Impact of Type D Personality on Depression, Anxiety, and Health-related Quality of Life among Coronary Artery Disease Patients: A Systematic Review and Meta-analysis

Sun Hyoung Bae; Jin-Hee Park

doi:10.7475/kjan.2019.31.3.219

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Bae and Park: Impact of Type D Personality on Depression, Anxiety, and Health-related Quality of Life among Coronary Artery Disease Patients: A Systematic Review and Meta-analysis

Review Article

Korean J Adult Nurs 2019;31(3):219-234.

Published online: 21 June 2019

DOI: https://doi.org/10.7475/kjan.2019.31.3.219

Impact of Type D Personality on Depression, Anxiety, and Health-related Quality of Life among Coronary Artery Disease Patients: A Systematic Review and Meta-analysis

Sun Hyoung Bae¹, Jin-Hee Park^2,

¹Associate Professor, College of Nursing · Research Institute of Nursing Science, Ajou University, Suwon, Korea

²Professor, College of Nursing · Research Institute of Nursing Science, Ajou University, Suwon, Korea

Corresponding author: Park, Jin-Hee https://orcid.org/0000-0002-0069-7819 College of Nursing, Ajou University, 164 Worldcup-ro, Yeongtong-gu, Suwon 16499, Korea. Tel: +82-31-219-7019, Fax: +82-31-219-7020, E-mail: jhee@ajou.ac.kr

Received 7 March 201915 April 2019 Accepted 8 May 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

The purpose of this study was to investigate the impact of Type D personality among patients with Coronary Artery Disease(CAD).

Methods

Seven databases were searched to conduct a systematic review and metaanalysis. Two reviewers independently searched, selected, extracted, and assessed the studies. The quality of studies was evaluated using the JBI Critical Appraisal Checklist. To estimate the effect size, metaanalysis of the studies was performed using the Comprehensive Meta-Analysis 3.0 program.

Results

Of 1,128 publications identified, 31 studies that met the inclusion criteria were used to estimate the effect size of Type D personality. Effect size(Standardized Mean Difference [SMD]) was used in the analyses. Patients with CAD who had Type D personality had higher levels of depression(SMD=0.92; 95% Confidecne Interval (CI)=0.74~1.10) and anxiety(SMD=1.19; 95% CI=0.81~1.57), but lower levels of physical and mental health-related quality of life(SMD=-0.56; 95% CI=-0.75~-0.38; SMD=-0.91; 95% CI=-1.10~-0.73). Publication bias was not detected.

Conclusion

Type D personality was associated with increased depression and anxiety and impaired health-related quality of life in patients with CAD. Personality and psychosocial risk screening in patients with CAD should be conducted in the clinical setting.

Keywords: Type D personality, Coronary artery disease, Depression, Anxiety, Quality of life

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Appendix 1. Studies Included in Systematic Review

A1. Annagür BB, Demir K, Avci A, Uygur Ö F. Impact of a Type D personality on clinical and psychometric properties in a sample of Turkish patients with a first myocardial infarction. Journal of Psychiatric Practice. 2017; 23(1):3–10. https://doi.org/10.1097/PRA.0000000000000201.

A2. Bunevicius A, Staniute M, Brozaitiene J, Stropute D, Bunevicius R, Denollet J. Type D (distressed) personality and its assessment with the DS14 in Lithuanian patients with coronary artery disease. Journal of Health Psychology. 2013; 18(9):1242–51. https://doi.org/10.1177/1359105312459098.

A3. Cha KS, Im SM, Cho O-H. Mental health and quality of life by Type-D personality of the patients with coronary artery disease. The Journal of the Korean Content Association. 2013; 13(5):286–94. https://doi.org/10.5392/JKCA.2013.13.05.286.

A4. Choi YO. A comparison of factors influencing health behavior compliance by Type D personality in the patients with coronary artery disease [master's thesis]. Gwangju: Chonnam National University;2013.

A5. Condén E, Rosenblad A, Ekselius L, Åslund C. Prevalence of Type D personality and factorial and temporal stability of the DS14 after myocardial infarction in a Swedish population. Scandinavian Journal of Psychology. 2014; 55(6):601–60. https://doi.org/10.1111/sjop.12162.

A6. De Fazio P, Caroleo M, Rizza P, Cerminara G, De Serio D, Indolfi C, et al. Specific personality traits and coping styles predict affective symptoms in early post acute coronary syndrome inpatients. The International Journal of Psychiatry in Medicine. 2012; 44(2):119–32. https://doi.org/10.2190/PM.44.2.c. A7. Denollet J. Personality and coronary heart disease: The Type- D Scale-16 (DS16). Annals of Behavioral Medicine. 1998; 20(3):209–15. https://doi.org/10.1007/BF02884962.

