Geetanjali Institute of Pharmacy, Geetanjali University, Udaipur, Rajasthan.
Cardiovascular diseases (CVDs) remain a major global health burden with high morbidity and mortality. Increasing evidence suggests a strong bidirectional relationship between mental health-particularly depression, anxiety, and stress-and cardiovascular outcomes. This study investigates the prevalence and severity of these psychological conditions among CVD patients admitted to a tertiary care hospital in southern Rajasthan. The objective of this study was to assess depression, anxiety and stress in CVD patients admitted to the hospital using the DASS-21 scale and to determine the proportion of CVD patients with depression, anxiety and stress levels. A six-month cross-sectional observational study was conducted at the cardiology department of Geetanjali Medical College and Hospital, Udaipur. A total of 190 adult CVD patients meeting inclusion criteria were evaluated using the DASS-21 (Depression Anxiety Stress Scale-21) psychometric tool. Data on socio-demographics, clinical history, lifestyle factors, and comorbidities were collected and analyzed using chi-square and Fisher’s exact tests. Among the studied population, moderate anxiety (40.5%) was the most prevalent psychological condition, followed by mild anxiety (35.8%) and mild stress (23.7%). Depression was rare, observed in only 3.7% of patients. Anxiety showed significant associations with gender (p=0.0084), age (p=0.0099), education (p=0.008), income (p=0.001), and rural locality. Stress was significantly linked with age (p=0.0095), occupation (p=0.017), and financial status (p=0.004). Contrary to expectations, non-smokers, non-alcoholic individuals, and vegetarians demonstrated higher anxiety levels than their counterparts. This study reveals a high burden of anxiety and stress among CVD inpatients, especially among females, elderly individuals, rural residents, and those with lower socioeconomic and educational status. Routine psychological assessment using tools like DASS-21 should be integrated into cardiovascular patient care to identify at-risk individuals and initiate timely mental health interventions.
Cardiovascular diseases (CVDs) are a significant global health concern, causing high mortality rates and poor health outcomes[1]. In 2019, approximately 179 lakh people lost their lives due to CVDs, with this number expected to rise to 236 lakh by 2030[2,3]. CVDs also account for 45% of deaths in the 40-69 age group. India accounts for 1/5th of these deaths globally, particularly in the younger population. Mental health issues, such as depression, anxiety, and stress, are common in patients with CVD, affecting disease outcomes and quality of life[4,5]. The relationship between mental health issues and cardiovascular well-being is bidirectional, with chronic conditions like CVD compounding mental health issues and unmanaged mental health obstructing recovery, increasing hospital readmissions, and increasing the risk of repetitive cardiovascular events[6,7].
The American Heart Association emphasizes the importance of monitoring and treating depression in heart disease patients[8]. Cross-related stress and anxiety are also crucial for cardiovascular health. Chronic stress is linked to high blood pressure and other cardiac risk factors, while long-term worry can increase the likelihood of unexpected cardiac death. Mental health is linked to cardiovascular disease through biological and psychological mechanisms[9]. Biological reactions involve biochemical changes that can harm the heart, such as chronic heart injury raising cortisol levels, inflammation, hypertension, and insulin-related metabolic resistance[10].
In the southern region of Rajasthan, cardiovascular diseases (CVDs) are among the leading health concerns, particularly in adults and elderly populations admitted to tertiary care hospitals. While the physical complications of CVDs are well recognized, there is limited information regarding the burden of psychological comorbidities such as depression, anxiety, and stress among these patients[11,13]. These mental health disturbances are often underdiagnosed in clinical settings, despite their significant impact on treatment adherence, prognosis, and overall quality of life. In light of the significant psychological burden among patients with cardiovascular diseases, this study was undertaken to assess depression, anxiety and stress in CVD patients admitted to the hospital using the DASS-21 scale, and to determine the proportion of CVD patients with depression, anxiety and stress levels[21,22].
MATERIALS & METHODS:
This cross-sectional observational study was conducted over a period of six months in the Department of Cardiology at Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India. The study was approved by the Institutional Ethics Committee of Geetanjali University (Ref: GU/HREC/EC/2024/2623 dated 09 September 2024).
