Islam M, Mullick MSI, Chowdhury HR, Ahsan MS. Psychosocial Stressors among Patients of Ischaemic Heart Disease, Diabetes Mellitus, Stroke and Depression : A Comparative Study

Islam M; Mullick MSI; Chowdhury HR; Ahsan MS

Research Article

J Psychiatry Mental Disord. 2025; 10(1): 1080.

Psychosocial Stressors among Patients of Ischaemic Heart Disease, Diabetes Mellitus, Stroke and Depression: A Comparative Study

Islam M*, Mullick MSI, Chowdhury HR and Ahsan MS

Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh

*Corresponding author: Monirul Islam, Assistant Professor, Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh Tel: +8801711800297. Email: monirulbsmmu@gmail.com

Received: January 02, 2025; Accepted: February 10, 2025; Published: February 15, 2025

Abstract

Stressful life experiences have been a significant contributing factor to the development of psychological discomfort. These events have been linked to the subsequent development of Ischaemic heart disease (IHD), Diabetes mellitus (DM), Stroke, and Depression. Our study aimed to investigate the various types, numbers, average stress scores, and gender disparities in stressful life events occurring within one year prior to the development of these four diseases. This cross-sectional descriptive study was carried out at Bangabandhu Sheikh Mujib Medical University’s (BSMMU), Department of Psychiatry, Dhaka, from July 2017 to June 2018. A total of 200 samples (50 patients from each department) were taken. After receiving informed consent, patients of both sexes, aged 18 and above, were asked to complete the socio-demographic questionnaire and the Dhaka Stress Scale-Adult version (DSS-A). Stressful life events of DSS-A were marked as experienced in the last year before the onset of the disease. The mean of the total number of life events experienced by these patients was 4.22(SD=1.8), 3.58(SD=1.8), 3.3(SD=1.8), and 4.5(SD=1.5) in IHD, DM, Stroke, and Depression, respectively. Of the four groups, male patients with depression and females with IHD experienced the highest number of life events, with a mean of 4 and 5, respectively. In our population, the average individual experiences an average of three to five stressful life events in the last year before having these four diseases. Mean stress score (MSC) was highest in males (MSC=286) and females (MSC=363) with depression. Among the four groups, 34 (17%) patients perceived a mild level of stress, followed by 67 (33.5%) patients at a moderate level and 99 (49.5%) patients at a severe level of stress. There were 227 (29%) stressful life events reported by depressed patients, followed by 212 (27%), 180 (23%), and 165 (21%) stressful life events by IHD, DM, and stroke patients, respectively. Stressful life events were more common in women than in men with depression, with a male: female ratio of 1:2.6. Overall male-female ratio of four diseases was 1:1.2. Total stress scores ranging from 33 to 680 with highest MSC of 339 (SD=125.7) reported by patients with depression followed by 307 (SD=142) MSC perceived by patients with Ischaemic Heart Disease and 274 (SD=152) by diabetic patients. However, It was lowest (MSC=252, SD=143.5) in patients with stroke. In conclusion, stressful life events play an important factor in the later development of Ischaemic heart disease, Diabetes mellitus, Stroke, and Depression.

Keywords: Stress; Stressful life events; Ischaemic heart disease; Diabetes mellitus; Stroke; Depression

Introduction

An examination of health status would be incomplete without evaluating psychosocial stress. Stress is one of the most common causes of psychiatric and medical conditions. It may result in enormous psychosocial difficulties. In ancient times, Hippocrates (460–377 BC) said, "It is better to know the patient who has the disease than it is to know the disease which the patient has” [1]. Understanding the psychosocial influences is an essential part of "knowing the patient".