A8. Doyle F, McGee HM, Conroy RM, Delaney M. What predicts depression in cardiac patients: sociodemographic factors, disease severity or theoretical vulnerabilities? Psychology & Health. 2011; 26(5):619–34. https://doi.org/10.1080/08870441003624398.

A9. Kaur S, Zainal NZ, Low WY, Ramasamy R, Sidhu JS. Factor structure of hospital anxiety and depression scale in Malay-sian patients with coronary artery disease. Asia Pacific Journal of Public Health. 2015; 27(4):450–60. https://doi.org/10.1177/1010539514533719.

A10. Kelpis TG, Anastasiadis K, Nimatoudis I, Kelpi MG, Hadjimil-tiades S, Papakonstantinou C. Prevalence of "distressed" personality in patients with coronary artery disease and its correlation with morbidity after coronary surgery. Hellenic Journal of Cardiology. 2013; 54(5):362–7.

A11. Lambertus F, Herrmann-Lingen C, Fritzsche K, Hamacher S, Hellmich M, Jünger J, et al. Prevalence of mental disorders among depressed coronary patients with and without Type D personality. Results of the multicenter SPIRR-CAD trial. General Hospital Psychiatry. 2018; 50:69–75. https://doi.org/10.1016/j.genhosppsych.2017.10.001.

A12. Lee KH. Depression and health status in patient with Type D personality coronary artery disease [master's thesis]. Seoul: Korea University;2015.

A13. Lee SJ, Koh S, Kim BO, Kim B, Kim C. Effect of Type D personality on short-term cardiac rehabilitation in patients with coronary artery disease. Annals of Rehabilitation Medicine. 2018; 42(5):748–57. https://doi.org/10.5535/arm.2018.42.5.748.

A14. Lim HE, Lee M-S, Ko Y-H, Park Y-M, Joe S-H, Kim Y-K, et al. Assessment of the Type D personality construct in the Korean population: a validation study of the Korean DS14. Journal of Korean Medical Science. 2011; 26(1):116–23. https://doi.org/10.3346/jkms.2011.26.1.116.

A15. Lin I-M, Wang S-Y, Chu I-H, Lu Y-H, Lee C-S, Lin T-H, et al. The association of Type D personality with heart rate varia-bility and lipid profiles among patients with coronary artery disease. International Journal of Behavioral Medicine. 2017; 24(1):101–9. https://doi.org/10.1007/s12529-016-9571-x. A16. Middel B, El Baz N, Pedersen SS, van Dijk JP, Wynia K, Reijneveld SA. Decline in health-related quality of life 6 months after coronary artery bypass graft surgery: the influence of anxiety, depression, and personality traits. Journal of Cardiovascular Nursing. 2014; 29(6):544–54. https://doi.org/10.1097/JCN.0b013e3182a102ae. A17. Molloy GJ, Perkins-Porras L, Strike PC, Steptoe A. Type-D personality and cortisol in survivors of acute coronary syndrome. Psychosomatic Medicine. 2008; 70(8):863–8. https://doi.org/10.1097/psy.0b013e3181842e0c. A18. Molloy GJ, Randall G, Wikman A, Perkins-Porras L, Messerli- Bürgy N, Steptoe A. Type D personality, self-efficacy, and medication adherence following an acute coronary syndrome. Psychosomatic Medicine. 2012; 74(1):100–6. https://doi.org/10.1097/PSY.0b013e31823a5b2f. A19. Mommersteeg PMC, Pot I, Aarnoudse W, Denollet J, Widdershoven JW. Type D personality and patient-perceived health in nonsignificant coronary artery disease: the Tweeste-den Mild Stenosis (TWIST) study. Quality of Life Research. 2013; 22(8):2041–50. https://doi.org/10.1007/s11136-012-0340-2.

A20. Ossola P, De Panfilis C, Tonna M, Ardissino D, Marchesi C. DS14 is more likely to measure depression rather than a personality disposition in patients with acute coronary syndrome. Scandinavian Journal of Psychology. 2015; 56(6):685–92. https://doi.org/10.1111/sjop.12244.

A21. Park J-H, Tahk S-J, Bae S-H. Impact of Type D personality on health status and health behaviors in patients with coronary artery disease. Korean Journal of Health Promotion. 2010; 10(3):123–30.

