Standardized Assessment of Psychological

Weil-Being and Quality-of-Life in Patients

with Implanted Defibrillators
CHRISTOPH HERRMANN,* FRIEDERIKE VON ZUR MUHEN,
ANSELM SCHAUMANN, ULLRICH BUSS, SYLKE KEMPER,*
C]HRISTIAN WANTZEN, and BERND-DIETER GONSKA
l''rora ihe Department of Cardiology and the *Department of Psychosomatic: Medicine,
University of Gbttingnn, Germany

HERRMANN. C, FT AI,.: Standardized Assessment of Psychological Weil-Being and Quality-of-Life in Pa-

tients with Implanted Defihrillators. The ICD bas become a standard treatment for patients witb maiig-
nant arrhyibmias. Despite its benefits it may cause additional discomfort to the patients. Thus, quality-of-
life needs to be assessed in tbese patients. Previous studies bave used only small samples or
unstandardized measures of quality-of-life tbat do not allow comparisons witb other patient groups. Tbe
present study used standardized questionnaires for a cross-sectional assessment of psycbological well-be-
ing and quality-of-life in ICD patients and to compare tbem to a similar group of coronary artery disease
(CAD) patients witbout ICD. Overall, quality-of-life did not differ between botb groups. ICD patients being
less anxious than tbe CAD group. Witb increasing numbers of ICD sbocks, bowever, tbe percentage ofpsv-
cbologically distressed ICD patients rose from 10% to > 50%. Psycbologically distressed patients had sig-
nificantly worse scores on most of tbe quality-of-life subscales, sbowed less treatnwnt satisfaction, and
more negative attitudes. It is concluded tbat ICD patients bave an acceptable mean quality-of-life and low
mean anxiety. However, a relevant subgroup of about 15%, especially patients with frequent shocks, ex-
perience psycbological distress and reduced quality-of-life and should receive special care. (PACE 1997;
20[Pt. 11:95-103}

implantable defihrillator, coronary artery disease, anxiety, depression, quality-of-life

Introduction peated follow-up examinations, and they may re-

During tho last 10 years, implantable car-
dioverter defibrillators (ICDs) have hecome an im-
portant tool for treating patients with life-threat-
ening ventricular arrhythmias, especially since
the prognostic implications of antiarrhythmic
drug therapy have become increasingly uncertain.
With ICD therapy, untoward drug effects may be
avoided and most episodes of ventricular tachy-
arrhythmias are reliahly terminated. On the other
hand, this treatment has some potentially negative
consequences on patients' well-being: they have
to undergo a surgical procedure, take part in re-
Address for reprints: Christoph Hcirrmann, M.D., Dept. of Psy-
chosomatic: Medicine. University of Gottingen, von-Siebold-
Slr. 5. D-37075 Gottingen, (Germany. Fax: 49-551-39-4592.
Received Fehruary 23. 1995; rcjvision August 28. 1995; ac-
cepted Novemher B. 1995.
quire additional hospitalizations for device-spe-
cific complications, such as infected, hroken, or
dislocated electrodes or aggregates. Finally, fre-
quent ICD shocks may lead to irritation and anxi-
ety.
Several authors have assessed the psycholog-
ical adjustment and quality-of-life in these pa-
tients.'^'" However, the reliability of their results
has to be questioned, because some of the studies
included very small numbers of patients,^•^•''
whereas some others^" lacked a standardized
method of documenting the patients' psychoso-
cial status. None of the previously published stud-
ies used sufficiently validated instruments to as-
sess the complex phenomenon of quality-of-life.
However, this is necessary for comparing different
patient groups because individual concepts of
quaiity-of-life may vary widely among patients
and investigators.

PACE. Vol. 20 January 1997, Part I 95

 HERRMANN. ETAL.