The Concept of Stress

Stress is defined as the disruption of our normal psychological and physiological functioning when a challenge threatens our ability to cope adequately, and things that produce stress are called stressors, which depend on individual adjusting capacity [2]. In the modern age, Walter Cannon was the first to write about stress and use the term extensively. Mr Cannon stated, "Stress is the nonspecific response of the body to any demand made upon it." [2]. There are three important components of stress: a stressful event, appraisal, and stress reaction. A stressful event is any situation that the individual perceives as threatening. Perception of an individual of an event is an appraisal, which challenges personal goals and coping ability. Stress reactions are the disruptive effects of stressful events on psychological and physiological functioning [3]. Any event can be stressful if an individual perceives it as stress. So, it is not possible to quantify an event as stressful in advance. Stressful events may be an acute and chronic source of Stress. Acute sources of stress or daily hassles are dayin and day-out frustrations, such as the illness of a family member or home maintenance. Chronic sources of stress, which have cumulative effects, are ongoing life difficulties that include low income and poor housing. There are three essential characteristics of stressful events: Hopelessness, overload, and conflict. Helplessness event occurs when an unwanted situation happens regardless of anything we do or not to do. Overload occurs when an event is so severe that we cannot cope with it. Conflict arises when environmental stimuli arouse two or more incompatible motives. On the other hand, appraisals may be primary and secondary. Primary appraisal is an individual's perception of an event as a threat to well-being. Secondary appraisal is an individual's judgment of the availability of personal coping sources. The third component of stress is stress reaction, which may involve emotional, cognitive, and physiological disruption [3].

Hans Selye's view on Stress

In 1936, Canadian biologist Hans Selye became the first researcher to examine how psychological stress affects the human body [4]. He distinguished between stress, stressor, and stress reaction, which he considered a complex phenomenon. The system goes into a defines state when it senses a threat and tries to regain equilibrium in various ways. The body goes into a "fight or flight" response as part of this adaptive system. However, "General Adaptation Syndrome" may result if the arousal state persists over time. The author distinguishes three stages in reaction to a stressor. The first is an "alarm reaction": the homeostatic balance is changed, which increases energy availability and makes the situation easier to handle. Homeostasis is restored if the danger disappears. When the stimulus persists, we enter the second stage, called "resistance or adaptation". Chemical parameters and visceral functions are kept in a modified state as long as the threat is present. This suggests a higher central and peripheral functioning level as well as a significant energy expenditure. However, a person's resilience varies depending on genetic, cognitive, and psychological characteristics, and they cannot always handle a hostile environment. Over time, it leads to an "exhaustion" of adaptability (third phase), and the individual may become unwell or perhaps pass away. This occurs particularly when the threat is unavoidable, undesired, and recurring; if the stress is brief, the body returns to normal with no adverse effects.

Selyes' theory has been supported by research in recent years, which increasingly demonstrates how prolonged stress may encourage the formation of somatic diseases in vulnerable individuals. In actuality, prolonged exposure to negative events impacts immunological function, metabolism, and hormonal balance [5]. In particular, chronic activation of the hypothalamus-pituitary-adrenal (HPA) axis raises glucocorticoid levels, leading to hypercortisolismrelated disorders. Moreover, central obesity, peripheral tissue insulin resistance, and glucose intolerance are all made easier by this illness, which also encourages immune function changes. However, not everyone experiences these processes in the same way, and certain gender-related differences have been discovered by researchers [6]. In fact, according to some writers, the greater susceptibility of women to autoimmune disorders and the greater vulnerability of men to infectious and vascular diseases may be explained, at least in part, by gender variations in the stress system [7]. Indeed, new evidence from molecular research indicates that estrogenic hormone is a key player in the onset of autoimmune illness [8].

Stress and IHD

The American Heart Association (AHA) estimates that 15.5 million Americans between the ages of 20 and over have coronary heart disease (CHD), and approximately every 42 seconds, an American will suffer from a myocardial infarction (MI) [9]. According to a 2014 study that used data from the World Health Organization (WHO) from 49 nations in Europe and northern Asia, CVD causes more than 4 million deaths annually [10]. Psychosocial factors such as low social support or low socioeconomic status have been found to be associated with the etiology and prognosis of CHD [11]. Educational level was reported to predict mortality in cardiac patients [12]. Williams et al. found that a higher mortality rate was associated with income [13]. It has been suggested that impaired autonomic function and lower heart rate variability may be a link between low social position and heart disease [14]. Being married has been associated with a lower risk of mortality in some studies examining community samples [15-17]. Religion or spirituality was found to protect against cardiovascular disease [18-20]. Self-efficacy has been found to predict the physical function, social, and family function in patients with CHD [21]. A gradient relationship was observed between the levels of anger and the risk of coronary heart disease [22-23]. Living alone was a bad prognostic factor after MI [24]. In a case-control study in Bangladesh [25], it was found that patients with the first attack of myocardial infarction reported 2.3 times as many psychosocial stressful events as the control patients.