A22. Pedersen SS, Denollet J, van Gestel YRBM, Serruys PW, van Domburg RT. Clustering of psychosocial risk factors enhan-ces the risk of depressive symptoms 12-months post percutaneous coronary intervention. European Journal of Preventive Cardiology. 2008; 15(2):203–9. https://doi.org/10.1097/HJR.0b013e3282f19d2f. A23. Pelle AJ, Erdman RAM, van Domburg RT, Spiering M, Kazemier M, Pedersen SS. Type D patients report poorer health status prior to and after cardiac rehabilitation compared to non-Type D patients. Annals of Behavioral Medicine. 2008; 36(2):167–75. https://doi.org/10.1007/s12160-008-9057-4.

A24. Smith ORF, Pedersen SS, van Domburg RT, Denollet J. Symptoms of fatigue and depression in ischemic heart disease are driven by personality characteristics rather than disease stage: a comparison of CAD and CHF patients. European Journal of Preventive Cardiology. 2008; 15(5):583–8. https://doi.org/10.1097/HJR.0b013e3283083e17.

A25. Son H-M. Quality of life and illness intrusiveness by Type-D personality in the patients with coronary artery disease. Journal of Korean Academy of Nursing. 2009; 39(3):349–56. https://doi.org/10.4040/jkan.2009.39.3.349.

A26. Spindler H, Pedersen SS, Serruys PW, Erdman RAM, van Domburg RT. Type-D personality predicts chronic anxiety following percutaneous coronary intervention in the drug- eluting stent era. Journal of Affective Disorders. 2007; 99(1-3):173–9. https://doi.org/10.1016/j.jad.2006.09.009.

A27. Svansdottir E, van den Broek KC, Karlsson HD, Gudnason T, Denollet J. Type D personality is associated with impaired psychological status and unhealthy lifestyle in Icelandic cardiac patients: a cross-sectional study. BMC Public Health. 2012; 12:42. https://doi.org/10.1186/1471-2458-12-42.

A28. van Gestel YRBM, Pedersen SS, van de Sande M, de Jaegere PPT, Serruys PW, Erdman RAM, et al. Type-D personality and depressive symptoms predict anxiety 12 months post-percutaneous coronary intervention. Journal of Affective Disorders. 2007; 103(1-3):197–203. https://doi.org/10.1016/j.jad.2007.01.030.

A29. Vilchinsky N, Yaakov M, Sigawi L, Leibowitz M, Reges O, Levit O, et al. Preliminary evidence for the construct and con-current validity of the DS14 in Hebrew. International Journal of Behavioral Medicine. 2012; 19(2):234–40. https://doi.org/10.1007/s12529-011-9147-8.

A30. Vukovic O, Tosevski DL, Jasovic-Gasic M, Damjanovic A, Zebic M, Britvic D, et al. Type D personality in patients with coronary artery disease. Psychiatria Danubina. 2014; 26(1):46–51.

A31. Williams L, O'Connor RC, Grubb NR, O'Carroll RE. Type D personality and three-month psychosocial outcomes among patients post-myocardial infarction. Journal of Psychosomatic Research. 2012; 72(6):422–6. https://doi.org/10.1016/j.jpsychores.2012.02.007.

Figure 1.

Flow diagram for study selection.

Figure 2.

Forest plot of depression, anxiety, and health-related quality of life.

Figure 3.

Regression plot.

Table 1.