The aim of the present cross-sectional stndy identical to the final version just publisbed by
was to assess major dimensions of psychological Siegrist et al.^^ The PLC also allows comparisons
adjustment and quality-of-life in ICD patients hy with other groups of cardiac patients. Tbe seven
means of well-validated instruments, and to com- suhscales of the profile are "general performance,"
pare these results to those ohtained in a compara- "social capacity," "positive mood," "negative
hle group of patients with coronary artery disease mood," "psychological capacity," "socioemo-
who were not treated with an ICD. In addition, we tional well-being," and "cardiac symptom load."
examined ICD-specific attitudes and causes of dis- On the first six scales, high scores represent high
tress. Finally, it was our intention to descrihe the quality-of-life, whereas on the cardiac symptom
associations among typical ICD related problems, scale, high scores mean a high symptom load.
psychological adjustment, and quality-of-life. For all patients, detailed medical data were
available from their patient records.
Methods All findings were entered into a database sys-
tem on a personal computer. Statistical proce-
Seventy consecutive ICD patients who at- dures were performed by means of the SPSS/PC
tended a university hospital's cardiology outpa- software package. Comparisons of group means
tient clinic for a routine ICD checkup were asked were performed with Stndent's f-tests for inde-
to complete a set of questionnaires during their pendent samples. The Chi-square was used for
visit. This set included a numher of unstandard- comparing frequencies of nominal data. Correla-
ized items dealing with patients' attitudes toward tions of psychological scores with duration of ICD
the ICD, its possihle effects on daily life, and the therapy were computed as Pearson's r. The rela-
patients' coping strategies. Items were scaled from tive effects of sbock frequency and psychological
0 ("not at all/never") to 3 ("very much/very of- adjustment on quality-of-life scores were exam-
ten"]. They were included hecause until now ined by means of an analysis of variance using the
there has been no well-validated instrument for ANOVA procedure with PLC scores as dependent
assessing ICD-specific prohlems and the answers variahles.
might help to understand differences in quality- Additional comparisons were made using data
of-llfe. Psychological distress was assessed hy from a group of 112 male patients with advanced
means of the German version of the Hospital Anx- coronary three-vessel disease, hut without ICDs,
iety and Depression Scale [HADS-D). This short, who bad completed tbe HADS-D and PLC at a mean
standardized self-assessment questionnaire was
specifically designed for the detection of mood
disorders in the physically ill.^^ Its psychometric
properties are well documented, and a consider- Table I.
able number of studies have shown the usefulness Basic Characteristics of iCD and CAD Patients
of the scale in English or German-speaking cardiac
patients,^^"^"^ including patients with ICD.'^ These ICD CAD
studies also allowed the comparison of the scores Patients Patients
of our IGD patients with those of other patient (n = 63) (n = 112)
groups. In general, high scores on the anxiety and
depression suhscales represent high degrees of Sex
psychological distress with a cutoff point of > 10 Male 79% 100%
Female 21% 0%
for clinically relevant mood disorders.
Mean age (years) 61 ± 13 61 ± 7
Quality-of-life was measured hy means of the Married 78% 90%
Quality-of-Life Profile for the Chronically 111 Retired 88% 78%
(PLC). This standardized German self-assessment Cardiac diagnosis
questionnaire had also heen validated in cardiac Coronary artery disease 68% 100%
patients.^'' A more recent factor analysis in a larger Dilated cardiomyopathy 18% 0%
Other 14% 0%
patient group led to a slightly modified version,^^
Ejection fraction 36% ± 16% 55% ± 17%
wbich was used in the present study and is almost

96 January 1997, Parti PACE, Vol. 20

 QUALITY-(3F-LIFE WITH IMPLANTED DEFIBRILLATORS

of 2.6 ± 0.5 years after an initial cardiological

checkup. Tbe questionnaires were part of a postal
follow-up for a study of quality-of-life in chronic
CAD.^'' The basic characteristics of these patients
are displayed in Tahle 1. All of them bad a history
of confirmed myocardial infarction, 38% had pre-
viously undergone coronary angioplasty, and 63%
had received hypass surgery. More detailed results
of this study will he published separately.