Stress and DM

Diabetes mellitus (DM) is typified by an inability to sustain appropriate glucose homeostasis [26]. Type 2 diabetes is a major public health problem, with the world prevalence among adults estimated to be 6.4% in 2010. By 2030, it is expected that the burden of diabetes will affect more than 439 million adults worldwide, or 7.7% of the global population. Over the next 20 years, the developed world will see an increase of 20% in the number of adults living with diabetes, and developing countries will see a rise of 69% [27]. Stress is recognized to have a direct and indirect relationship with diabetes [28-29]. According to numerous studies, diabetes may induced by stress [30-34], and several hormones, including cortisol, are known to be involved [33]. Emotional stress, eating disorders, and depression make it harder to regulate oneself, and they can have negative consequences on glycemic control and lead to complications [35]. Basic health education regarding diabetes should be delayed until the patient can manage their stress because extreme stress can hinder the patient's capacity to benefit from it [36]. Animal research suggests that stress affects the onset of type I diabetes. Animals that were partially pancreatectomized surgically have been shown to develop diabetes after restraint stress [37]. Henry Maudsley observed that diabetes often followed the occurrence of a sudden trauma [38]. Walter B. Cannon provoked stress-induced hyperglycemia in normal cats [39]. According to research, people with diabetes are more likely to experience a significant loss in their family before their symptoms appear. [39-42]. According to Hinkle et al., following stressful psychiatric interviews, diabetes patients showed increases in blood glucose and ketones [43-45]. Bradley reported that noise stress increased or decreased blood glucose in hyperglycemic or hypoglycemic diabetic subjects, respectively [46]. Mikat et al. [47] have shown that stress may play a role in the expression of hyperglycemia in animals. Grant et al. [48] suggested a relationship between life events and changes in type II diabetic symptoms. They suggested that there may be life-event-responsive diabetic patients. Surwit et al. [49] have shown that the degree of hyperglycemia is dependent on the animal exposed to stressful environmental stimuli.

Stress and Stroke

The World Health Organization stated that stroke killed 5.7 million people and 16 million first-time incidents in 2005; by 2030, these figures could rise to 7.8 million and 23 million, respectively [50]. Stroke ranks fourth in terms of lost productivity and is the second most common preventable cause of death globally [51]. Many studies confirmed that Stroke is highly associated with stressful life events. A positive association was found for high levels of neighbourhood cohesions in one study [52]. In most studies, stress is considered chronic when the psychological or physical response to stressors persists for at least 6 months [53]. This stress is directly related to an increase in cerebrovascular disease risk by increasing excessive sympathomimetic activity [54]. Riley et al. [55] reported from the Chicago Health and Aging Project and found that a high association between distress and stroke was found only for haemorrhagic stroke. Although only a few studies have examined the relationship between stress and the incidence of stroke, evidence indicates that stress is a significant risk factor for stroke [56-59]. Among 20,627 participants in the UK EPIC-Norfolk experiment, who were aged 41–80 years, the risk of stroke for a one standard deviation decrease in the Mental Health Inventory (MHI-5 scale) score (showing greater emotional distress) [60]. In addition, using the general health questionnaire to measure psychological distress, Middle-aged men (45–59 years old) who participated in the Caerphilly trial were shown to have a greater risk of fatal ischemic stroke (45%), but not of nonfatal stroke. [61]. Moreover, evidence indicates that self-perceived psychological stress was linked to an increased risk of stroke [62]. According to one study, employment strain and occupational stress even doubled the chance of stroke [63]. It was found In a systematic review of 26 studies, psychological distress was a significant trigger of ischemic stroke [64]. Kornerup et al. showed that older adults who have experienced a greater number of life events are at a higher risk of stroke [65]; Furthermore, they found that within a month of the event, recent stressful life events are associated with incident stroke [66]. Incident stroke has also been linked to earthquakes observed in the Hanshin- Awaji earthquake [67]. Socioeconomic status as a stressor also affects the incidence and mortality of stroke [68-70]. The incidence of stroke is higher in those with lower socioeconomic status [69]. In 2000-2008, the stroke incidence rates in low to middle income countries have exceeded high-income countries by 20% [71]. According to a metaanalysis by Huang Y et al. (2015), women, in particular, were more likely to have a stroke if they worked in high-stress occupations [72].

