Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation





First Advisor

Dr. Debra K. Moser


The incidence of heart failure (HF) has increased each year as more people are living longer with heart disease and other chronic conditions. Recently, there has been much interest in the psychological dimensions of HF and the influence psychological symptoms have on the health outcomes (e.g., self-care, rehospitalization, mortality and quality of life) of patients living with HF. Patients with HF frequently experience symptoms of anxiety, depression, and hostility that may be associated with poor health outcomes. The purpose of this dissertation was to examine how psychological variables influence health outcomes of patients with HF, how psychological variables change over time, and whether different trajectories of psychological variables are associated with health outcomes. The specific aims of this dissertation were to: (1) evaluate the psychometric properties of the Brief Symptom Inventory (BSI) Hostility subscale in patients with HF; (2) determine whether anxiety, depression, and hostility predict self-care behaviors in patients with HF; and (3) describe trajectories of anxiety and depressive symptoms among patients with HF at baseline and 3 and 12 months post-baseline, and explore whether these symptom trajectories predict 1-year cardiac event-free survival and physical health-related quality of life (P-HRQOL).

Secondary analyses of longitudinal data from a large, multi-region registry representing the Midwest, Southwest, Southeast, Northwest and Northeast United States (Heart Failure Quality of Life Trialists Collaborative) were conducted. Data from three subsets of participants enrolled in the Collaborative with complete data on the variables of interest comprised the samples for the three studies in this dissertation. In the first study, a psychometric evaluation of the BSI Hostility subscale was conducted using data from 345 patients with HF. The subscale demonstrated adequate internal consistency reliability (Cronbach’s alpha = .77) and construct validity. In the second longitudinal study of 214 patients with HF, baseline anxiety, depression, and hostility did not predict self-care at 12 months; however, higher perceived social support predicted greater self-care. In the third study, baseline, 3-month, and 12-month data from 597 patients with HF were used to examine the association of anxiety and depression trajectories with one-year cardiac event-free survival and P-HRQOL in patients with HF. Distinct trajectories of anxiety and depression predicted mortality, hospital readmission, and P-HRQOL.

The findings of these studies filled some gaps in our understanding regarding how anxiety, depression, and hostility influence health outcomes of patients with HF. The findings suggest how a measure of hostility may be improved to assess hostility in patients with HF and the importance of assessing psychological symptoms routinely in order to identify changes in these symptoms. Results showed that psychological variables did not predict self-care, a component of risk reduction in improving health outcomes among patients with HF, but that social support, an important psychosocial variable, was a strong predictor of self-care. Trajectories of psychological variables were significant predictors of health outcomes in patients with HF at 1-year follow-up. Implications include the importance of monitoring psychological symptoms over time. A better understanding of how psychological symptoms change is meaningful, as it affords clinicians the opportunity for timely interventions designed to reduce the risk of adverse events and improve health outcomes. Even though numerous studies exist which examine psychological symptoms and health outcomes in patients with HF, there are very few longitudinal studies investigating trajectories of psychological symptoms in this population. Subsequently, more research is needed to investigate psychological symptom trajectories and identify high risk groups. In addition, the design and testing of interventions aimed at reducing psychological symptoms is critical to improve health outcomes in patients with HF.

Digital Object Identifier (DOI)

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Nursing Commons