International Journal of Nursing Studies 69 (2017) 57–65

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Predictors of depression in outpatients with heart failure: An

observational study
Lucinda J. Gravena,* , Geraldine Martorellaa , Glenna Gordona , Joan S. Grant Keltnerb ,
Melinda K. Higginsc
a
Florida State University College of Nursing, United States
b
University of Alabama School of Nursing, United States
c
Nell Hodgson Woodruff School of Nursing, Emory University, United States

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

Article history: Background: Depression is a common comorbidity of heart failure. Little is known about the influence of
Received 28 July 2016 heart failure symptomatology and coping resources, such as social support and social problem-solving,
Received in revised form 2 November 2016 on depression.
Accepted 30 January 2017
Objective: To examine whether individual and clinical characteristics, heart failure symptomatology, and
the subcomponents of social support and social problem-solving increase the likelihood of depression in
Keywords: outpatients with heart failure.
Depression
Methods: A secondary data analysis of a cross sectional study with 201 outpatients with heart failure was
Heart failure
Marital status
conducted. The following self-report questionnaires were used to collect data: the Heart Failure
Problem-solving Symptom Survey, the Interpersonal Support Evaluation List-12, the [Removed for Blind Review] Social
Social problem-solving Network Survey, the Social Problem-Solving Inventory Revised-Short, and the Center for Epidemiological
Social support Studies – Depression scale. Descriptive statistics examined patient characteristics. Logistic regression
Symptoms explored predictors of depression from among individual and clinical characteristics, heart failure
symptomatology, and subcomponents of social support (i.e., belonging, tangible, and appraisal support)
and social problem-solving (i.e., positive and negative problem orientation; rational, impulsiveness/
carelessness, and avoidance problem-solving styles).
Results: The sample was primarily Caucasian (86.1%) male (62.6%) with an average age of 72.57 years.
Individuals who were unmarried, experienced a higher symptom burden, and those who perceived less
belonging support were more likely to be depressed. The subcomponents of social problem-solving did
not influence depression.
Conclusions: Belonging support was the most beneficial type of social support related to depression.
Components of social problem-solving were not related to depression. Assessment of marital status,
heart failure symptomatology, and perceived belonging support is needed to identify potential stressors
and available social support in order to promote psychological adaptation.
© 2017 Elsevier Ltd. All rights reserved.

What is already known about the topic?
Individuals experiencing more HF symptoms are more likely to

Heart failure affects approximately 26 million individuals suffer depression.
worldwide.
Individuals with HF reporting decreased belonging support, or

Depression is a common co-morbidity of heart failure. perceiving there are fewer people available with which to do
things, are more likely to be depressed.
What this paper add:

Non-married individuals with HF are more likely to suffer
depression. 1. Introduction

Heart failure (HF) has reached epidemic status, with approxi-

* Corresponding author at: 98 Varsity Way, Florida State University College of
Nursing, Tallahassee, FL 32306-4310, United States.
E-mail address: lgraven@fsu.edu (L.J. Graven).
mately 26 million individuals currently living with HF worldwide
(Ponikowski et al., 2014). As a primary diagnosis, HF accounts for
up to 4% of hospitalizations in developed countries and continues