Inclusion and Exclusion Criteria: Patients diagnosed with cardiovascular diseases (CVD) such as ischemic heart disease/coronary artery disease (IHD/CAD), valvular heart disease (VHD), rheumatic heart disease (RHD), heart failure (HF), and arrhythmias, aged 18 years and above, and those who provided written informed consent were included in the study. Patients diagnosed with conditions other than CVD, those already diagnosed with psychological disorders or on psychiatric medication, and pregnant or lactating women were excluded from the study[18,23].
Sample Size: The sample size for this study was calculated using Cochran’s formula. Considering a 95% confidence level (Z?-α/2 = 1.96) and 80% power of the study (Z?-β = 0.8413), with the prevalence rate of cardiovascular disease in India reported as 4.72% (2017), and an absolute error margin (E) of 5%, the required minimum sample size was estimated to be 142 patients. However, to improve the robustness of the study, data were collected from a total of 190 patients[19,20].
The Depression, Anxiety and Stress Scale – 21 items (DASS-21) was used to assess the psychological status of the study participants. The DASS-21 is a validated self-report tool consisting of three subscales, each containing seven items, measuring depression, anxiety, and stress symptoms over the past week. Each item was rated on a 4-point Likert scale (0 = did not apply to me at all to 3 = applied to me very much/most of the time). Scores for each domain were summed and multiplied by two to yield the final score. The severity of depression, anxiety, and stress was then categorized as normal, mild, moderate, severe, and extremely severe according to standard cutoff values[12].
Data Collection: A total of 190 patients admitted with cardiovascular disease in the tertiary care hospital were enrolled. Socio-demographic details, clinical history, and relevant medical data were obtained using a structured proforma along with the DASS-21 scale for psychological assessment[14,15].
Statistical Analysis: Data were entered into Microsoft Excel and analyzed using IBM SPSS version 30.0. Descriptive statistics were applied for baseline variables. Associations between categorical variables were tested using the Chi-square test/Fisher’s exact test. A p value of <0.05 was considered statistically significant[16,17].
RESULT:
A study of 190 patients, including 117 males and 73 females, found minimal depression in both genders. Chi - square test showed anxiety and gender were found to be significantly associated, with females having higher average anxiety levels. Fisher’s exact test examine stress and gender were also found to be significantly associated, with males reporting normal stress levels compared to females. These findings suggest a potential link between anxiety and gender. The study found that individuals aged 35-44 and 45-54 had the highest combined psychological distress, while depression was minimally observed. Chi-square test showed anxiety and stress were significantly correlated with age, with adults over 75 years experiencing more severe anxiety than expected. Patients over 75 years exhibited higher stress than expected, while those aged 55-64 years experienced lower stress. The totals represent the number of participants within each age category, not the overall study population. The study found no association between diet and depression, anxiety and stress. Vegetarian diet leads to higher levels of anxiety and stress among respondents compared to non-vegetarians. A study involving 91 smokers and 99 non-smokers found a strong association between smoking and anxiety calculated via fisher's exact test, with non-smokers experiencing higher levels of anxiety than smokers. The study involved 190 participants, including 59 alcoholics and 131 non-alcoholics, with non-alcoholics exhibiting higher levels of anxiety and stress but there is no significant association found. The study involved 54 urban and 136 rural participants, finding that rural patients had higher anxiety levels, while urban populations had a higher prevalence of stress, locality also did not demonstrate a statistically significant association. The study, which included 63 employees, 38 farmers, 61 housewives, 23 retired, and 5 unemployed individuals. The Occupation-Wise Distribution of Depression, Anxiety, and Stress, there is a significant association between occupation and anxiety and stress, as assessed using the Chi-square test. The study involved 22 patients of < 10,000 income (monthly), 52 subjects of 10,000-25,000 income, 32 patients of 26,000-40,000 income, 7 patients of 41,000-55,000 income, 2 patients of > 55,000 income & 75 patients of no income. Mental Health Conditions among Participants Based on Monthly Income, there is a significant interrelation between income and anxiety, p-value = 0.001 < 0.05. No income group describes significantly more moderate or severe anxiety. The 10,000-25,000 group presents less severe anxiety than expected. The higher income group (41-55k and more) shows lower anxiety. There is a considerable association between income and stress, p-value = 0.004 < 0.05, No income group describes significantly more stress. The higher income group (41-55k+) indicates no stress. These p-values were estimated using the Chi-square test. The research involved 190 patients, the distribution of depression, anxiety and stress based on marital status, and found a significant association between marital status and anxiety, calculated via the chi-square test. The study found a significant association between education and anxiety, with illiterate participants reporting more severe anxiety. Higher education groups (Graduate and more) reported less anxiety, while illiterate participants reported more severe anxiety. This finding was supported by a chi-square test [Table1].
