained variance of HRQoL. An exploratory mediation
analysis, using the Sobel test, was therefore applied, and it showed that depressed mood and perceived disease severity, but not
self-esteem, mediated the relationship between disease severity and HRQoL. Conclusions: Lower HRQoL was found in
adolescents with severe heart disease. Psychosocial factors have a significant effect on the psychological state of adolescents, and
they should be addressed and treated. Key words: adolescents, health-related quality of life, heart disease, depressed mood,
self-esteem, perceived disease severity.

HRQoL ⫽ health-related quality of life. HRQoL focuses on functional limitations and their emo-
tional impact (12). Most studies reported that adolescents with
INTRODUCTION heart disease have a reduced HRQoL compared with healthy
adolescents (3,13) even after surgical correction for congenital
A dvanced diagnostic and therapeutic measures for congen-
ital and acquired heart disease have led to a larger pro-
portion of patients who reach adolescence and adulthood (1).
heart disease (14). On the other hand, Fekkes et al. (12) found
similar and even better HRQoL reported by adolescents and
Patients, with structural congenital cardiac anomalies and adults with minor congenital heart disease than that of healthy
those with acquired heart dysfunction, vary in severity and are controls. Other studies found that the HRQoL of adolescents
often categorized into mild, moderate, and severe states. These with heart disease was not related to the severity of disease
three categories of disease severity may have been a result of (3). Participation in sports, which is an aspect of HRQoL, was
surgical interventions or conservative therapy (2). found to be related to higher self-esteem (15,16) but not to the
Living with heart disease has many psychosocial conse- severity of disease (15).
quences for adolescents (3). Previous studies reported higher Personal characteristics, such as self-esteem, and similar
levels of psychological distress and behavioral problems constructs like self-concept and self-perception, are consid-
(4 –7) than those of healthy adolescents. Other studies reported ered a personal resource that facilitates positive perceptions of
lower levels of psychological distress, or no difference com- stressful life situations (17) and reduced psychological distress
pared with control groups (8,9). (18 –21). Studies found lower self-esteem or self-concept in
These contrasting reports raise the question of what factors patients with heart disease (10,22,23), although an improve-
are related to higher psychological distress and worse psycho- ment in self-esteem was reported in children and adolescents
social adjustment in adolescents with heart disease. Possible after heart surgery (24).
related factors may be cardiac status, health-related quality of Cognitive perceptions of personal situations and the mean-
life (HRQoL), and personal factors such as self-esteem or ing ascribed to them are subjective and differ among individ-
cognitive perceptions of disease severity. uals (17,25). The more negative or severe the perceptions are,
Several studies found that increased severity of cardiac the higher the psychological distress found in individuals with
problems was associated with either higher psychological various diseases (17,26,27) and in adolescents and adults with
distress and behavioral problems (6,7,10,11) or no association heart disease (28). Rietveld and colleagues (28) reported that
between severity of disease and psychological or behavioral negative perceptions, but not severity of disease, were asso-
parameters (4). ciated with higher distress and worse psychological adjust-
ment.
Another factor that affect coping with illness is ethnicity,
From the Social Work Department (M.C., D.M.), Rambam-Health Care
Campus, Haifa, Israel; Pediatric Cardiology (H.L., A.L.), Meyer Children’s although it was not previously assessed in relationship to
Hospital, Rambam-Health Care Campus, Haifa, Israel; School of Social Work adolescents with heart disease. Previous studies suggested that
(M.C.), Faculty of Social Welfare and Health Studies, Haifa University, the more conservative Arab society tends to perceive illness
Israel; Bruce Rappaport Faculty of Medicine (A.L.), Technion, Haifa, Israel.
Address correspondence and reprint requests to Avraham Lorber, Pediatric and disability as God’s will (29 –31), which may promote
Cardiology, Meyer Children’s Hospital, Rambam-Health Care Campus, acceptance and adjustment but may also increase passivity and
Haifa, Israel. E-mail: a_lorber@rambam.health.gov.il impede active coping.
Received for publication March 20, 2006; revision received January 16,
2007. Studies on adolescents with heart disease are sparse, and
DOI: 10.1097/PSY.0b013e318051542c often assess adolescents and adults together (28) or adoles-

Psychosomatic Medicine 69:313–318 (2007) 313


0033-3174/07/6904-0313
Copyright © 2007 by the American Psychosomatic Society
M. COHEN et al.