Stress and Depression

Depression is the most important psychiatric illness. The 12-month prevalence in the community is around 2– 5%. According to various research, the lifetime rates range from 4 to 30%. Rates of major depression are about twice as high in women as in men [73]. Adverse early experiences may affect the development of the hypothalamicpituitary- adrenal (HPA) axis and the later development of depression. A lack of social support is one of the current life occurrences that frequently triggers depressive disorders. Early life experience and personality may modify the impact of life events [74]. Childhood deprivation predisposes to depressive disorders in adult life. Late-life depressive disorder is associated with parental separation, particularly divorce [75]. It appears that non-caring and overprotective parenting styles are associated with depression in adulthood. Abuse, both physical and sexual, raises the risk of starting major depression [76]. Mothers with postnatal depression associated with neglect and emotional indifference will increase the risk of depression in the subsequent generation [77]. Many researches have shown that: 1. Stressful life situations are six times more common in the months preceding the beginning of depressive disorder. 2. Suicide attempts are also associated with stressful life events 3. 'Loss' and 'threat' events are associated with depression and anxiety, respectively. 4. Life events are important antecedents of all forms of depression [73]. Things that cause feelings of humiliation and entrapment are associated with the start of depression [78]. Some studies have been carried out in Bangladesh to find the relationship between stressors and psychiatric disorders. A case-control study [79] reported that depressed patients had two and half times as many psychosocial stressors as control patients

Bangladesh is a densely populated country, and there is no systematic stress evaluation system. No nationwide survey on stressful life event factors has yet been conducted in Bangladesh. There is a paucity of literature on stress in Bangladesh. Since information about psychosocial stressors of depression, Diabetes mellitus, Stroke, and Ischaemic heart disease is totally lacking, the researchers feel these are very important issues from psychiatric and medical points of view. Hence, this study is designed to disseminate information and to launch an intensive effort to identify and adequately manage the psychosocial stressors of Bangladeshi adults suffering from depression, Diabetes mellitus, Stroke, and Ischaemic heart disease.

Methodology

The descriptive type of cross-sectional study was carried out in the Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, during the period from July 2017 to June 2018. A total of 200 samples (Fifty patients from each department) were taken from the Department of Psychiatry, Cardiology, Endocrinology, and Neurology of BSMMU. A psychiatric and medical diagnosis of each case was confirmed clinically in the presence of the consultant of the respective department. Those patients who were non-communicable and did not give consent were excluded from the study. After obtaining informed consent, patients of both sexes, aged 18 and above, were asked to complete the socio-demographic Questionnaire and Dhaka Stress Scale-Adult version (DSS-A) [80]. Stressful life events of DSS-A were marked as experienced in the last year prior to the onset of the disease.

Results

Sample Characteristics

A total of 200 patients (50 patients from each department) were enrolled in the study. Age ranged from 19 to 80 years with a mean of 35.8±10.8. The majority of the patients were in the 41-50 age group, constituting 34.5% of the study population, followed by 25.5% in the 31-40 age group. Minimum patients (2.1%) were in the 18-20 age group. Out of 200 patients, 103 (51.5%) were male and 97 (48.5%) females. Male to female ratio was 1.1:1. It was found that 18 (9%) patients were unmarried, and 149 (74.5%) patients were married. Most of the patients, i.e., 81.5%, came from the nuclear family, and 18.5% came from the joint family. It was also found that 129 (64.5%) patients came from urban backgrounds and 71 (35.5%) patients from rural backgrounds. There were 188 (94%) Muslim patients and 11 (5.5%) Hindu patients. The educational status of 22 (11%) patients was at the primary level, 45 (22.5%) at the secondary level, 44 (22%) at the higher secondary level, and 71 (35.5%) at the graduate and above level. Only 18 (9%) patients were illiterate. Among the 200 patients, there were 512 (6%) patients were unemployed, 24 (12%) retired, 68 (34%) housewives, 14 (7%) farmers, and 23 (11.5%) businessmen. However, 52 (26%) patients were service holders.