Table 1: Statistical association of demographic and lifestyle variables with depression, anxiety and stress (P-values)
|
|
P - value |
||
|
Variables |
Depression |
Anxiety |
Stress |
|
Gender |
0.618 |
0.0084* |
0.04* |
|
Age |
0.92 |
0.0099* |
0.0095* |
|
Diet |
0.648 |
0.15 |
0.225 |
|
Smoking |
0.456 |
0.034* |
0.16 |
|
Alcohol |
0.79 |
0.868 |
0.358 |
|
Locality |
0.79 |
0.953 |
0.326 |
|
Occupation |
0.63 |
0.0002* |
0.017* |
|
Income |
0.82 |
0.001* |
0.004* |
|
Marital Status |
0.66 |
0.032* |
0.27 |
|
Education |
0.66 |
0.008* |
0.93 |
The Depression, Anxiety, and Stress Scale (DASS-21) was used to assess psychological parameters. Based on the scoring, 17 participants experienced depression, 152 reported symptoms of anxiety, and 60 had stress. The severity of these conditions was categorised into normal, mild, moderate, severe, and extremely severe. The detailed findings of demographic variables, clinical characteristics, and DASS-21 scores are presented in the tables below.
Figure 1: Distribution of Depression, Anxiety, and Stress Severity Levels among Cardiovascular Disease Patients.
Figure 2: Number of Patients Affected by Depression, Anxiety, and Stress.
Statistical analysis was performed using Chi-square, Fisher’s exact test to assess associations between psychological outcomes and demographic/clinical factors. Among the total population, 183 (96.3%) had normal depression levels, 6 (3.2%) demonstrates mild depression, and 1 (0.5%) participant indicated moderate depression. No cases of severe depression were identified in this study. The outcomes revealed that 28 participants (14.7%) experienced normal anxiety levels, while 68 participants (35.8%) had mild anxiety. Most of the participants, 77 (40.5%) were categorized as having moderate anxiety. Moreover, 15 participants (7.9%) indicated severe anxiety, and 2 participants (1.1%) experienced extreme severe anxiety. The results demonstrated that 142 participants (74.7%) had normal stress levels, while 45 participants (23.7%) had mild stress. Only 3 patients (1.6%) exhibited moderate stress, & no cases of severe/extreme stress were observed.
DISCUSSION:
From September 2024 to February 2025, the study involved every subject who fulfilled the inclusion requirements. 190 participants with CVD from one private medical college & hospital was included. Of the 190 cases, 61.58% (n = 117) were men and 24.21% (n = 46) were between the ages of 55-64 years. The majority of patients 88.95% (n = 169) were married. 33.15% of inpatients were employed, and 40% (n = 63) of inpatients were illiterate. Rural regions were home to the majority of the study subjects (71.57%, n = 136), & 39.47% (n = 75) had no monthly salary. Almost 52.11% (n = 99) of those who were admitted were non-smokers, 68.95% (n = 131) of respondents with no alcohol consumption. The diet of mostly individuals 57.37% (n = 109) were vegetarian. The findings of our study were a relatively low rate of clinical depression at 3.68%. The assessment is in comparison to Mohammad A. et. al., who had 56% of individuals with minimal abnormal depression and 14% having clinical depression[8]. A contributing factor for the lower prevalence in our research might be the participants demographics, including age, socioeconomic background, availability of mental healthcare provisions, or cultural attitudes focusing on mental health. The literature demonstrates that male patients will have a greater extent of abnormal depression relative to women. But the present research reveals that females have a mildly greater prevalence of depression compared with men. Our results indicate that females had greater anxiety scores than males, that is the opposite to the results of Mohammad A. et al., where males were reported to have higher anxiety in comparison with females[8]. Regarding stress, our results also distinguished with those of Parisa Janjani et al., who pointed that mild stress was the highly frequent among patients (44.92%)[10]. On the other hand, our research indicated that majority of participants (74.73%) showed normal stress levels. Concerning to the age group of subjects, Damodar G. et al. presented the observations as most of the subjects belonged to the age category 61 to 80 years & 41 to 60 years[3]. Our research determined that most patients were in the 55 to 64 age category, subsequently the 45 to 54 age group. On evaluating anxiety levels by age, Mohammad A. et al. stated that younger patients (41-50 years) had 23% lesser anxiety levels than the elderly individuals (61+ years)[8]. Likewise, our study also observed lower anxiety in