cents with young children (3). The goals of this study were a) in comparison with their peers. The adolescents were asked to rate whether
to assess the level of HRQoL, depressed mood, and self- they engage in each activity more than their peers (⫽1), the same (⫽2), or less
(⫽3). They were asked to rate their school achievements in the same way.
esteem in adolescents with different levels of disease severity
(severe, mild, low) and in comparison with age-matched con-
trols; b) to identify relationships of cardiac and demographic Statistical Methods
variables, depressed mood, perceptions of disease severity, Descriptive statistics were used to examine the characteristics of the
and self-esteem, with HRQoL of adolescents with heart dis- sample. ␹2 analysis was used to assess differences in nominal variables.
Analysis of variance was used to assess differences between the study group,
ease; and c) to assess if perceived severity of heart disease, according to severity, and the control groups, followed by post hoc Scheffé
depressed mood, and self-esteem may mediate the relationship test to identify differences between pairs of groups. Correlations between
between severity of disease and HRQoL. study variables were assessed by Pearson and Spearman analyses. Multivar-
iate regression analysis was used to assess the contribution of study variables
METHOD to explain variance of HRQoL of the study group. Independent variables were
entered by means of the enter method in the following order: age, gender,
Participants and Procedure
ethnicity, severity of disease, perceived severity, depression, and self-esteem. The
The participants were 90 adolescents— 45 Jews and 45 Arabs, aged 12 to independent variables were entered simultaneously without exclusion of variables
18 years with congenital or acquired heart disease—followed up in the from the model. The Sobel test (37) was used to assess possible mediation
Pediatric Cardiology Department at the Rambam-Health Care Campus, Haifa. between disease severity and quality and life by depressed mood, perceived
Participants were recruited among patients who visited the clinic between severity of disease, and self-esteem. For the regression and mediation analysis,
March 2004 and October 2005, based on sampling on 1 working day per n ⫽ 90 proved sufficient according to the formula suggested by Green (38), using
week. The clinic’s visitors were distributed randomly throughout the week. Cohen’s (39) calculations of sample size based on power analysis, for large effect
The sample consisted of 11.5% patients, aged 12 to 18 years, at the clinic but size (R2 ⱖ 0.26). Levels of significance are shown in the tables. A probability
they constituted 64% of adolescents visiting on the recruitment days (1 day level of 0.05 was accepted as significant. All statistics are two-tailed analysis.
per week). Eighteen adolescents refused to participate or were unable to
answer the questionnaires due to communication problems, six did not com-
plete the questionnaire, and another 26 were not approached by the inter- RESULTS
viewer because of time constraints. Demographic Characteristics of the Study
The adolescents and their parents gave informed consent. The adolescents and Control Groups
answered the questionnaires, their parents were asked to rate their perception
of disease severity, and relevant medical data were collected. The control The groups were similar in the distribution of gender, father’s
group consisted of 39 Jews and 48 Arab healthy adolescents. The control education and employment, and adolescents’ level of religiosity
group constituted a convenience sample; they were approached in their (Table 1). The groups were age-matched (15.00 ⫾ 0.25 (mean ⫾
schools; and they and their parents gave informed consent. The study was standard deviation) for adolescents with heart disease and
approved by the hospital’s Ethics Committee.
15.02 ⫾ 0.28 for healthy adolescents). There were no differences
Questionnaires in demographic characteristics between children with congenital
and acquired heart disease (p ⬎ .05, data not shown).
Demographic data included age, gender, religion, father’s education and
employment, and religiosity. HRQoL was measured in the study group only
by the Netherlands Organisation for Applied Scientific Research Academic
Medical Centre Adult Quality of Life-Congenital Heart Disease questionnaire TABLE 1. Demographic Characteristics of Adolescents With Heart
(TAAQOL-CHD) (32), a cardiac-specific module of the generic HRQoL Disease and Healthy Adolescents
instrument. It contains three subscales: complaints or limitations during the
previous month, worries during the previous month, and burden of the Study Control
medical examinations. Only the 9-item complaints or limitations subscale was n ⫽ 90 n ⫽ 87
used (e.g., shortness of breath after strolling, feeling dizzy, looking pale). The Variables ␹2 (df)
other two were not used because of the length of the questionnaire and n % n %
because these variables were not directly assessed in the present study. Each
item consists of two questions. First, the frequency of occurrence of each Gender
complaint or limitation during the last month is scored on a 3-point scale (1 ⫽ Male 58 64.4 52 59.8 0.41 (1)
never; 2 ⫽ occasionally; 3 ⫽ often). If such problem occurred, the degree it Female 32 35.6 35 40.2
bothers the respondents is assessed on a 4-point scale (from 1 ⫽ not at all to Father’s education
4 ⫽ very much). The two scores are multiplied, and the final scores range Elementary 19 21.1 21 24.1 4.78 (2)
from 1 to 12; the higher the score, the worse is the HRQoL. Convergent and High school 42 46.7 27 31.0
discriminant validity showed satisfactory coefficients (32). In the present Academic 29 32.2 39 44.8
study, the internal reliability (Cronbach’s ␣) was 0.82. Fathers employed
Self-esteem was assessed by the Rosenberg self-esteem scale (33), a Yes 88 98.9 84 96.6 1.07 (1)
10-item measure of positive and negative aspects of self-esteem. The items No 2 1.1 3 3.4
were rated on a 4-point response scale (0 ⫽ strongly disagree to 4 ⫽ strongly Ethnicity
agree). Internal reliability (Cronbach’s ␣) was 0.60. Jewish 45 50.0 39 44.8 0.48 (1)
Depressed mood was assessed by the Center for Epidemiologic Studies Arab 45 50.0 48 55.2
Depression scale (34). A short (10-item) version was used; its validity was Religiosity
confirmed in previous studies (35); and it was found suitable for adolescents Secular 38 42.2 42 48.3 1.53 (2)
(36). Answers ranged from 1 (not at all) to 5 (very much). Internal reliability Mildly religious 37 41.1 41 47.1
(Cronbach’s ␣) was 0.82. Very religious 15 16.7 4 4.6
Degree of engagement in sports activity, watching TV, and playing/
chatting on the computer, and perceived school achievements were assessed df ⫽ degrees of freedom.