http://dx.doi.org/10.1016/j.ijnurstu.2017.01.014
0020-7489/© 2017 Elsevier Ltd. All rights reserved.
58 L.J. Graven et al. / International Journal of Nursing Studies 69 (2017) 57–65
to be associated with high mortality rates (Mozaffarian et al., 2015;
Ponikowski et al., 2014). Symptoms of HF increase as HF progresses
(Butler, 2010), creating the potential for high levels of stress (
Graven et al., 2015a). In fact, depression is often a co-morbid
condition, with studies indicating that as many as 50% of HF
patients report some degree of depressive symptoms (Brouwers
et al., 2014; Heo et al., 2014a; Rutledge et al., 2006). In turn,
depression in HF patients is associated with poor outcomes,
including increased hospitalizations and mortality (Jenner et al.,
2009; Yohannes et al., 2010), making depression an important co-
morbidity that must be clinically assessed and managed. Thus,
identification of risk factors associated with depression is
necessary for accurate clinical assessment.
Symptoms of HF are complex and vary among patients, creating
potential for psychological distress. Evidence suggests symptoms
of HF influence depressive symptoms, particularly as symptom-
atology increases (Graven et al., 2015a; Fan and Meng, 2015).
Symptomatology is often examined according to disease severity
and functional status as operationalized by the New York Heart
Association (NYHA) HF Class (Brouwers et al., 2014; Maeda et al.,
2013; Shimizu et al., 2014). Yet, evidence indicates that the NYHA
HF Class may not be representative of patients’ self-assessed
symptoms (Raphael et al., 2007). Thus, examining the totality of
the symptom experience (i.e., frequency, severity, and amount of
interference with daily life) may provide more accurate informa-
tion regarding the influence of HF symptomatology in predicting
depression in this population.
Social support and social problem-solving are important coping
resources that may impact the development of depression (Lazarus
and Folkman, 1984). Evidence suggests that social support is
related to depression in patients with HF. Lower levels of support
and lack of satisfaction with support are found to influence
depression (Chung et al., 2013; Friedmann et al., 2014; Shimizu
et al., 2014). Furthermore, social support may actually influence
the relationship between HF symptom severity and depressive
symptoms, thereby decreasing the risk of depressive symptoms
(Graven et al., 2015a).
Individual and Clinical
Characteristics
Race
Gender
Age
Income
Marital status
Number of people in house
Educational level
NYHA HF Class
Coping Resources
Social Support
Structural Support Functional Support
Social Network Belonging Support
Tangible Support
Appraisal Support
Depression
Fig. 1. Theoretical Framework based upon Lazarus and Folkman (1984).
However, social support is a multifaceted construct of which its
subcomponents (i.e., functional and structural support) have not
been adequately examined in prior research. Functional support is
defined as individuals’ perception of support provided by
significant others and includes belonging (i.e., availability of
people to do things with), tangible (i.e., provision of good and
services), and appraisal support (i.e., assistance with self-evalua-
tion and affirmation by others) (Cohen et al., 1985). In contrast,
structural support is the concrete provision of support through
interaction with one’s social network (i.e., individuals or groups
within individuals’ community) (Fig. 1) (Graven et al., 2015b).
While studies have identified the importance of social support on
depression in HF patients (Chung et al., 2013; Graven et al., 2015a;
Friedmann et al., 2014 Friedmann et al., 2014), components of
social support which are most beneficial in influencing depression
remain relatively unknown (Heo et al., 2014b), prompting more
research in this area. Further, knowledge of the potential value of
these individual components may assist in assessing and managing
HF patients regarding depression.
How individuals problem-solve HF-related issues on a daily
basis may also influence depression. Social problem-solving
involves how individuals manage problems or make decisions in
a real world environment and includes problem orientation (e.g.,
whether they view problems in life positively or negatively) and
problem-solving style (e.g., the approach they use to solve
problems). Individuals use specific problem-solving skills to
manage everyday problems and identify effective solutions. These
skills are typically reflective of specific problem-solving styles (i.e.,
rational problem-solving, impulsivity/carelessness, and avoidance
styles) and may either be constructive or dysfunctional (D’Zurilla
et al., 2004; Elliott et al., 2004). Rational problem-solving style is a
constructive approach to solving problems which involves
deliberate and systematic methods aimed at solving problems,
including problem identification, generation of possible solutions,
active decision-making, and solution implementation and evalua-
tion. Impulsivity/carelessness style is characterized by impulsive,
hurried, and incomplete attempts at applying problem-solving
Disease-Related
Stressors
Heart Failure Symptoms
Problem-Solving Characteristics
Problem Orientation Problem-Solving Style
Positive vs. Negative Rational
Impulsivity/Carelessness
Avoidance
 L.J. Graven et al. / International Journal of Nursing Studies 69 (2017) 57–65
strategies, while avoidance style involves a lack of action or
procrastination in problem-solving. Both impulsivity/carelessness
and avoidance styles are considered dysfunctional approaches to
solving problems (D’Zurilla et al., 2004).
Social problem-solving is associated with reduced depression
in other populations and may be related to depression in HF
patients (Erdley et al., 2014; Pfeiffer et al., 2014). However, little is
known regarding whether specific problem-solving styles used by
individuals with HF are related to depression. This information
could be useful in clinical management with regards to risk
identification and intervention development for depression,
creating a need for more in-depth research in this area.
Thus, this study builds off of previous results presented within
the parent study which examined the direct and indirect
relationships among HF physical symptoms, social support, social
problem-solving, depressive symptoms, and self-care behaviors in
outpatients with HF (Graven et al., 2015a). Study findings indicated
depression was an outcome and not a mediator in these relation-
ships. The contributions of individual and clinical characteristics
and specific types of social support (i.e., belonging, tangible,
appraisal support, and social network) and problem-solving
characteristics (i.e., problem orientation and problem-solving
styles) as predictors of depression were not examined (Graven
et al., 2015a). In-depth examination of these relationships can
identify potential risk factors for depression in HF patients and
inform clinical practice.
1.1. Theoretical framework
Selected constructs from the theory of Stress, Appraisal, and
Coping guided this study (Lazarus and Folkman, 1984). Stress
occurs when events within individuals’ environment is believed to
exceed available personal resources, resulting in a threat to well-
being. Individuals manage these threats and their psychological
sequelae through the use of coping resources (e.g., social support,
problem-solving skills, etc.). Coping resources may be influenced
by individual and clinical characteristics, in addition to disease-
related stressors (Lazarus and Folkman, 1984). In this study, HF
symptoms are viewed as potential stressors which may influence
depression. Coping resources, such as social support and social
problem-solving are utilized to manage HF symptoms and could
potentially decrease risk of depression (Fig. 1). Therefore, the
purpose of this study was to examine whether individual and
clinical characteristics, HF symptomatology, and the subcompo-
nents of social support and social problem-solving influence the
likelihood of depression in patients with HF. Specific aims of this
study were to: (1) describe individual and clinical characteristics
(i.e., age, gender, race, marital status, number of people in
household, education level, and NYHA HF Class) of patients with
and without depression and to (2) determine whether HF
symptoms, the subcomponents of social support (e.g., belonging,
tangible, and appraisal support; social network) and social
problem-solving (i.e., problem orientation and problem-solving
style), were independent predictors of depression, while control-
ling for individual and clinical characteristics as potential
covariates.
2. Methods
2.1. Design, setting, and sample
This study was a secondary analysis of data obtained from a
cross-sectional, descriptive, correlational study originally designed
to explore the relationships among HF physical symptoms, social
support, social problem-solving, depression, and self-care using
structural equational modeling. Full details of the original study
59
design and methods have been previously reported (Graven et al.,
2015a). Aspects relevant to the current study are summarized here.
Sample size was calculated for the parent study based upon
recommendations for structural equation modeling (Kelloway,
1998). A power analysis was not conducted for this secondary
analysis. However, Polit (2010) recommends a minimum of 10 cases
per predictor in the logistic regression model to maintain stability of
the estimates. There were 14 predictors in the model. Our sample of
201 exceeds the recommended minimum sample size.
This study was conducted in accordance with the Declaration of
Helsinki. Following institutional review board approval, HF patients
55 years of age or older were recruited from three outpatient clinics
in [location removed for blind review]. Inclusion criteria for
enrollment were: (1) a diagnosis of HF confirmed by the physician
