The principal finding from our study was that elevated depressive symptoms were associated with more avoidant coping styles, less optimistic attitudes, and lower levels of perceived support. This was true when depressive symptoms was measured as number of symptoms, as well as when depressive symptoms was measured by dichotomizing chronic illnesses such as cancer and HIV/AIDS populations which show that passive emotional-coping styles are related to poorer outcomes, whereas active coping styles are related to positive morbidity outcomes48
and lower mortality risk.49
Based on our findings, the presence of depression may indicate the presence of coping styles that adversely impact the optimal management of this disease. Avoidant coping such as denial potentially predisposes a patient to ignore medical recommendations, or symptoms that could signify the need for medical attention.50
On the other hand, adaptive coping may not only help problem-solve strategies for treatment and monitoring increasingly debilitating symptoms, 51-53
it might help in allotting emotional resources to managing illness.51
Therefore, optimal medical management of HF may require problem-focused coping strategies such as behavioral engagement, and emotion-focused coping such as maintaining an optimistic view of current health. This may suggest coping as a potential pathway through which the presence of depression impacts prognosis in HF.
To our knowledge, this study is the first to examine the association of optimism with depressive symptoms in HF patients. A growing body of evidence supports the notion that optimism has important consequences for heart disease patients. In patients who have undergone coronary artery bypass grafting, optimism may be related to faster recovery54
and lower rehospitalization rates.27
Although the mechanisms are unclear, the difference in outcome expectations between optimists and pessimists may provide an explanation: Optimists tend to expect a more favorable outcome, whereas pessimists tend to have negative expectations. Because behavior is often determined by expectations, optimists may be more likely to make efforts to remain engaged in disease management and take preventive action when necessary.55, 56
Intuitively, it might seem as though pessimism is antithetical to optimism, and integral to depression. However, within the context of health outcomes, optimism and pessimism appear to be separate constructs, rather than opposite ends of the same spectrum.55
Therefore, higher optimism may have an independent impact on health outcomes than lower pessimism, including the outcome of depressive symptoms.57
Focused research on the impact of optimism on depressive symptoms is needed to replicate our results as well as to identify underlying mechanisms.
Patients with coronary heart disease have been shown to gain health benefits from the presence of social support,58-60
although the interpretation of this literature may depend on its definition.16
Our results extend these findings to the HF patient population. In HF patients, emotional support derived through social contact may become critical in offsetting depressed mood, and instrumental support may offset the physical limitations of the disease.12, 61
However, prospective studies are needed to determine the mechanisms through which social support impacts depressive symptoms and clinical outcomes in HF patients.
Increasing attention is being paid to the importance of positive affect in patients with heart disease. Findings so far have been mixed, with some studies showing that positive affect is linked to longevity.62
However, the effects of positive affect have been reported to disappear when the impact of depression is examined,62
suggesting that the impact of depression in heart disease may supersede the impact of many other psychosocial factors. Overall, the impact of positive affect has received very limited attention in HF, and although our current study was not designed to examine the relative impact of positive affect versus depression on outcomes, we believe this is an important area of future research for heart disease in general, and HF in particular.
The key limitation of this study is its cross-sectional design. Because of this, we can neither establish the presence of a causal pathway between depressive symptoms and coping styles, nor can we establish the direction of causation should it exist. It is possible that depressive symptoms may result from poorer coping strategies and low social support,14
but it is also possible that the latter characteristics emerge from depressive symptoms, or that both depressive symptoms and poor coping styles emerge from a common underlying factor.63
However, teasing apart the relationship between coping styles and depression has been historically challenging,13
and our data provide evidence that coping styles and depressive symptoms are related in HF patients. We hope that our findings might provide impetus for future prospective studies examining the link between coping styles and the onset or exacerbation of depressive symptoms.
Our study also does not test whether maladaptive coping has implications for HF related morbidity and mortality, and whether modifying coping styles will alleviate the incidence of depressive symptoms in HF patients. Randomized clinical trials are needed to ascertain the most efficacious intervention in treating depressive symptoms in HF. Interventional studies may expand our understanding as to whether modifying coping styles alleviates depressive symptomatology in HF patients, and whether this change ultimately affects HF-related morbidity and mortality.
Despite these limitations, this study provides insight into the coping styles and strategies that are associated with depressive symptoms in HF patients. Findings related to behavior disengagement, mental disengagement, denial, venting, low perceived social support, and low dispositional optimism appeared particularly robust. Investigations examining the types, sources, and quality of social support will continue to further our understanding of the connection between social support and depressive symptoms. Screening for these coping styles in a primary care setting may help identify patients who have clinically significant depressive symptoms. Results regarding optimism should be treated as hypothesis-generating, given the limited literature in this area. Findings from this study provide impetus for future prospective studies that will help elucidate causal pathways that may exist between depressive symptoms and coping.