314 Psychosomatic Medicine 69:313–318 (2007)


QoL IN ADOLESCENTS WITH HEART DISEASE

TABLE 2. Health-Related Characteristics of Adolescents With Heart Disease (by Severity)

Severe Moderate Mild


n ⫽ 21 n ⫽ 27 n ⫽ 42
Variables
n % n % n %

Diagnosis (n ⫹ %)
Cyanotic 7 33.3 9 33.3 3 7.2 ␹2 (2) ⫽ 30.39**
Acyanotic 10 55.6 15 55.6 35 83.3
Acquired 4 11.1 3 11.1 4 9.5
Surgical intervention (n ⫹ %) 16 74.1 20 74.1 24 57.1 ␹ (1) ⫽ 3.24
Has a pacemaker (n ⫹ %) 4 0.0 0 0.0 1 2.4 ␹2 (1) ⫽ 9.68*
Receives medications (n ⫹ %) 16 51.4 14 51.4 7 16.7 ␹2 (1) ⫽ 15.33**
Quality of life (M ⫹ SD) 3.43 1.19 2.11 1.19 1.59 0.74 F(2,88) ⫽ 12.41**
Perceived severity—adolescent’s life (M ⫹ SD) 2.35 0.82 1.81 0.82 1.21 0.58 F(2,88) ⫽ 16.46**
Perceived severity—parents’ life (M ⫹ SD) 2.70 0.82 2.09 0.82 1.49 0.61 F(2,88) ⫽ 22.30**

M ⫽ mean; SD ⫽ standard deviation.


* p ⬍ .01; ** p ⬍ .001.