Results
Sixty-three (90.0%) of the 70 patients com-
pleted the questionnaires. Their basal characteris-
tics are also shown in Tahle 1. About 80% of the
patients were men; two-thirds had coronary artery
disease, the other third had dilated cardiomy-
opathies or other diagnoses. Most patients had a
reduced ejection fraction. More than half of the
patients had survived a cardiac arrest {Tahle II).
The mean time interval since tbe ICD implanta-
tion was 1.4 years; during this time, the patients
had received up to 56 ICD shocks with slight
differences between objective ICD memory and
patients' self-reports. While 58.8% had received
second-generation ICDs, 41.2% carried third-gen-
eration devices. Of tbe latter, 50% had had at least
one episode of antitachycardia pacing (ATP).
None of the patients bad experienced serious ICD
related complications such as infected or dislo-
cated leads. The only subjective complications re-
ported hy the patients were transient pain at the
site of the ICD (1 patient), syncope [1 patient), and
psychological maladaptation.
Table II.
Additional Characteristics of ICD Patients
Survivors of sudden death 36 (57%)
Days since iCD 510 ± 408
implantation (54-173-460-720-1690)*
ICD generation
Second 37 (59%)
Third 26(41%)
Number of ICD shocks
Selt-report 4.0 ± 8.3 (0-56)
ICD memory 5.3 ± 9.6 (0-47)
* values represent mini mum-first quartile-median-third quartile-
maximum.
Figure 1. Quality-of-life in implantahle cardioverter
defibrillator (ICD) patients versus coronary artery dis-
ease (CAD) patients without ICD. PLC mean scores and
standard deviations by group. White bar ^ ICD (n = 63);
black bar - CAD (n = 112). All group comparisons: P >
0.05.
Significant anxiety was found in 12.7%, de-
pression in 9.6%, and at least one ahnormal score
on tbe HADS-D in 17.5% of the patients. Fourteen
and nine-tentbs percent wisbed special psycbo-
logical support, and 34.8% indicated they would
like to meet other ICD patients for discussing ICD
related problems.
The comparison of quality-of-life scores on
the PLC showed no significant differences be-
tween IGD patients and the group of CAD patients
without ICD (Figure 1). This included similar lev-
els of cardiac symptom load experienced hy both
groups. Mean HADS-D depression scores were
similar in hoth groups (5.2 ± 3.8 vs 5.8 ± 3.8; P =
NS). HADS-D anxiety scores were, however, sig-
nificantly lower in ICD patients (5.0 ± 3.7 vs 6.9 ±
3.7; P < 0.01). Because these comparisons might
have been influenced by the existing group, dif-
ferences in gender distribution, cardiac diagnosis,
or ejection fraction variahles were tested for a pos-
sihle association with PLC and HADS-D scores hy
Student's /-test, one-dimensional analysis of vari-
ance, or Pearson correlation, respectively. These

PACE, Vol. 20 January 1997, Part I 97

 HERRMANN, ET AL.

%HADS-D>10

0-4 shocks 5-9 shocks

Figure 2, Percentage of abnormal HADS-D scores in

ICD patients by number of shocks. Black bar ^ shocks
counted by ICD memory; white bar — shocks reported Figure 3. Quality-of-life in ICD patients by number of
by patients. Significance: P < 0.01 for both series. shocks. PLC mean scores and standard deviations.
White bar = 0-4 sbocks (n = 46}; gray bar ^ 5-9 shocks
(n = 6); black bar = > 10 shocks (n = 11); + ^ P<0.05.
tests showed no significant association of any of
the above mentioned variables with any PLC or
HADS-D suhscores.
While the time since ICD implantation was al-
most unrelated to HADS-D and PLC scores (all
correlations < 0.30), there was a clear association
hetween tbe number of ICD shocks and the fre-
quency of mood disturhances as assessed hy the
HADS-D (Fig. 2). More than 50% of patients who
had received > 10 shocks had abnormal HADS-D
scores. The influence of ICD discharges on the
quality-of-life (PLC) suhscales was loss pro-
nounced (Fig. 3). Analysis of variance showed that
these minor associations hetween shock fre-
quency and PLC scores were secondary to the ef-
fect of shock frequency on psychological adjust-
ment (as defined by HADS-D scores). This means
that psychological maladjustment as reflected in
high anxiety and depression scores was directly
associated with shock frequency, whereas overall
quality-of-life was not directly influenced by the
numher of ICD shocks, but indirectly, hy being in-
versely related to anxiety and depression. Accord- Figure 4. Quality-of-life in ICD patients by HADS-D
ingly, there were several significant differences in scores. PLC mean scores and standard deviations.
White bar = HADS-D normal (n - 52); black bar ^
quality-of-life scores of patients with normal ver- HADS-D abnormal (n ^ 11); + = P < 0.05; x ^ P <
sus abnormal HADS-D scores, indicating lower 0.01; O - P < 0.001.