or medical chart; (2) age 55 years or older; (3) living in an outpatient
setting; and (4) able to read, speak, and understand English. Patients
with a history of cognitive impairment or those with potential
impairment, as evidenced by a score of 30 on the Telephone
Interview for Cognitive Status (TICS) (Brandt et al., 1988), were
excluded from participation. Initial screening of clinical and
cognitive status was conducted over the telephone, with eligible
participants then scheduled for individual interviews at their
physician’s office. Following informed consent, participants were
interviewed using a set of self-report questionnaires presented in
random order. No incentives were offered for participation.
2.2. Measures
Individual and clinical information were collected via self-
report using a researcher-developed survey to assess sample
characteristics and determine study eligibility. NYHA HF classifi-
cation was determined by patient self-report and based upon
information gathered regarding the patients’ ability to perform
usual activities (Criteria Committee of the New York Heart
Association, 1994). In addition, the TICS was used to screen
potential participants for cognitive impairment (Brandt et al.,
1988). The TICS is a valid and reliable instrument consisting of 11
items that assess five areas of cognition (i.e., orientation, attention,
language, learning, and memory). The maximum score is 41, with
scores 30 suggesting some degree of cognitive impairment
(Brandt et al., 1988).
2.3. Heart failure symptoms
The Heart Failure Symptom Survey (HFSS) was used to measure
HF symptoms (Hertzog et al., 2010). This survey asks patients to
evaluate 14 common HF symptoms based upon the last seven days
and to rate these symptoms on 4 subscales, including frequency,
severity, and symptom-related degree of interference with
physical activity and enjoyment of life on a 0–10 scale where 0
is never, not severe, or no interference and 10 is very frequently,
very severe, or great deal of interference. Higher scores on each
subscale represent higher symptom burden with respect to the
specific subscale. A total score can also be calculated by computing
the average score of all 4 subscales, with higher scores indicating
an overall higher symptom burden (Graven et al., 2015a). Previous
studies have supported its validity and reliability (Hertzog et al.,
2010; Quinn et al., 2010). Due to multicollinearity issues among the
subscales, a total score for HF symptoms was calculated and used in
this study, with adequate support for its psychometric properties
reported previously (Graven et al., 2015a).
2.4. Social support
Two measures of social support were used to fully examine this
multifaceted construct. Perceived functional support was
60 L.J. Graven et al. / International Journal of Nursing Studies 69 (2017) 57–65
measured using the 12-item Interpersonal Support and Evaluation
List 12 (Cohen et al., 1985). Scores for each subscale (i.e.,
belonging, tangible, and appraisal support) range from 0 to 12,
with higher scores indicating higher levels of the specific type of
support. Validity and reliability are supported in prior research
(Cohen et al., 1985; Graven et al., 2014). Subscales were used in this
study to examine the individual contribution of each type of
functional support, with evidence of adequate internal consisten-
cy, using Cronbach’s alpha (i.e., 0.85 [appraisal support]; 0.74
[tangible support]; and 0.79 [belonging support]).
Structural support (i.e., social network) was measured using the
[removed for blind review] (Graven et al.,2015b). This single
dimension 12-item survey asks participants to quantify the
number of people who provide them with support and to rate
their satisfaction with the support provided on a scale of 1
(strongly disagree) to 7 (strongly agree). Total scores range from 12
to 84, with higher scores suggesting the availability of a larger
social network and higher level of satisfaction with available
support. Prior research has supported its validity and reliability in
individuals with HF (Graven et al., 2015b).
2.5. Social problem-solving
The Social Problem-Solving Inventory Revised-Short (SPSIR-S)
is a 25-item survey which measures problem-solving character-
istics, such as problem-orientation and problem-solving style. The
instrument contains 5 subscales: positive problem orientation
(PPO), negative problem orientation (NPO), rational problem-
solving (RPS), impulsivity/carelessness style (ICS), and avoidance
style (AS). Higher scores on each subscale represent more use of
that particular problem-solving characteristic (D’Zurilla et al.,
2002). Although the instrument has an overall score, for the
purpose of this study, only subscales were examined. Validity and
reliability are supported in previous research (D’Zurilla et al.,
2002). In this study, Cronbach’s alphas for the all subscales were
adequate (i.e., >0.80), with the exception of the positive problem
orientation subscale (a = 0.672).
2.6. Depression
Depression was measured using the Center for Epidemiological
Studies – Depression Scale (CES-D). Scores on this 20-item survey
range from 0 to 60, with higher scores indicating the presence of
more depressive symptoms (Radloff, 1977). A cut-off score of 16
was used in this study to indicate depression based upon
sensitivity and specificity analyses conducted in chronic illness
and general populations (Chin et al., 2015; Lewinsohn et al., 1997;
Parikh et al., 1988). Scores less than 16 are not indicative of
depression (Chin et al., 2015; Lewinsohn et al., 1997; Parikh et al.,
1988; Radloff, 1977). Prior studies have supported its validity and
reliability in general and HF populations (Lesman-Leegte et al.,
2009; Lewinsohn et al., 1997).
2.7. Data analysis
The Statistical Package for the Social Sciences (SPSS) version 20
was used for data analysis, with statistical significance set at
a = 0.05 for all tests. Prior to analysis, raw data were evaluated for
normality and multi-collinearity. Descriptive statistics, chi square
tests, t-tests, and Mann-Whitney U tests were used to examine
patient characteristics and scores on study variables of those with
and without depression. Logistic regression utilizing the Wald
method of backward elimination for variable selection was used to
evaluate the contribution of each predictor to depression, while
taking into account other variables in the model. Depression was
entered as the dependent variable with 1 = depressed (16 on the
CES-D) and 0 = not depressed (<16).
2.8. Logistic regression model building
Data were analyzed using a three-step approach for logistic
regression as recommended by Hosmer and Lemeshow (2000).
Initially, potential covariates (i.e., age, gender, race, marital status,
number of people in household, income, NYHA HF Class, level of
education) were identified by literature review (Brouwers et al.,
2014; Fan and Meng, 2015; Johansson et al., 2006; Macabasco-
O’Connell et al., 2010; Maeda et al., 2013).
In step 1, potential covariates were analyzed individually using
chi-square tests and t-tests to determine their independent
relationship with depression (see SeeTable 1). Covariates with a
p  0.25 were identified and considered potential candidates for
the multivariate model. In order to create a parsimonious model,
variables with a p > 0.25 were not included in the model. The
criterion of p  0.25 allowed variables to be included in the model
that may potentially contribute to depression, while preventing
the under-selection of variables that occur with smaller criteria
(Hosmer and Lemeshow, 2000). Thus, in step 2, covariates with a
p  0.25 (i.e., age, gender, race, marital status, number of people in
household, income, and NYHA HF Class) were entered into a
logistic regression model to determine potential candidates for the
multivariate model. The model was reduced using 0.05 signifi-
cance. In step 3, potential candidates from step 2 (i.e., marital
status, number of people in household and NYHA HF Class) were
controlled for by combining them into a logistic regression analysis
with predictors of interest (i.e., HF symptomatology; belonging
support, tangible support, and appraisal support; social network;
positive and negative problem orientation; and rational, impul-
sivity/carelessness, and avoidance problem-solving styles). The
model was further reduced using the 0.05 significance criterion.
3. Results
3.1. Sample characteristics and univariate analyses
Participants (n = 201) ranged in age from 55 to 99 years, with an
average age of 72.57 years (SD, 8.94) and were mostly Caucasian
(86.1%) males (62.6%). Most participants had NYHA Class II HF
(47.3%). Of the sample, only 22.4% were experiencing depression
(CES-D score 16). Participants reporting more symptoms of
depression were of a low-middle socioeconomic class
($50,000/year; [73.4%]), minority (35% of total minority partic-
ipants vs. 20% for non-minority), lived with fewer people (2–3
people in household; [53.3%]) and had at least some college
education (64.5%).
Significant sociodemographic and clinical differences within
groups (non-depressed vs. depressed) were noted for marital
status (p < 0.001), NYHA HF Class (p = 0.002), income (p = 0.018),
and number of people in household (p = 0.046). Regarding the
study variables, significant group differences included HF symp-
tomatology (p < 0.001), appraisal (p < 0.001), tangible (p < 0.001),
and belonging support (p < 0.001), negative problem orientation
(p < 0.001) and avoidance problem-solving style (p < 0.001). Full
individual and clinical characteristics of the sample, including
univariate analyses, are presented in Table 1. Descriptive statistics
and univariate analyses for the study variables are displayed in
Table 2.
3.2. Predictors of depression
In the current study, logistic regression revealed three
predictors of depression, including marital status [not married]
 L.J. Graven et al. / International Journal of Nursing Studies 69 (2017) 57–65 61