Health-Related Characteristics of Adolescents With ␹2 (1) ⫽ 13.26; p ⬍ .001) and more of them received medi-
Heart Disease cations (90.9% versus 34.2%; ␹2 (1) ⫽ 12.84; p ⬍ .001).
Table 2 shows the distribution of disease-related variables However, adolescents with acquired and congenital heart dis-
in adolescents with heart disease. Seventy-nine of the 90 ease reported similar levels of HRQoL (p ⬎ .05).
adolescents had congenital heart disease, 19 were cyanotic,
and 60 were acyanotic. The acyanotic patients had predomi-
nantly moderate and mild disease. An additional 11 adoles- Psychosocial Characteristics of the Study
cents had acquired heart disease: rheumatic disease (n ⫽ 6), and Control Groups
Kawasaki disease (n ⫽ 1), post myocarditis dilated cardiomy-
Table 3 shows that the adolescents with severe disease
opathy (n ⫽ 1), and cardiac dysrhythmia (n ⫽ 3).
were significantly more depressed and reported lower self-
Sixty adolescents had had surgery. The post surgery time
esteem than adolescents with moderate and mild disease and
varied. Adolescents with severe heart disease reported the
worst HRQoL, and those with mild disease reported the best healthy adolescents, whereas no significant differences in
HRQoL (Table 2). The same differences between the three levels of depressed mood and self-esteem were found between
groups were found for perceived severity of the disease by the adolescents with moderate and mild disease and healthy ado-
adolescents and their parents. lescents. Adolescents with severe and moderate disease par-
Health-related characteristics of adolescents with acquired ticipated significantly less in sports than did adolescents with
and congenital heart disease were compared. There was no mild disease and healthy adolescents. Adolescents with mild
significant statistical difference between them in the percent- disease and healthy adolescents were similar in their partici-
age of adolescents with a pacemaker, but fewer adolescents pation in sports. Time spent watching TV, computer games, or
with acquired heart disease had undergone surgery (18.2% chatting was similar across groups, and no significant differ-
versus 73.4% of the adolescents with congenital disease; ences were evident in school achievements.

TABLE 3. Psychosocial Variables for Adolescents With Heart Disease (by Severity) and for Healthy Adolescents

Severe Moderate Mild Control


Variable n ⫽ 21 n ⫽ 27 n ⫽ 42 n ⫽ 87 F(3,170)
Mean ⫾ SD Mean ⫾ SD Mean ⫾ SD Mean ⫾ SD

Depressed mood 2.16 ⫾ 0.95 1.62 ⫾ 0.70 1.55 ⫾ 0.61 1.66 ⫾ 0.50 4.14*a
Self-esteem 3.00 ⫾ 0.59 3.29 ⫾ 0.39 3.41 ⫾ 0.35 3.46 ⫾ 0.37 7.72**a
Sports activities 1.10 ⫾ 0.31 1.47 ⫾ 0.57 2.00 ⫾ 0.82 2.21 ⫾ 0.79 17.79**b
TV watching 2.05 ⫾ 0.69 2.06 ⫾ 0.76 1.81 ⫾ 0.52 1.79 ⫾ 0.60 2.06
Computer games/chatting 1.70 ⫾ 0.73 2.03 ⫾ 0.70 1.89 ⫾ 0.66 2.07 ⫾ 0.67 1.88
School achievements 2.50 ⫾ 1.23 2.09 ⫾ 0.82 2.16 ⫾ 0.93 2.06 ⫾ 0.79 1.40

SD ⫽ standard deviation.
* p ⬍ .01; ** p ⬍ .001.
a
According to the Scheffé test, significant difference was found between adolescents with severe heart disease and the other groups.
b
According to the Scheffé test, significant difference was found between adolescents with severe and moderate heart disease and the adolescents with mild heart
disease and healthy adolescents.

Psychosomatic Medicine 69:313–318 (2007) 315


M. COHEN et al.

TABLE 4. Correlations Between Study Variables for Adolescents With Heart Disease

Variable 1 2 3 4 5 6 7 8 9 10

1. Age —
2. Gendera ⫺0.10 —
3. Ethnicitya 0.00 0.14 —
4. Severity ⫺0.12 0.15 0.16 —
5. Perceived severity— adolescents 0.15 ⫺0.15 0.02 0.41*** —
6. Perceived severity— parents 0.02 ⫺0.04 0.03 0.56*** 0.63*** —
7. Do sports ⫺0.15 0.09 ⫺0.23* ⫺0.46*** ⫺0.45*** ⫺0.45*** —
8. Quality of life 0.10 0.07 0.10 0.33** 0.50*** 0.31** ⫺0.34*** —
9. Self-esteem ⫺0.19 0.12 ⫺0.19 ⫺0.11 ⫺0.24* ⫺0.05 0.29** ⫺0.35*** —
10. Depressed mood 0.27* 0.16 0.15 0.32* 0.48*** 0.28** ⫺0.34** 0.47*** ⫺0.51*** —

* p ⬍ .05; ** p ⬍ .01; *** p ⬍ .001.


a
Spearman correlation.