Descriptive Summary of Included Studies

Author	Country	Design	n	Age M±SD	Gender n	Diagnosis	Type D Scale, %	Outcome scale	Quality score
Annagür et al. 2016 [A1]	Turkey	CS	131	54.8±11.1	M: 117/W: 16	MI	DS1438.2	Anxiety: STAI, HAI Depression: BDI	7
Bunevicius et al. 2013 [A2]	Netherlands	CS	543	57.9±8.9	M: 388/W: 155	CAD	DS1433.6	Anxiety: HADS-A Depression: HADS-D	6
Cha et al. 2013 [A3]	Korea	CS	111	NA	M: 62/W: 49	CAD (Angina, MI)	DS1436.1	Anxiety: SCL-90R Depression: SCL-90R HRQoL: WHOQOL-BREF	8
Choi, 2013 [A4]	Korea	CS	240	66.8±8.2	M: 77/W: 163	CAD (Angina, MI)	DS1438.3	Depression: CES-D	7
Condén et al. 2014 [A5]	Sweden	PC	946	70.1±11.8	M: 633/W: 313	MI	DS1425.1	Anxiety: HADS-A Depression: HADS-D	7
De Fazio et al. 2012 [A6]	Italy	CS	70	63.4±13.2	M: 48/W: 22	ACS	DS1476.0	Anxiety: HADS-A Depression: HADS-D	8
Denollet et al. 1998 [A7]	Belgium	CS	100	55.9±9.1	M: 90/W: 10	CHD (MI, CABG, PTCA)	DS1629.0	Anxiety: TMAS Depression: BDI	7
Doyle et al. 2011 [A8]	Ireland	CS	339	61.1±10.8	M: 295/W: 44	ACS	DS1430.1	Anxiety: HADS-A Depression: HADS-D, BDI	7
Kaur et al. 2014 [A9]	Malaysia	CS	195	56.8±106	M: 144/W: 51	CAD	DS1428.2	Anxiety: HADS-A Depression: HADS-D	7
Kelpis et al. 2013 [A10]	Greece	CS	323	65.1±9.0	M: 260/W: 63	CAD	DS1418.2	Anxiety: HADS-A Depression: HADS-D	6
Lambertus et al. 2018 [A11]	Germany	CS	570	59.2±9.5	M: 450/W: 120	CHD	DS1460.1	Depression: HADS-D, HAM-D	7
Lee, 2015 [A12]	Korea	PC	84	57.5±7.8	M: 65/W: 19	CAD (Angina, MI)	DS1431.0	Depression: BDI HRQoL: SF-12	7
Lee et al. 2018 [A13]	Korea	CS	63	59.8±11.1	M: 44/W: 19	ACS	DS1433.3	Anxiety: HADS-A Depression: HADS-D	7
Lim et al. 2011 [A14]	Korea	CS	111	61.4±10.6	M: 70/W: 41	CHD	DS1427.0	Anxiety: STAI Depression: CES-D HRQoL: GHQ	6
Lin et al. 2016 [A15]	Taiwan	CS	168	61.3±7.3	M: 145/W: 23	CAD	DS1425.0	Anxiety: BAI Depression: BDI	6
Middel et al. 2014 [A16]	Netherlands	PC	198	64.9±9.9	M: 155/W: 43	CHD	DS1411.6	Anxiety: HADS-A Depression: HADS-D HRQoL: SF-36	8
Molloy et al. 2008 [A17]	United Kingdom	CS	70	60.6±10.3	M: 58/W: 12	ACS	DS1638.6	Depression: BDI	8
Molloy et al. 2012 [A18]	United Kingdom	PC	165	61.7±10.9	M: 142/W: 23	ACS	DS1430.3	Depression: BDI	7
Mommersteeg et al. 2013 [A19]	Netherlands	CS	273	62.1±9.65	M: 133/W: 140	CAD	DS1430.0	Anxiety: HADS-A Depression: HADS-D HRQoL: SAQ	8
Ossola et al. 2015 [A20]	Italy	PC	304	61.4±10.9	M: 245/W: 59	ACS	DS1434.2	Anxiety: HADS-A Depression: HADS-D	8
Park et al. 2010 [A21]	Korea	CS	106	NA	M: 83/W: 23	CAD	DS1427.4	Anxiety: HADS-A Depression: HADS-D HRQoL: SAQ	7
Pedersen et al. 2007 [A22]	Netherlands	PC	306	64.0±10.7	M: 150/W: 156	CAD	DS1436.2	Anxiety: HADS-A Depression: HADS-D	8
Pelle et al. 2008 [A23]	Netherlands	PC	368	58.1±10.2	M: 290/W: 78	CAD	DS1436.3	Anxiety: HADS-A Depression: HADS-D HRQoL: SF-36	7
Smith et al. 2008 [A24]	Netherlands	PC	401	62.9±10.9	M: 296/W: 105	CHD	DS1432.3	Depression: MQ	8
Son, 2009 [A25]	Korea	CS	200	59.9±11.7	M: 99/W: 101	CAD (Angina, MI)	DS1438.0	HRQoL: Korean version of HRQoL	7
Spindler et al. 2007 [A26]	Netherlands	PC	167	60.3±11.0	M: 102/W: 65	CAD	DS1458.7	Anxiety: HADS-A Depression: HADS-D	8
Svansdottir et al. 2012 [A27]	Iceland	PC	268	62.9±10.5	M: 199/W: 69	CAD	DS1426.1	Anxiety: HADS-A Depression: HADS-D	8
van Gestel et al. 2007 [A28]	Netherlands	PC	416	62.8±10.8	M: 312/W: 104	Angina	DS1424.8	Anxiety: HADS-A Depression: HADS-D	8
Vilchinsky et al. 2011 [A29]	Israel	PC	94	56.3±7.6	M: 94/W: 0	ACS	DS1422.3	Anxiety: BSI-A Depression: BSI-D	8
Vukovic et al. 2014 [A30]	Serbia	CS	79	53.9±8.5	M: 62/W: 17	CAD	DS1434.2	Depression: BDI	7
Wiliams et al. 2012 [A31]	United Kingdom	CS	192	66.0±10.8	M: 138/W: 54	MI	DS1433.9	HRQoL: MacNew	8