Table 1
Sample Characteristics within Non-Depressed vs. Depressed.

Non-Depressed (n = 156) Depressed (n = 45) Chi-Square/t-test (P value)

Age 73 (9 years) 71 (9 years) 1.456 (0.147)*
Gender
Male 103 (66.0%) 23 (51.1%) 3.321 (.068)*
Female 53 (34.0%) 22 (48.9%)

Race
Non-Minority 138 (88.5%) 35 (77.8%) 3.325 (0.068)*
Minority 18 (11.5%) 10 (22.2%)

Marital status
Married/living with significant other 102 (65.0%) 15 (33.0%) 14.749 (0.000)*,z
Not married 54 (35.0%) 30 (67.0%)

Number of people in household

1 32 (20.5%) 18 (40.0%) 9.701 (0.046)*,y
2 93 (59.6%) 18 (40.0%)
3 25 (16.0%) 6 (13.3%)
4 4 (2.6%) 1 (2.2%)
5 or more 2 (1.3%) 2 (4.4%)

Income
<$30,000 22 (14.1%) 12 (26.7%) 13.595 (0.018)*,y
$30,000-$50,000 45 (28.8%) 21 (46.7%)
$50,000-$75,000 53 (34%) 8 (17.8%)
$75,000-$100,000 30 (19.2%) 4 (8.9%)
$100,000 4 (2.6%) 0 (0.0%)
No answer 2 (1.3%) 0 (0.0%)

NYHA HF class
1 36 (23.1%) 3 (6.7%) 14.607 (0.002)*,y
2 78 (50.0%) 17 (37.8%)
3 14 (9.0%) 9 (20.0%)
4 28 (17.9%) 16 (35.6%)

Education
6th grade 0 (0.0%) 1 (2.2%) 7.080 (0.313)
7th–9th grade 4 (2.6%) 2 (4.4%)
10th–12th grade 10 (6.4%) 5 (11.1%)
High school graduate 42 (26.9%) 8 (17.8%)
Some college or certificate 34 (21.8%) 12 (26.7%)
College graduate 49 (31.4%) 14 (31.1%)
Graduate degree 17 (10.9%) 3 (6.7%)

Length of time since HF diagnosis**

<1year 13 (8%) 6 (13%) 5.009 (.286)
1–5 years 46 (30%) 8 (18%)
5–10 years 41 (26%) 17 (38%)
10–15 years 26 (17%) 8 (18%)
>15 years 30 (19%) 6 (13%)

Notes: NYHA – New York Heart Association; HF = heart failure potential candidate for the multivariate model.
*
=p  0.25.
y
=p < 0.05.
z
=p < 0.001.
**
Not considered as potential candidate for the model.

(odds ratio [OR] = 2.878, 95% confidence interval [CI] = 1.198–
6.913); HF symptoms (OR = 1.949; 95% CI = 1.429–2.658); and
belonging support (OR = 0.777; 95% CI = 0.677–0.891). Individuals
who were not married were 2.8 times more likely to be depressed,
while those experiencing greater distress related to HF symptoms
were 1.9 times more likely to experience depression. In addition,
for every 1 point scored lower on the belonging scale, patients
were 1.29 (1/0.777) times more likely to be depressed (Table 3).
Multicollinearity was evaluated and within acceptable levels (i.e.,
VIF <10; tolerance >0.1). The overall model had a classification rate
of 86.1% and was statistically significant, with a x2(2) = 68.811,
p < 0.001. The Hosmer and Lemeshow test indicated the model fit
these data well (x2(8) = 4.597, p = 0.800).
4. Discussion
Although depression is a common co-morbid condition in
patients with HF (Conley et al., 2015; Hallas et al., 2011), few
studies have fully examined the influence of important coping
resources, such as social support and social problem-solving on
depression in HF patients (Heo et al., 2014b; Lazarus and Folkman,
1984). This study expanded upon statistical analyses in the parent
study (Graven et al., 2015a), by providing an in-depth examination
of the characteristics of patients with and without depression and
the influence of HF symptomatology and subcomponents of social
support (e.g., belonging, tangible, and appraisal support; social
network) and social problem-solving (i.e., positive and negative
problem orientation; rational, impulsivity/carelessness, and
62 L.J. Graven et al. / International Journal of Nursing Studies 69 (2017) 57–65

Table 2
Study Instruments: Descriptive Statistics.

Scale Subscales Used Possible Actual Overall Mean Non- Depressed* py

Range Range (SD) Depressed*
Heart Failure Symptom Survey (HFSS) Total Scale 0–10 0–7.39 1.50 (1.53) 0.82 [0.30, 2.52 [1.30, <0.001
1.63] 3.77]
Graven & Grant Social Network Survey (GGSNS) Total Scale 12–84 12–84 56.46 (18.73) 62 [49,72] 54 [39,66] 0.042
Interpersonal Support Evaluation List – 12 Appraisal Support 0–12 0–12 9.74 (3.05) 12 [10,12] 8 [5,10] <0.001
(ISEL-12) Tangible Support 0–12 0–12 10.30 (2.47) 12 [10,12] 9 [7,12] <0.001
Belonging Support 0–12 0–12 9.05 (3.02) 10 [8,12] 7 [4,10] <0.001

Social Problem Solving Inventory Positive Problem 0–20 5–20 14.27 (3.80) 15 [12,18] 13 [11,15] 0.040
Orientation

Revised – Short (SPSIR) Rational Problem Solving 0–20 0–20 12.95 (4.50) 14 [11,16] 13 [9,16] 0.162
Negative Problem 0–20 0–20 12.89 (6.51) 10 [5,15] 16 [10,19] <0.001
Orientation
Impulsivity/Carelessness 0–20 0–20 12.68 (5.98) 15 [8,18] 11[8,16] 0.031
Style
Avoidance Style 0–20 0–20 12.87 (6.39) 16 [10,19] 8 [6,14] <0.001

Center for Epidemiological Studies – Depression Total Scale 0–60 0–49 9.65 (10.17) – – –
*
Median [IQR].
y
p-value for Mann-Whitney test.

avoidance problem-solving styles) as potential predictors of
depression in patients with HF.
Logistic regression analysis indicated three predictors of
depression: marital status, HF symptomatology, and belonging
support. Marital status was found to have the largest impact on
depression, with findings indicating that being unmarried is
associated with greater risk of depression. Although previous
studies have examined this relationship, findings are not consis-
tent. While some studies have failed to find a significant
relationship between marital status and depression (Chung
et al., 2009; Rohyans and Pressler, 2009), others support our
findings (Pena et al., 2011; Scott et al., 2010). Being unmarried also
may increase the risk for other psychological disorders. Prior
research indicates that unmarried individuals are more likely to
develop anxiety, panic, and mood disorders, as well as substance
use (Scott et al., 2010). Although it appears marriage may provide
general psychological protection, more detailed social support
should always be assessed since marital status may not capture all
aspects of support.
Consistent with prior research (Fan and Meng, 2015; Herr et al.,
2014), results of this study highlight the significant influence of HF
symptomatology on depression. Examining the totality of the
symptom experience by evaluating symptom frequency and
severity, as well as the degree of symptom-related interference
with daily life adds new insight to available literature regarding HF
symptoms and psychological well-being. It also provides support
for evaluating HF symptoms more thoroughly when assessing
depression risk in these patients. While our data does support
previous findings that higher NYHA HF Class is associated with
depression, the total HFSS score was more predictive of depression
and remained a significant predictor even after adjusting for NYHA
HF Class. Thus, given our findings and the known variability of
clinical assignment of NYHA HF Class (Raphael et al., 2007), it
appears that self-report symptomatology may be more sensitive
for predicting depression in HF patients and subsequently, more
appropriate when assessing risk factors for depression versus
disease severity (i.e., NYHA HF Class). Complete assessment of HF
symptomatology and its effect on daily life is necessary to help
patients effectively manage symptoms and prevent adverse
psychological outcomes.
Less belonging support was predictive of more depression in
this study. Patients who perceived that there was no one available
to do things with were more likely to be depressed. Information in
the literature related to belonging support and depression is
minimal, with researchers focusing more on the impact of
emotional support which has been shown to have a positive
influence on depression (Heo et al., 2014b). Our findings illustrate
that improving belonging support may help to reduce depression.