Comparison of Number of Life Events

A comparison of the numbers of life events experienced in the last year prior to the onset of disease by patients with Ischaemic heart disease, Diabetes Mellitus, Stroke, and Depression is delineated in Table 1. The mean of the total number of life events experienced by these patients was 4.22(SD=1.8), 3.58(SD=1.8), 3.3(SD=1.8), and 4.5(SD=1.5) in IHD, DM, Stroke, and Depression, respectively. Of the four groups, male patients with depression experienced the highest number of life events, with a mean of 4. It was 3.8, 3.2, and 3 in IHD, DM, and Stroke, respectively. Among the four groups, female patients with IHD experienced the highest number of life events, with a mean of 5. It was 4, 4.1, and 4.8 in DM, Stroke, and depression, respectively.

Table 1: Comparison of the number of life events experienced in the last year among patients with Ischaemic Heart Disease, Diabetes Mellitus, Stroke, and Depression (n=200).




  
    Characteristics
    Mean of number of life events in IHD
    Mean of number of life events in DM
    Mean of number of life events in Stroke
    Mean of number of life events in Depression
  
  
    Age
     
     
     
     
  
  
    18-20

      21-30

      31-40

      41-50

      =51
    4.5

      3.85

      4.12

      4.41

      4.6
    -

      -

      3.6

      3.2

      4.2
    -

      -

      4

      3.5

      3.1
    4.3

      4

      4.2

      5.7

      4.3
  
  
    
    4.22(SD=1.8)
    3.58(SD=1.8)
    3.3 (SD=1.8)
    4.5(SD=1.5)
  
  
    Sex
     
     
     
     
  
  
    Male

      Female
    3.8

      5 
    3.2

      4 
    3

      4.1 
    4

      4.8 
  
  
    Male: Female 
    1: 1.3
    1: 1.3
    1: 1.4
    1: 1.2
  
  
    Marital status
     
     
     
     
  
  
    Unmarried

      Married

      Separated

      Divorced

      Widow/widower 
    3.65

      4.2

      3.5

      5

      5.5
    5

      3.4

      3

      4.7

      5
    -

      3.2

      3

      3.8

      3.4
    4.2

      4.6

      -

      5.2

      5
  
  
    Habitat
     
     
     
     
  
  
    Urban

      Rural
    4.2

      4.2
    3.7

      3.2
    3.2

      3.5
    4.3

      4.9



Table 1: Comparison of the number of life events experienced in the last year among patients with Ischaemic Heart Disease, Diabetes Mellitus, Stroke, and
Depression (n=200).

Comparison of Mean Stress Scores

Mean stress scores according to Socio-demographic status are shown in Table 2. It was found that the 51 and above age group of DM experienced the highest stress (MSC=322) than the other age groups, followed by the same age group of IHD (MSC=318). Female patients with Depression perceived more stress (MSC=364) than IHD, DM, and Stroke. Similarly, male patients with Depression perceived more stress (MSC=286) than IHD, DM, and Stroke. However, Illiterate patients and patients having a primary level of education with Depression experienced the highest level of stress than all other groups (MSC=440 and 377, respectively). According to marital status, Divorced patients with Depression perceived the highest stress (MSC=458) than all other groups, followed by widows/widows with IHD (MSC=436). Depressed patients living in rural areas faced the highest stress (MSC=367), followed by patients of IHD living in urban areas (MSC=316).

Table 2: Comparison of mean stress scores according to Socio-demographic status among patients with Ischaemic Heart Disease, Diabetes Mellitus, Stroke, and Depression (n=200).