ACS=acute coronary syndrome; BAI=beck anxiety inventory; BDI=beck depression inventory; BSI=brief symptom inventory; CAD=coronary artery disease; CES-D=center for epidemiological studies-depression scale; CHD=coronary heart disease; CS=cross-sectional study: GHQ=general health questionnaire/quality of life-12; HADS=Hospital anxiety depression scale; HAI=Health anxiety inventory; HAM-D=Hamilton depression rating scale; HRQoL=health-related quality of life; MacNew=MacNew heart disease health-related quality of life instrument; MI=myocardial infarction; MQ=Masstrichit questionnaire; NA=not applicable; PC=prospective cohort study; SAQ=Seattle angina questionnaire; SCL-90R=symptom checklist-90-Revision; SF-12=medical outcomes study questionnaire short form 12; SF-36=medical outcomes study questionnaire short form 36; STAI=state-trait anxiety inventory; TMAS=Taylor manifest anxiety scale; W=women; WHOQOL-BREF=World Health Organization quality of life assessment instrument-BREF.

Table 2.

General Characteristics of Studies Included in Systematic Review and Meta-analysis (N=31)

Characteristics		Categories	n (%)
Publication year		≤2010	9 (29.0)
		2011~2015	18 (58.1)
		≥2016	4 (12.9)
Publication country		Korea	7 (22.6)
Publication country		Others	24 (77.4)
Participants	Number	≤99	6 (19.4)
	(range=63.0~946.0, mean=245.2, median=195.0)	100~199	11 (35.5)
		200~499	11 (35.5)
		≥500	3 (9.6)
	Mean age	≤59.9	11 (37.9)
	(range=53.9~71.1, N=29)	60.0~64.9	14 (48.3)
		≥65.0	4 (13.8)
	% of Male	≤49.9	4 (12.9)
	(range=32.1~100.0, mean=72.8, median=75.0)	50.0~79.9	18 (58.1)
		≥80.0	9 (29.0)
	Diagnosis group	Angina	1 (3.2)
		Acute coronary syndrome	7 (22.6)
		Coronary artery disease	15 (48.4)
		Coronary heart disease	5 (16.1)
		Myocardial infarction	3 (9.7)
Type D personality	Prevalence
	(range=11.6~76.0, mean=33.7, median=32.3)
	Measurement	DS14	29 (93.5)
		DS16	2 (6.5)
Outcome & measurement^†	Depression		29 (93.5)
		BDI	8 (27.6)
		CES-D	2 (6.9)
		HADS	17 (58.6)
		Others	2 (6.9)
	Anxiety		22 (71.0)
		HADS	16 (72.7)
		STAI	2 (9.1)
		Others	4 (18.2)
	Health-related quality of life		9 (29.0)
		SAQ	2 (22.3)
		SF-12, SF-36	3 (33.3)
		MacNew	1 (11.1)
		Others	3 (33.3)

BDI=beck depression inventory; CES-D=center for epidemiological studies-depression scale; DS14=14 item of type D personality scale; DS16=16 item of type D personality scale; HADS=Hospital anxiety depression scale; MacNew=MacNew heart disease health-related quality of life instrument; SAQ=Seattle angina questionnaire; SF-12=medical outcomes study questionnaire short form 12; SF-36=medical outcomes study questionnaire short form 36; STAI=state-trait anxiety inventory;

^† Multiple response.

Table 3.

Meta-analysis of the Impact of Type D personality on Depression, Anxiety, and Health-related Quality of Life in Patients with Coronary Artery Disease (N=3,417)

Variables	k	n	Homogeneity test			Overall effect	95% CI	z	p	ER		FSN^†
Variables	k	n	Q	df	p	Overall effect	95% CI	z	p	t	p	FSN^†
Depression	26	6,419	163.70	25	.001	0.92	0.74~1.10	10.30	.001	0.69	.429	4,958
Anxiety	17	4,308	342.70	16	.001	1.19	0.81~1.57	6.10	.001	1.47	.162	2,766
HRQoL: physical	4	666	3.05	3	.384	-0.56	-0.75~-0.38	-6.04	.001	0.82	.499	31
HRQoL: mental	4	666	0.50	3	.920	-0.91	-1.10~-0.73	-9.69	.001	0.60	.734	90

CI=confidence interval; ER=Egger's regression; FSN=Fail-safe number; HRQoL=health-related quality of life; k=number of studies;

^† FSN was analyzed using Orwin method.

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