Table 3
Final Model Summary.

b S. E. Wald df Sig. Exp(b) 95% CI

Lower Upper
Marital Status 1.057 0.447 5.593 1 0.018* 2.878 1.198 6.913
(ref: married)
NYHA HF Class 1.644 3 0.650
NYHA Class II vs. I 0.288 0.736 0.153 1 0.695 1.334 0.315 5.642
NYHA Class III vs. I 0.988 0.876 1.297 1 0.255 2.712 0.487 15.095
NYHA Class IV vs. I 0.423 0.823 0.263 1 0.608 1.526 0.304 7.664
HF Symptoms 0.667 0.158 17.791 1 0.000** 1.949 1.429 2.658
Belonging Support 0.253 0.070 13.004 1 0.000** 0.777 0.677 0.891
Constant 1.277 0.996 1.646 1 0.200 0.279

Nagelkerke R2 = 0.443.
NYHA = New York Heart Association; HF = heart failure.
*
p < 0.05.
**
p < 0.001.
 L.J. Graven et al. / International Journal of Nursing Studies 69 (2017) 57–65
The availability of someone to participate in activities with may
help patients redirect their focus from HF-related stressors (e.g., HF
symptomatology) to more enjoyable thoughts and activities,
thereby potentially reducing risk for depression through distrac-
tion (Cohen et al., 1985; Lazarus and Folkman, 1984).
Although appraisal and tangible support were significant in the
univariate analyses, neither were significant predictors of depres-
sion in this study after adjusting for NYHA HF class. No published
studies were found which examined appraisal support and
depression in HF patients; thus, this study provides new
knowledge. Limited studies have investigated tangible support
in HF patients and results vary. While, some studies found that less
tangible support was related to more depressive symptoms
(Thornhill et al., 2008; Yu et al., 2004), other researchers failed
to find a significant relationship (Heo et al., 2014b). Congruent with
previous research (Heo et al., 2014b), social network also was not
significantly related to depression in this study. The lack of
significance may be explained by the conceptual underpinnings of
social support and empirical evidence. Appraisal (i.e., affirmation
of one’s actions, thoughts, or statements) and tangible support (i.e.,
provision of goods or services) (Cohen et al., 1985) are more
palpable and may not be influenced by relationship quality as
much as belonging support (Horowitz et al., 2003; Reis and Collins,
2000). Thus, appraisal support and tangible support may be more
influential on physiological outcomes of HF, such as self-care and
hospital readmissions (Graven and Grant, 2014; Graven et al.,
2015c; Rodriguez-Artalejo et al., 2006 Rodriguez-Artalejo et al.,
2006) versus psychological outcomes, such as depression.
Problem-solving characteristics (i.e., problem orientation and
problem-solving style) were not significant in this study. This
finding was surprising since the way individuals appraise and solve
problems has predicted depression in other populations (e.g.,
adolescents, renal failure, HIV, stroke caregivers) (Becker-Weid-
man et al., 2010; Erdley et al., 2014; Prachakul et al., 2007).
Nevertheless, findings of the current study are consistent with
those of the parent study in which the total scale score for social
problem-solving was used versus subscales (Graven et al., 2015a).
Our results suggest that problem-solving characteristics may not
have much impact on psychological distress in HF patients.
Further, the potential relationship between social support and
social problem-solving may be more complex due to the
interactive appraisal of stressors and coping strategies that are
used by two or more individuals (Rich and Bonner, 2004). Hence,
individuals who have someone to spend time and interact with
(i.e., belonging support) are likely to appraise stressors more
effectively and to use more beneficial strategies to address HF
situations and manage depressive symptoms. Thus, future studies
should examine the influence of social resources on the social
problem-solving process.
4.1. Limitations
This study is one of few which examines individual subcom-
ponents of social support and social problem-solving and their
individual contributions to depression in patients with HF.
However, this study does have limitations which impact gener-
alizability of findings. Only 22.4% of our sample scored 16 on the
CES-D. Therefore, the study population may have underrepresent-
ed depression, given empirical literature suggests that the
percentage of HF patients experiencing depression is higher
(Brouwers et al., 2014; Heo et al., 2014a; Rutledge et al., 2006). The
sample was also comprised primarily of older, non-minority,
Caucasian men further limiting generalizability of study findings to
other groups of HF patients. In addition, the cross-sectional design
limits the ability to infer causality and evaluate the influence of
these variables on depression over time. Thus, our understanding
63
of how coping resource utilization may change with increased HF-
related stressors remains unknown. Also, multicollinearity issues
among the HFSS subscales prevented examination of the individual
influences of symptom frequency, severity, and symptom-related
interference with physical activity and enjoyment of life on
depression in this study. Consequently, we still do not know which
component of symptomatology contributes to depression the most
in HF patients. Lastly, anti-depressant use and other variables
which have been found to influence depression in prior studies
(e.g., relationship quality, personality, anxiety, co-morbidities, etc.)
were not examined in this study and should be considered for
inclusion in future research examining predictors of depression
(Brouwers et al., 2014; Chapa et al., 2014; Horowitz et al., 2003; Sin,
2012; Yohannes et al., 2010).
4.2. Implications for policy, practice, and research
Although the percentage of depressed participants in this study
was low, it is important to identify patients who are at risk for or
experiencing depression in order to improve clinical outcomes. In
fact, clinical guidelines by the American Heart Association
recommend routine screening for depression in patients with
cardiac disease (Lichtman et al., 2008). Yet, depression screening is
not routinely conducted and, often, appropriate screening tools are
not available for use (Lea, 2014). While national standards exist
(Lichtman et al., 2008), policies need to be developed within
outpatient clinics to comply with depression screening standards.
Research indicates that early identification of depression is
important to facilitate appropriate interventions (Silver, 2010)