98 January 1997, Part I PACE, Vol. 20

 QUALITY-OF-LIFE WITH IMPLANTED DEFIBRILLATORS

reporting of the ICD implantation procedure,

X doubts about the usefulness of the regular ICD
checkups, increased overall anxiety, and marital
x- V %,
problems. All of these negative attitudes and ex-
periences were even more pronounced in psycho-
logically distressed patients with abnormal
HADS-D scores. High HADS-D scores, but not fre-
* • .

quent ICD shocks, were also correlated with a sig-

*
nificantly higher degree of perceived stress by ICD
checkups, wishes for ICD explantation, and re-
ports of financial problems caused by ICD related
disabilities.

Discussion
The treatment with automatic ICDs is an ef-
fective strategy for managing life-threatening ven-
tricular arrhythmias. Early reports have suggested
some side effects of this therapy on psychological
very much
adjustment.^~^ Consequently, it had to be asked if
not at all
these effects also affected patients' overall quality-
Figure 5. Positive experiences and attitudes by HADS-
D scores. Mean values of ICD specific items. —•— = to-
tal group: —•— = HADS-D normal (n = 52); —A—
HADS-D abnormal (n = 11}; + = P < 0.05; x - P <
0.01; O - P< 0.001.

quality-of-life on all dimensions for psychologi-

cally distressed patients [Fig. 4).
Responses to the unstandardized questions
revealed that psychological adjustment was also
4 . * ' •

associated with patients' attitudes toward the ICD:

despite relatively high mean satisfaction, anxious
and/or depressed patients felt significantly less
able to go on vacations, were significantly less sat-
isfied with their ICD therapy, and felt less secure
(Fig. 5). High levels of support by spouses and
family were reported regardless of psychological
status.
The most frequently encountered negative at-
titudes included fear of recurrent shocks and
avoidance of activities that were perceived as po-
tential triggers for arrhythmic events. Patients also 1.5
very much
complained of feeling dependent on the ICD.
These negative attitudes were also more pro- Figure 6. Negative experiences and attitudes by num-
nounced in patients with a total number of ^ 5 ber of ICD sbocks. Mean values of ICD specific items.
shocks (Fig. 6) or abnormal HADS-D anxiety or de- —•— - total group; —•— - 0-4 shocks (n = 46);
pression scores (Fig. 7). In addition, frequent —A— - ^ 5 shocks (n = 17); + = P < 0.05; X = P <
shocks were associated with a significantly worse 0.01; O=P < 0.001.