  
    Groups
    Characteristics
    MSC* in IHD
    MSC in DM
    MSC in Stroke
    MSC in Depression
  
  
    Age
    18-20
    -
    -
    -
    253
  
  
     
    21-30
    292
    -
    -
    294
  
  
     
    31-40
    302
    263
    306
    316
  
  
     
    41-50
    316
    248
    276
    316
  
  
     
    =51
    318
    322
    235
    312
  
  
     
     
     
     
     
     
  
  
    Sex
    Male
    280
    235
    250
    286
  
  
     
    Female
    354
    303
    273
    364
  
  
     
     
     
     
     
     
  
  
    Education
    Illiterate
    342
    356
    240
    440
  
  
     
    Primary
    205
    115
    235
    377
  
  
     
    Secondary level
    366
    262
    251
    289
  
  
     
    Higher secondary level
    299
    197
    274
    343
  
  
     
    Graduate and above
    290
    313
    246
    323
  
  
     
     
     
     
     
     
  
  
    Marital status
    Unmarried
    259
    374
    -
    250
  
  
     
    Married
    305
    257
    249
    338
  
  
     
    Separated
    258
    244
    208
    -
  
  
     
    Divorced
    345
    420
    316
    458
  
  
     
    Widow/widower
    436
    346
    232
    386
  
  
     
     
     
     
     
     
  
  
    Habitat
    Urban
    316
    288
    253
    313
  
  
     
    Rural
    292
    232
    275
    367
  
  
    *MSC: Mean Stress Score.



Table 2: Comparison of mean stress scores according to Socio-demographic
status among patients with Ischaemic Heart Disease, Diabetes Mellitus, Stroke,
and Depression (n=200).

Comparison of Study Population According to Severity of Stress

Table 3 shows the study populations categorized according to the severity of stress reported by the patients with IHD, DM, Stroke, and Depression in the year prior to the onset of the disease. There were 34 (17%) patients in the mild stress category, followed by 67 (33.5%) patients in the moderate stress category and 99 (49.5%) patients in the severe stress category.

Table 3: Comparison of categorization of study population according to level of severity of stress in patients with Ischaemic Heart Disease, Diabetes Mellitus, Stroke, and Depression (n=200).




  
    Category
    No. of    patients (%) in IHD
    No. of    patients (%) in DM
    No. of    patients (%) in Stroke
    No. of    patients (%) in MDD
    Total
  
  
    Mild stress
    6 (12%)
    12 (24%)
    13 (26%)
    3 (6%)
    34 (17%)
  
  
    Moderate stress
    17 (34%)
    16 (32%)
    17 (34%)
    17 (34%)
    67 (33.5%)
  
  
    Severe stress
    27 (54%)
    22 (44%)
    20 (40%)
    30 (60%)
    99 (49.5%)
  
  
    Total
    50 (100%)
    50 (100%)
    50 (100%)
    50 (100%)
    200 (100%)



Table 3: Comparison of categorization of study population according to level of severity of stress in patients with Ischaemic Heart Disease, Diabetes Mellitus, Stroke,
and Depression (n=200).

Total Number of Stressful Life Events

Study populations, categorized according to the total number of stressful life events reported by the patients with IHD, DM, Stroke, and Depression in the year prior to the onset of the disease, are shown in Table 4. There were 227 (29%) stressful life events reported by depressed patients, followed by 212 (27%) SLEs by patients with Ischaemic Heart Disease, 180 (23%) SLEs by patients with Diabetes Mellitus, and 165 (21%) stressful life events reported by stroke patients. Stressful life events are more common in women than in men with depression, with a male: female ratio of 1:2.6. Overall ratio of four diseases was 1:1.2.

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Citation:Islam M, Mullick MSI, Chowdhury HR, Ahsan MS. Psychosocial Stressors among Patients of Ischaemic Heart Disease, Diabetes Mellitus, Stroke and Depression : A Comparative Study. J Psychiatry Mental Disord. 2025; 10(1): 1080.

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Category	Male (%)	Female (%)	Male: Female	Total (%)
*Total No. of SLEs in IHD**	120 (34.3%)	92 (21%)	1.3:1	212 (27%)
Total No. of SLEs in DM	67 (19.2%)	113 (26%)	1:1.7	180 (23%)
Total No. of SLEs in Stroke	100 (28.5%)	65 (15%)	1.5:1	165 (21%)
Total No. of SLEs in MDD	63 (18%)	165 (38%)	1:2.6	227 (29%)
Total	350 (100%)	435 (100%)	1:1.2	784 (100%)
*SLEs: Stressful Life Events.

Category	Minimum	Maximum	Mean ± SD
IHD	46	594	307 ± 142
DM	33	641	274 ± 152
Stroke	33	637	252 ± 143
MDD	111	680	339 ± 125