and may contribute to improved overall health status (Xiong et al.,
2012), subsequent hospitalizations, and quality of life (Rutledge
et al., 2006; Xiong et al., 2012).
Further, findings of this study provide important information to
guide clinical practice. Being unmarried, perceiving a lack of
belonging support, and experiencing high symptom burden are
important factors to be included in a risk profile for depression in
HF patients. Patients with HF frequently visit healthcare providers
for routine appointments and acute issues. Marital status and
available support should be evaluated during clinic appointments.
Complete assessment of HF symptoms and the degree of
interference with daily life should be conducted at each healthcare
visit to fully assess the extent of HF symptomatology. Clinicians
should identify patients with these risk factors at each visit, screen
these patients for depression using a valid and reliable depression
screening tool (e.g., CES-D, Beck Inventory-II, etc.), and refer them
for clinical or psychological follow-up as needed.
Empirical evidence also indicates that belonging support may be
enhanced. HF patients who participate in peer support programs
report the importance of sharing information and experiences with
other HF patients and the potential to build friendships in an
environment that is deemed safe and accepting (Lockhart et al.,
2014). Thus, participating in peer support groups may help HF
patients cope more effectively with HF-related stressors while
facilitating the development of relationships that enhance belonging
support. The increased use of technology (e.g., text messaging and
social networking) provides additional options for enhancing
belonging support (Aggarwal et al., 2015; Franklin, 2015). Nonethe-
less, clinicians should evaluate patients for available support and
encourage patients to participant in group activities (e.g., church or
social clubs; peer support groups; social media) to the extent that
they are cognitively and physically able to increase belonging
support. Additionally, families often accompany HF patients to
healthcare visits. Clinicians can use these opportunities to educate
family members on the importance of belonging support and
identify ways family members can spend time with their loved one
based upon the physical ability of the patient.
64 L.J. Graven et al. / International Journal of Nursing Studies 69 (2017) 57–65
Future research related to depression in HF patients is needed to
increase knowledge related to predictors of depression and how
coping resources are used by patients with HF. Anxiety, relationship
quality, personality, and number of co-morbidities may influence
coping mechanisms, as well as depression and should be included in
future studies. Additionally, longitudinal studies are needed to
examine causality and examine how coping resource utilization
changes as HF progresses. This information is necessary to inform
intervention development which target coping resources, such as
social support and problem-solving to enhance coping and reduce
depression. While this study evaluated HF symptomatology, we were
unable to examine the individual contributions of symptom
frequency, severity, and degree of symptom-related interference
with activity or enjoyment of life to depression. Thus, more symptom
research is needed to fully understand which component of
symptomatology contributes the most to depression in individuals
with HF.
5. Conclusion
Living with HF and its symptoms can be stressful, requiring
adequate coping resources to assist with maintaining psychological
well-being. The current study provides additional cues to improve
the psychological well-being of the HF population. Findings of this
study advance prior research by suggesting that being unmarried or
living alone and having less belonging support increases the risk of
depression in HF patients. Assessing availability of living situations
and perceived belonging support in HF patients is important,
especially since many HF patients are older and require more
assistance with daily activities. Increased HF symptomatology may
also elevate depression risk in this population. An in-depth
assessment of HF symptomatology is needed to understand the
totality of the symptom experience for each patient in an effort to
identify potential stressors and promote psychological adaptation.
As always, patients who are at risk for depression should be clinically
screened, with proper psychological referral, if needed.
Funding
No external funding supported this research study.
Conflicts of interest
None.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.
ijnurstu.2017.01.014.
References
Aggarwal, B., Pender, A., Mosca, L., et al., 2015. Factors associated with medication
adherence among heart failure patients and their caregivers. J. Nurs. Educ. Pract.
5 (3), 22–27. doi:http://dx.doi.org/10.5430/jnep.v5n3p22.
Becker-Weidman, E.G., Jacobs, R.H., Reinecke, M.A., et al., 2010. Social problem-
solving among adolescents treated for depression. Behav. Res. Ther. 48 (1), 11–
18. doi:http://dx.doi.org/10.1016/j.brat.2009.08.006.
Brandt, J., Spencer, M., Folstein, M., 1988. The telephone interview for cognitive
status. Neuropsychiatry Neuropsychol. Behav. Neurol. 1 (2), 111–117.
Brouwers, C., Kupper, N., Pelle, A.J., et al., 2014. Depressive symptoms in outpatients
with heart failure: importance of inflammatory biomarkers, disease severity,
and personality. Psychol. Health 29 (5), 564–582. doi:http://dx.doi.org/10.1080/
08870446.2013.869813.
Butler, J., 2010. The management of heart failure. Pract. Nurs. 21 (6), 290–296. doi:
http://dx.doi.org/10.12968/pnur.2010.21.6.48325.
Chapa, D.W., Akintade, B., Son, H., et al., 2014. Pathophysiological relationships
between heart failure and depression and anxiety. Crit. Care Nurs. 34 (2), 14–24.
doi:http://dx.doi.org/10.4037/ccn2014938.
Chin, W.Y., Choi, E.P.H., Chan, K.T.Y., et al., 2015. The psychometric properties of the
center for epidemiological studies depression scale in Chinese primary care
patients: factor structure, construct, validity, reliability, sensitivity, and
responsiveness. PLoS One 10 (8), e0135131. doi:http://dx.doi.org/10.1371/
journal.pone.0135131.
Chung, M.L., Lennie, T.A., Riegel, B., et al., 2009. Marital status as an independent
predictor of event-free survival of patients with heart failure. Am. J. Crit. Care 18