PACE, Vol. 20 January 1997, Part I 99

 HERRMANN. ET AL.
M' •
• *
X
i>
X is no gold standard for measuring quality-of-life.
y -h
-1-
+
very much
Figure 7. Negative experiences and attitudes by HADS-
D scores: Mean values of ICD specific items. —•— - to-
tal group: —•— - HADS-D normal (n ^ 52); —A— =
HADS-D abnormal (n = 11); + = P < 0.05; x - P <
0.01; -O - P < 0.001.
of-life. Some authors^'^*^" subsequently addressed
this subject, but their studies had some importaut
limitations; the investigation by Schohl et al.^" ret-
rospectively studied patients' attitudes toward
ICD therapy by means of a simple questionnaire
derived from clinical practice. Despite some inter-
esting findings regarding patients'attitudes, this
study failed to include any standardized measures
that could allow comparisons with other patient
groups. Anxiety and quality-of-life were retro-
spectively requested by single items of unknown
validity and reliability at an unknown time
postimplantation. Thus, it is unclear what the au-
thors really measured because the patients' an-
swers might have been subject to response bias.
A second group of investigators^"^ prospec-
tively examined anxiety in ICD recipients by
means of the well-established State Trait Anxiety
Inventory (STAI). It is not surprising that these au-
thors found a decrease of state anxiety after ICD
100 January 1997, Part I
implantation^ because it is well known that await-
ing cardiac surgery increases anxiety and depres-
sion,^'^ which returns to relatively normal levels
after the procedure. Although these authors at-
tempted to also measure quality-of-life, they did
not use any instrument with previously tested va-
lidity or reliability to do so. Thus, this study does
not answer the question as to what was really mea-
sured and how the effects of ICD therapy on the ill-
defined "quality-of-life" were mediated. It cannot
be excluded that the observed effects were arti-
facts of low retest reliability, We admit that there
However, there are a couple of well-validated
multidimensional scales with defined subscales
for assessing physical, social, and psychological
aspects of quality-of-life.^^-^^ These instruments
allow comparisons with other patient groups as
well as meaningful longitudinal assessments.
The present study is the first one to use the
PLC, one such instrument, in a group of ICD pa-
tients. Besides the psychological dimension,
which had already been assessed in previous stud-
ies, the PLC gives scaled scores for social and
physical functioning and well-being, resulting in a
comprehensive description of quality-of-life. In-
cluding an additional number of ICD specific
items is in accordance with a modular approach at
measuring quality-of-life,^" and allows linkage of
overall quality-of-life to the specific effects of ICD
therapy. Since there are no standardized instru-
ments for assessing ICD related attitudes and ex-
periences, it was necessary to use unstandardized
items derived from literature and clinical practice
for this part of the study in order to create hy-
potheses ahout how ICD-specific problems were
correlated with psychological adjustment.
Our results indicate that for the majority of
patients ICD therapy does not reduce quality-of-
life or psychological functioning. This finding is
in accordance with recent research from other au-
thors.^•'''^*' The comparison with CAD patients
without ICDs shows no significant differences in
PLC scores, including cardiac symptom load. Al-
though there were some clinical differences be-
tween the two groups (gender distribution, cardiac
diagnosis, ejection fraction), none of them was sig-
nificantly associated with PLC scores. Thus, with
respect to the PLC, the differences in basic charac-
teristics do not appear to be relevant for this com-
PACE, Vol. 20
 QUALITY-OF-UFE WITH IMPLANTED DEFIBRILLATORS
parisou. It can also be stated that both patient
groups experienced similar levels of cardiac
symptoms. Mean anxiety scores of the ICD pa-
tients were even lower than those of the CAD pa-
tients without ICDs. This cannot be explained by
the higher proportion of women in the ICD group,
because women generally score higher on the
HADS-D than men. The moderately lower propor-
tion of married ICD patients and their higher rate
of retirement might be suspected to increase but
not decrease mean anxiety scores.^^ While the
CAD group had advanced coronary disease (all pa-
tients had suffered at least one myocardial infarc-
tion and 80% bad undergone invasive therapies),
but only slightly reduced ventricular function, the
ICD patients had a lower degree of coronary
pathology and revascularization, but a consider-
ably worse ejection fraction. However, a previous
study of a large group of 3,705 heart patients has
revealed that all of these cardiac findings are only
minimally related to anxiety and depression,^"^
and there is no evidence that differences in sever-
ity of disease may account for the observed differ-
ences in mean anxiety between CAD and ICD
groups. Instead, lower anxiety in the present ICD
group may be the result of a feeling of security
granted by the ICD. The patients, a large number of
whom had already survived a sudden death, ap-
parently appreciated the effective protection