Relationships Between Study Variables and ␤ for perceived severity was ⫺0.49 (t ⫽ ⫺5.04; p ⬍
Table 4 shows the correlation between the study variables. .0001). The Sobel test showed Z ⫽ 3.14 (p ⬍ .001). Accord-
Age, gender, and ethnicity were not significantly associated ingly, depressed mood and perceived disease severity were
with other study variables, except for sports activities, which factors mediating the effects of disease severity on HRQoL.
were significantly lower for the Arab adolescents. Severity of Self-esteem was also correlated with HRQoL (␤ ⫽ ⫺0.35; t ⫽
disease was significantly and positively associated with ado- ⫺3.50; p ⬍ .01) but was not significantly correlated with
lescents’ and parents’ perceptions of disease severity, and severity of disease (␤ ⫽ ⫺0.07; t ⫽ ⫺0.64; p ⬎ .05) and,
negatively associated with participation in sports. Also, higher hence, did not mediate the association between disease sever-
disease severity was associated with worse HRQoL, depressed ity and HRQoL.
mood, but not with self-esteem. Perceived severity by adoles-
cents and parents was associated with lower participation in DISCUSSION
sports, worse HRQoL, and higher depressed mood, but only Our results demonstrate lower HRQoL and self-esteem
adolescents’ perceived severity was associated with lower and heightened depressed mood among adolescents with
self-esteem. the more severe form of heart disease. Those with moderate
Multiple regression analysis was conducted to assess the and mild states of disease were no different in these aspects
contribution of demographic and health-related variables, de- from matched healthy adolescents. However, when control-
pressed mood, and self-esteem for the explained variance of ling for other study variables, severity of disease was not
HRQoL of adolescents with heart disease. According to the related to HRQoL of the adolescents but to depressed
regression model, 44% of the variance of HRQoL was ex- mood, self-esteem, and their own perception of disease
plained by the study variables (adjusted R2 ⫽ 0.39; F(7,81) ⫽ severity. In addition, perceived disease severity and de-
9.72; p ⬍ .001). Perceived severity of the disease, higher pressed mood might mediate the relationship between dis-
depression, and lower self-esteem were significantly related to ease severity and HRQoL.
HRQoL. In the full regression model, disease severity was not The finding that adolescents with moderate and mild
significantly associated with HRQoL, but when tested as sole heart disease were similar in levels of depressed mood and
predictor of HRQoL, it explained 11% (r ⫽ 0.32; ␤ ⫽ 0.32; self-esteem to the healthy adolescents, in contrast to ado-
t ⫽ 3.21; p ⬍ .001) of its variance. In addition, adolescents’ lescents with severe heart disease, supports previous find-
perceived severity and depressed mood correlated with ings (7,10,11). However, the present study pointed to the
HRQoL (␤ ⫽ 0.54; t ⫽ 6.02; p ⬍ .0001 and ␤ ⫽ 0.47; t ⫽ major role of depressed mood, perceived disease severity,
4.94; p ⬍ .0001). Disease severity correlated with perceived and self-esteem, but not the severity of disease itself, as
severity (␤ ⫽ 0.39; t ⫽ 3.93; p ⬍ .0001) and with depressed predictors of HRQoL. These findings are in accordance
mood (␤ ⫽ 0.33; t ⫽ 3.24; p ⬍ .001), so they could be with studies on adolescents with heart disease (3) and on
possible mediators of the association between disease severity adolescents and adults with other chronic health problems
and HRQoL. When disease severity and depressed mood were (40). The possible mediating role of depressed mood and
entered as predictors of HRQoL, with R2 ⫽ 0.27 (F(2,87) ⫽ perceived severity of disease again accords with the cog-
16.14, p ⬍ .0001), ␤ for disease severity fell to 0.24 (t ⫽ 2.54; nitive theories that regard cognitive perceptions and psy-
p ⬍ .05), and ␤ for depressed mood was 0.42 (t ⫽ 4.45; p ⬍ chological reaction as a link between disease consequences
.0001). The Sobel test (35) showed Z ⫽ 3.32 (p ⬍ .0001). The and adjustment (17,41).
same calculations were applied to disease severity and per- The present study provides an exploratory mediation effect
ceived severity, with R2 ⫽ 0.31 (F(2,87) ⫽ 19.30; p ⬍ .0001), in adolescents with heart disease, which may make an impor-
and then ␤ for disease severity fell to 0.14 (t ⫽ 1.40; p ⬎ .05), tant contribution to our understanding of the processes of

316 Psychosomatic Medicine 69:313–318 (2007)


QoL IN ADOLESCENTS WITH HEART DISEASE

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