(6), 562–570. doi:http://dx.doi.org/10.4037/ajcc2009388.
Chung, M.L., Moser, D.K., Lennie, T.A., et al., 2013. Perceived social support predicted
quality of life in patients with heart failure, but the effect is mediated by
depressive symptoms. Qual. Life Res. 22, 1555–1563. doi:http://dx.doi.org/
10.1007/s11136-012-0294-4.
Cohen, S., Mermelstein, R., Kamarck, R., et al., 1985. Measuring the functional
components of social support. In: Sarason, I.G., Sarason, B.R. (Eds.), Social
Support: Theory, Research, and Applications. Martinus Nijhoff Publishers,
Dordrecht, pp. 73–94.
Conley, S., Feder, S., Redeker, N.S., 2015. The relationship between pain, fatigue,
depression and functional performance in stable heart failure. Heart Lung 44
(2), 107–112. doi:http://dx.doi.org/10.1016/j.hrtlng.2014.07.008.
Criteria Committee of the New York Heart Association, 1994. Nomenclature and
Criteria for Diagnosis of Diseases of the Heart and Great Vessels, ninth ed. Little,
Brown, & Co., Boston, MA.
D’Zurilla, T.J., Nezu, A.M., Maydeu-Olivares, A., 2002. Manual for the Social Problem-
Solving Inventory-Revised. Multi-Health Systems, North Tonawanda, NY.
D’Zurilla, T.J., Nezu, A.M., Maydeu-Olivares, A., 2004. Social-problem solving: theory
and assessment. In: Chang, E.C., D’Zurilla, T.J., Sanna, L.J. (Eds.), Social-Problem
Solving: Theory Research, and Training. American Psychological Association,
Washington, DC, pp. 11–27.
Elliott, T.R., Grant, J.S., Miller, D.M., 2004. Social problem-solving abilities and
behavioral health. In: Chang, E.C., D’Zurilla, T.J., Sanna, L.J. (Eds.), Social-Problem
Solving: Theory Research, and Training. American Psychological Association,
Washington, DC, pp. 117–133.
Erdley, S.D., Gellis, Z.D., Bogner, H.A., et al., 2014. Problem-solving therapy to
improve depression scores among older hemodialysis patients: a pilot
randomized trial. Clin. Nephrol. 82 (1), 26–33. doi:http://dx.doi.org/10.5414/
CN108196.
Fan, X., Meng, Z., 2015. The mutual association between depressive symptoms and
dyspnea in Chinese patients with chronic heart failure. Eur. J. Cardiovasc. Nurs.
14 (4), 310–316. doi:http://dx.doi.org/10.1177/1474515114528071.
Franklin, N.C., 2015. Technology to promote and increase physical activity in heart
failure. Heart Fail. Clin. 11 (1), 173–182. doi:http://dx.doi.org/10.1016/j.
hfc.2014.08.006.
Friedmann, E., Son, H., Thomas, S.A., et al., 2014. Poor social support is associated
with increases in depression but not anxiety over 2 years in heart failure
outpatients. J. Cardiovasc. Nurs. 29 (1), 20–28. doi:http://dx.doi.org/10.1097/
JCN.0b013e318276fa07.
Graven, L.J., Grant, J.S., 2014. Social support and self-care behaviors in individuals
with heart failure: an integrative review. Int. J. Nurs. Stud. 51, 320–333. doi:
http://dx.doi.org/10.1016/j.ijnurstu.2013.06.013.
Graven, L.J., Grant, J.S., Vance, D.E., et al., 2014. Factors associated with depressive
symptoms in patients with heart failure. Home Healthc. Nurse 32 (9), 550–555.
doi:http://dx.doi.org/10.1097/NHH.0000000000000140.
Graven, L.J., Grant, J.S., Vance, D.E., et al., 2015a. Predicting depressive symptoms and
self-care in patients with heart failure. Am. J. Health Behav. 39 (1), 77–87. doi:
http://dx.doi.org/10.5993/AJHB.39.1.9.
Graven, L.J., Grant, J.S., Gordon, G., 2015b. Development and preliminary testing of
the Graven and Grant Social Network Survey in patients with heart failure. J.
Nurs. Care 4 (4), 1–7. doi:http://dx.doi.org/10.4172/2167-1168.1000275.
Graven, L.J., Grant, J.S., Gordon, G., 2015c. Symptomatology and coping resources
predict self-care behaviors in middle to older age patients with heart failure.
Nurs Res Prac 840240, 1–8. doi:http://dx.doi.org/10.1155/2015/840240.
Hallas, C.N., Wray, J., Andreou, P., et al., 2011. Depression and perceptions about
heart failure predict quality of life in patients with advanced heart failure. Heart
Lung 40 (2), 111–121. doi:http://dx.doi.org/10.1016/j.hrtlng.2009.12.008.
Heo, S., Moser, D.K., Pressler, S.J., et al., 2014a. Depressive symptoms and the
relationship of inflammation to physical signs and symptoms in heart failure
patients. Am. J. Crit. Care 23 (5), 404–413. doi:http://dx.doi.org/10.4037/
ajcc2014614.
Heo, S., Lennie, T.A., Moser, D.K., et al., 2014b. Types of social support and their
relationships to physical and depressive symptoms and health-related quality
of life in patients with heart failure. Heart Lung 43 (4), 299–305. doi:http://dx.
doi.org/10.1016/j.hrtlng.2014.04.015.
Herr, J.K., Salyer, J., Lyon, D.E., et al., 2014. Heart failure symptom relationships: a
systematic review. J. Cardiovasc. Nurs. 29 (5), 416–422. doi:http://dx.doi.org/
10.1097/JCN.0b013e31829b675e.
Hertzog, M.A., Pozehl, B., Duncan, K., 2010. Cluster analysis of symptom occurrence
to identify subgroups of heart failure patients: a pilot study. J. Cardiovasc. Nurs.
25 (4), 273–283. doi:http://dx.doi.org/10.1097/JCN.0b013e3181cfbb6c.
Horowitz, A., Reinhardt, J.P., Boerner, K., et al., 2003. The influence of health, social
support quality and rehabilitation on depression among disabled elders. Aging
Ment. Health 7 (5), 342–350. doi:http://dx.doi.org/10.1080/
1360786031000150739.
 L.J. Graven et al. / International Journal of Nursing Studies 69 (2017) 57–65
Hosmer, D.W., Lemeshow, S., 2000. Applied Logistic Regression, second ed. John
Wiley & Sons, Inc., New York.
Jenner, R.C., Strodl, E.S., Schweitzer, R.D., 2009. Anger and depression predict
hospital use among chronic heart failure patients. Aust. Health Rev. 33 (4), 541–
548. doi:http://dx.doi.org/10.1071/AH090541.
Johansson, P., Dahlström, U., Broström, A., 2006. Consequences and predictors of
depression in patients with chronic heart failure: implications for nursing care
and future research. Prog. Cardiovasc. Nurs. 21 (4), 202–211.
Kelloway, E.K., 1998. Using LISREL for Structural Equation Modeling: A Researcher’s
Guide. Sage Publishing, Thousand Oaks.
Lazarus, R.S., Folkman, S., 1984. Stress, Appraisal, and Coping. Springer Publishing
Company Inc., New York.
Lea, P., 2014. Factors affecting nurses’ intent to assess for depression in heart failure
patients. Dimens. Crit. Care Nurs. 33 (6), 320–326. doi:http://dx.doi.org/
10.1097/DCC.0000000000000073.
Lesman-Leegte, I., Jaarsma, T., Coyne, J.C., et al., 2009. Quality of life and depressive
symptoms in the elderly: a comparison between patients with heart failure and