against malignant arrhythmias. This is also re-
flected in high overall treatment satisfaction,'^-^"
although most patients experience some problems
with the ICD.
With increasing numbers of ICD shocks, how-
ever, there was a dramatic increase in the number
of patients with anxiety and depression, with pre-
dominating fears of recurrent shocks, which are
experienced as very painful and upsetting. These
fears can lead to an anxious avoidance of physical
and social activities and produce a feeling of ICD
dependence.^ While some other authors already
described the influence of ICD therapy and fre-
quent discharges on patients'anxiety,*'"" the above
mentioned problems with measuring quality-of-
life precluded a reliable statement about how this
increase in anxiety affected overall quality-of-life.
Our results now indicate that ICD therapy primar-
ily affects emotional adjustment. Frequent shocks
make patients more anxious and depressed. In ad-
dition, these mood disturhances are associated
PACE. Vol, 20 January 1997, Part I
with negative attitudes towards several aspects of
ICD therapy, although it is not known if mood dis-
turbance was the result of lower ICD acceptance,
or rather, a cause of higher problem reporting.
Although shock frequency also influenced
some dimensions of quality-of-life, it could be
shown that these effects were secondary to its ef-
fects on anxiety and depression. Thus, one can say
that psychological maladjustment, which is
mainly caused by frequent ICD shocks, mediates a
decrease in overall quality-of-life. This conclusion
entails two treatment options.
First, anxious or depressed patients, who can
easily be identified by means of simple self-report
questionnaires such as the HADS(-D}, might be
considered for special psychotherapeutic support.
Although there is no definite evidence from large
controlled trials, first results suggest a beneficial
effect of psychosocial interventions, especially
support groups'^'^^'^^ on patients' psychological
adaptation. This is in accordance with findings
from several controlled trials in CAD patients,
who, as a consequence of psychological counsel-
ing, showed significant decreases of anxiety and
depression,^^ and even significant reductions in
total and cardiovascular mortality.^^ Ahout 15%
of all ICD patients might need special care. This
was the percentage of abnormal findings on the
HADS-D as well as of patients who explicitly
wished psychological help. A considerably higher
percentage (35%) of patients wished to meet other
ICD patients and talk about their ICD related prob-
lems. They could be offered a support group pro-
gram, although it still remains to be documented if
its probable effect on psychological function-
15.21,22
mg also improves overall quality-of-life.
Second, efforts should be made at reducing
ICD shock frequency by avoiding inadequate
shocks and taking advantage of modern ICDs' ATP
capahilities, which may terminate up to 90% of all
tachyarrhythmias^^ and can be expected to im-
prove patients' quality-of-life.''
One limitation of the present study is its
cross-sectional design and the variable time since
ICD implantation. The latter showed no relevant
effect on HADS-D or PLC scores. The cross-sec-
tional design appears adequate for answering the
principal questions for which the study was un-
dertaken: it documents important associations of
quality-of-life with central aspects of ICD therapy.
101
 HERRMANN, ET AL.
It would certainly not make much sense to com-
pare the quality-of-life of hospitalized patients
awaiting ICD implantation with postoperative
qnality-of-life under daily living conditions. Nev-
ertheless, some longitudinal effects might require
a prospective study design. For example, no defi-
nite answer can be given to the question if psy-
chological maladjustment in patients with fre-
quent ICD shocks was entirely a consequence of
the experienced shocks or if patients with psycho-
logical problems of other origin might also have a
higher risk of arrhythmias and consequently re-
ceive more shocks. This question can only be an-
swered by prospective studies taking advantage of
the ICDs' capability of permanently recording ar-
rhythmic events.
Such future investigations of psychological
well-being and quality-of-life in ICD patients
should, in our opinion, be conducted in a prospec-
tive manner and use only adequate, well-validated
assessment tools. Recently, after completion of
our study. May and coworkers^^ published a first
prospective study using the Sickness Impact Pro-
file, which may be considered an adequate tool for
use in ICD patients. These authors found a tempo-
rary worsening of quality-of-life 6 months after
ICD implantation, which is in contrast to our
cross-sectional data. That study did not control for
References
1.Fricchione GL. Olson LC, Vlay SC. Psychiatric
syndromes in patients with the automatic internal
cardioverter defibrillator: Anxiety, psychological
dependance. abuse, and withdrawal. Am Heart J
1989; 117:1411-1414.
2. Vlay SC, Olson LC, Fricchione GL, et al. Anxiety
and anger in patients with ventricular tach-
yarrhythmias. Responses after automatic internal
cardioverter defibriUator implantation. PACE
1989; 12:366-373.
3. Pycha C, Calabrese JR, Gulledge AD, et al. Patient
and spouse acceptance and adaptation to im-
plantable cardioverter defibrillators. Gleve Clin I
Med 1990; 57:441-444.
4. Keren R, Aarons D, Veltri EP. Anxiety and depres-
sion in patients with life-threatening ventricnlar
arrhythmias: Impact of the implantabln car-
dioverter-defibriilator. PACE 1991; 14:181-187.
5. Liideritz B, Jung W, Deister A, et al. Quality of life
after implantation of a cardioverter/ defibrillator
in malignant arrhythmia. Dtsch med Wochenschr
1993; 118:285-289.
102 January 1997. Part I
shock frequency, nor did it examine the associa-
tion of quality-of-life with ICD-specific problems.
Thus, as the authors admit, the changes of quality-
of-life they observed are difficult to interpret. In
addition, that study is limited by the small num-
ber of patients (< 20) who completed the postim-
plant questionnaires. Prospective, detailed stud-
ies in larger patient groups are therefore desirable
for a full understanding of the effects of ICD ther-
apy on quality-of-life and the way in which they
are mediated.
We contend that in this field of highest techni-
cal standards the level of psychological instru-
ments used in most studies, so far, is rather low and
their suitability for the purposes of the investiga-
tions is rarely well documented. Since there are
several established multidimensional quality-of-
life questionnaires, it does not seem acceptable to
reduce this complex phenomenon to a few unvali-
dated yes/no questions. The present study, as well
as the one by May et al..^'' may provide an example
of suitable and psychometrically sound instru-
ments that are well accepted hy the patients. They
disprove the opinion'" that standardized instru-
ments will not be applicable in ICD patients. In par-
ticular, the HADS-D is available in many languages
and may be considered a current standard for as-
sessing anxiety and depression in heart patients.
6. )ung W. Manz M, Deister A, et al. Angstverhalten
bei Patienten mit implantierbarem Kardioverter-
Defibrillator. (abstract) Z Kardiol 1993; 82 (Suppl.
3]:32.
7. Jung W. Manz M, Deister A, et al. Quality of life in
ICD Recipients, [abstract) Circulation 1994; 90(Pt.
2):I-499.
a. Liideritz B, Jung W, Deister A, et al. Patient accep-
tance of the implantable cardioverter defibrillator
in ventricular tachyarrhythmias. PACE 1993; 16:
1815-1821.
9. Liideritz B, Jung W, Deister A, et al. Patient accep-
tance of implantable cardioverter devices; Chang-
ing attitudes. Am Heart J 1994; 127:1179-1184.
10. Schohl W, Trappe HJ, Lichtleu P. Acceptance and
quality of life after implantation of thn automatic
cardioverter defibrillator. Z Kardio! 1994; 83:
927-932.
11. Zigmond AS, Snaith RP. The hospital anxiety and
depression scale. Acta Psychiatr Scand. 1983; 67:
361-370.
12. Ghanner KS, James MA, Papouchado M, et al.
PACE, Vol. 20
 QUALITY-OF-LIFE WITH IMPLANTED DEFIBRILLATORS
Anxiety and depression in patients with chest
pain referred for exercise testing. Lancet 1985;
11:820-823.
13. Underwood MJ, Firmin RK. Jehu D. Aspects of
psychological and social morbidity in patients
awaiting coronary artery bypass grafting. Br Heart
) 1993; 69:382-384.
14. Herrmann Ch. Buss U, Breuker A, et al, Relation-
ships of cardiologica] findings and standardized
psychological self-ratings to clinical symptoms in
3.705 patients referred for exercise testing. Z Kar-
diol 1994; 83:264-272.
15. Barakat K. Finmicelli G, Bostock J, et al. A ran-
domized crossover study to assess the efficacy of
group counselling in patients with implantable
cardioverter defibrillators. (abstract) PACE 1994;
17:864.
16. Junge A, Funfstiick G, Siegrist J. Ein Fragebogen
zur Erfassung der Lebensqualitat-erste teststatis-
tische Ergebnisse am Beispiel von Hypeitonikem.
Diagnostica 1990; 36:353-358.
17. Siegrist J, 3 September, 1991. personal communi-
cation.
18. Siegrist J, Broer M, Junge A. Profil der Leben-
squalitat Chronischkranker (PLC) Testhandbuch.
Gottingen, Toronto, Hogrefe, 1995.
19. Herrmann C, Kemper S, Riiger U, et al. Vorhersage
der Lebensqualitat mannlicher Postinfarktpatien-
PACE, Vol, 20 January 1997, Part I
ten mit koronarer 3-Cefap-Erkranknng. Z Kardiol
1995; 84(SuppI. 1).
20. Bullinger M, Ludwig M, Steinbiichel Nv. Leben-
squalitat bei kardiovaskularen Erkrankungon. Got-
tingen, Toronto, Zurich, Hogrefe, 1991.
21. Badger JM, Morris PLP. Observations of a support
group for automatic implantable cardioverter-de-
fibrillator recipients and their spouses. Heart Lung
1989; 18:238-243.
22. Teplitz L, Egenes KJ, Brask L. Life after sudden
death: the development of a support group for au-
tomatic implantable cardioverter-defibrillator pa-
tients. J Cardiovasc Nurs 1990; 4:20-32.
23. Thompson DR, Meddis R. A prospective evalua-
tion of in-hospital counselling for first time my-
ocardial infarction men, J Psychosom Res 1990;
34:237-248.
24. Ketterer MW. Secondary prevention of ischemic
heart disease: The case for aggressive behavioral
monitoring and intervention. Psychosomatics
1993; 34:478-484.
25. Trappe HJ, Pfitzner P. Heintze B, et al. Role of an-
titachycardia pacing in patients with third-gener-
ation cardioverter-defibrillators. Z Kardiol 1995;
84:35-43.
26. May CD, Smith PR, Murdock CJ, et al. The impact
of the implantable cardioverter defibrillator on
quality-of-life. PACE 1995; 18;1411-1418.
103