age and gender-matched community controls. J. Card. Fail. 15 (1), 17–23. doi:
http://dx.doi.org/10.1016/j.cardfail.2008.09.006.
Lewinsohn, P.M., Seeley, J.R., Roberts, R.E., et al., 1997. Center for epidemiological
studies-depression scale (CES-D) as a screening instrument for depression
among community-residing older adults. Psychol. Aging 12, 277–287.
Lichtman, J.H., Bigger, J.T., Blumenthal, J.A., et al., 2008. Depression and coronary
heart disease: recommendations for screening, referral, and treatment.
Circulation 118 (17), 1768–1775 1161/CIRCULATIONAHA.108.190769.
Lockhart, E., Foreman, J., Mase, R., et al., 2014. Heart failure patients’ experiences of a
self-management peer support program: a qualitative study. Heart Lung 43,
292–298. doi:http://dx.doi.org/10.1016/j.hrtlng.2014.04.008.
Macabasco-O’Connell, A., Crawford, M.H., Stotts, N., et al., 2010. Gender and racial
differences in psychosocial factors of low-income patients with heart failure.
Heart Lung 39 (1), 2–11. doi:http://dx.doi.org/10.1016/j.hrtlng.2009.05.001.
Maeda, U., Shen, B., Schwarz, E.R., et al., 2013. Self-efficacy mediates the associations
of social support and depression with treatment adherence in heart failure
patients. Int. J. Behav. Med. 20 (1), 88–96. doi:http://dx.doi.org/10.1007/s12529-
011-9215-0.
Mozaffarian, D., Benjamin, E.J., Go, A.S., et al., 2015. Heart disease and stroke
statistics: 2015 update. Circulation 131 (4), e29–e322. doi:http://dx.doi.org/
10.1161/CIR.0000000000000152.
Parikh, R.M., Eden, D.T., Price, T.R., et al., 1988. The sensitivity and specificity of the
center for epidemiological studies depression scale in screening for post-stroke
depression. Int. J. Psychiatry Med. 18, 169–181.
Pena, F.M., Modenesi Rde, F., Piraciaba, M.C.T., 2011. Prevalence and variables
predictive of depressive symptoms in patients hospitalized for heart failure.
Cardiol. J. 18 (1), 18–25.
Pfeiffer, K., Beische, D., Hautzinger, M., et al., 2014. Telephone-based problem-
solving intervention for family caregivers of stroke survivors: a randomized
controlled trial. J. Consult. Clin. Psychol. 82 (4), 628–643. doi:http://dx.doi.org/
10.1037/a0036987.
Polit, D., 2010. Logistic regression, In: Polit, D. (Ed.), Statistics and Data Analysis for
Nursing Research. second ed. Pearson, New Jersey, pp. 306–332.
Ponikowski, P., Anker, S.D., AlHabib, K.F., et al., 2014. Heart failure: preventing
disease and death worldwide. ESC-HF 1 (1), 4–25. doi:http://dx.doi.org/
10.1002/ehf2.12005.
Prachakul, W., Grant, J.S., Keltner, N.L., 2007. Relationships among functional social
support HIV-related stigma, social problem-solving, and depressive symptoms
65
in people living with HIV: a pilot study. J. Assoc. Nurses AIDS Care 18 (6), 67–76.
doi:http://dx.doi.org/10.1016/j.jana.2007.08.002.
Quinn, C., Dunbar, S.B., Higgins, M., 2010. Heart failure symptom assessment and
management: can caregivers serve as proxy? J. Cardiovasc. Nurs. 25 (2), 142–
148. doi:http://dx.doi.org/10.1097/JCN.0b013e3181bf93a0.
Radloff, L.S., 1977. The CES-D scale: a self-report depression scale for research in the
general population. Appl. Psychol. Meas. 1 (3), 385–401. doi:http://dx.doi.org/
10.1177/014662167700100306.
Raphael, C., Briscoe, C., Davies, J., et al., 2007. Limitations of the New York Heart
Association functional classification system and self-reported walking dis-
tances in chronic heart failure. Heart 93 (4), 476–482. doi:http://dx.doi.org/
10.1136/hrt.2006.089656.
Reis, H.T., Collins, N., 2000. Measuring relationship properties and interactions
relevant to social support. In: Cohen, S., Underwood, L.G., Gottlieb, B.H. (Eds.),
Social Support Measurement and Intervention: A Guide for Health and Social
Scientists. Oxford University Press, New York, pp. 136–192.
Rich, A.R., Bonner, R.L., 2004. Mediators and moderator of social problem-solving.
In: Chang, E.C., D’Zurilla, T.J., Sanna, L.J. (Eds.), Social-Problem Solving: Theory
Research, and Training. American Psychological Association, Washington, DC,
pp. 29–45.
Rodriguez-Artalejo, F., Guallar-Castillon, P., Herrera, M.C., et al., 2006. Social
network as a predictor of hospital readmission and mortality among older
patients with heart failure. J. Card. Fail. 12, 621–627. doi:http://dx.doi.org/
10.1016/j.cardfail.2006.06.471.
Rohyans, L.M., Pressler, S.J., 2009. Depressive symptoms and heart failure. Clin.
Nurse Spec. 23 (3), 138–144. doi:http://dx.doi.org/10.1097/NUR.0-
b013e3181a443b4.
Rutledge, T., Reis, V.A., Linke, S.E., et al., 2006. Depression in heart failure: a meta-
analytic review of prevalence, intervention effects, and associated clinical
outcomes. JACC 48 (8), 1527–1537. doi:http://dx.doi.org/10.1016/j.
jacc.2006.06.055.
Scott, K.M., Wells, J.E., Angermeyer, M., et al., 2010. Gender and the relationship
between marital status and first onset of mood, anxiety, and substance use
disorders. Psychol. Med. 40, 1495–1505. doi:http://dx.doi.org/10.1017/
S0033291709991942.
Shimizu, Y., Susuki, M., Okumura, H., et al., 2014. Risk factors for onset of depression
after heart failure hospitalization. J. Cardiol. 64 (1), 37–42. doi:http://dx.doi.org/
10.1016/j.jjcc.2013.11.003.
Silver, M., 2010. Depression and heart failure: an overview of what we know and
don’t know. Clevel. Clin. J. Med. 77 (3), S7–S11.
Sin, M., 2012. Personal characteristics predictive of depressive symptoms in
Hispanics with heart failure. Issues Ment. Health Nurs. 33, 522–527. doi:http://
dx.doi.org/10.3109/01612840.2012.687438.
Thornhill, K., Lyons, A.C., Nouwen, A., et al., 2008. Experiences of living with
congestive heart failure: a qualitative study. Br. J. Health Psychol. 13 (1), 155–
175. doi:http://dx.doi.org/10.1348/135910706X170983.
Xiong, G., Fiuzat, M., Kuchibhatla, M., et al., 2012. Health status and depression
remission in patients with chronic heart failure: patient reported outcomes in
the SADHART-CHF trial. Circ. Heart Fail. 5, 688–692.
Yohannes, A.M., Willgoss, T.G., Baldwin, R.C., et al., 2010. Depression and anxiety in
chronic heart failure and chronic obstructive pulmonary disease: prevalence,
relevance, clinical implications, and management principles. Int. J. Geriatr.
Psychiatry 25 (12), 1209–1221. doi:http://dx.doi.org/10.1002/gps.2463.
Yu, D.S.F., Lee, D.T.F., Woo, J., et al., 2004. Correlates of psychological distress in
elderly patients with congestive heart failure. J. Psychosom. Res. 57 (6), 573–
581. doi:http://dx.doi.org/10.1016/j.jpsychores.2004.04.368.