the younger population (18-34 years) and much greater in the elderly (75+ years). This is persistent with the overall trend that anxiety increases with age, perhaps due to such factors as deteriorating physical health, sense of aloneness, and worry about age-related issues. In terms of cardiac diagnostic findings, Damodar G. et al. stated that IHD or CHD (75%) was the most common condition[3]. Likewise, our research revealed that majority of patients were diagnosed with Coronary Artery Disease (CAD) at (51%). A critical difference was seen in the assessment of comorbidities. Bahall et al. research mentioned hypertension as the maximum comorbidity at 84.5%, & diabetes at 65.7%[6]. Our evaluation, however, observed that anemia was the most common comorbidity at 34%, followed by diabetes at 18.9%. This divergence may be due to variation across population in nutrition, chronic disease monitor, or healthcare utilization. Anemia in patients with CVD can be related to inadequate oxygen supply and decreased clinical outcomes. Parisa J. et al. described a correlation between smoking & psychological illness, but our study indicated a specific association between smoking & anxiety, where 47.89% of smokers reported symptoms of anxiety[8]. The consequence is that smoking must be managed not only as a health risk in the physical sense as well as a sign or causative parameter for mental illness. In contrast to Mohammad A. et al., who established an insignificant connection between marital anxiety & marital status, our research revealed a considerable interrelation within marital status & anxiety[8]. This demonstrates that marital status could disrupt psychological well-being, possibly through aspect like emotional support, social withdrawal, or relationship distress. In association with occupation and mental health, the results of our study demonstrates that occupation had a high interrelation with anxiety but no significant correlation between occupation & depression. This deviates from Mohammad A. et al., whose work found a correlation between occupation & depression but no depression with anxiety[8]. Further, FNU Satyjeet et al. establish that stress had no connection with occupation, our study determined a close correlation between the occupational status of the subject and levels of stress[24,25]. Our research also examined how educational status plays a part in psychological outcomes. We recognized no correlation between educational level & depression, as contrary to Faryal Ghafoor et al., who found that primary and middle educated individuals had more chances of developing depression, with reducing risks as the education level was higher[26]. In assessing anxiety, our research reflected that there was a significant correlation with education level. Particularly, graduate & above levels of education indicated less anxiety, while illiterate participants reported significantly higher levels of anxiety. However, Mohammad A. et al. identified that the post-graduate group indicated the highest rates of anxiety, which disputes our results[8]. Our research evaluated the correlation between amounts of income and psychological effects in particular anxiety, depression, and stress. In regard to anxiety, we observed a high connection with income, where no-income participants had significantly higher levels of moderate to severe anxiety. Conversely, participants in the higher income level (? 41,000-55,000 and above) had lower levels of anxiety, revealing that financial security is likely to have a protective effect. These outcomes are contrary to Mohammad A. et al., in which no evident relationship within anxiety & income was documented. In the context of depression, our results support those of both Mohammad A. et al. and Bahall M. et al., who also did not observe any significant correlation between income & depression[6,8]. While estimating stress, our research reported that those who had no income identified significantly higher stress, while those in the higher income group (? 41,000-55,000 and more) indicated no stress. This finding varies from FNU Satyjeet et al., who found no significant correlation between stress and income[27,28,29,30].
Limitation: While the findings of this study provide important insights into the prevalence of depression, anxiety and stress among patients with cardiovascular disease, certain limitations should be acknowledged. First, as this was a single-center study conducted in a tertiary care hospital, the results may not be generalizable to other healthcare settings or the broader population. Second, the cross-sectional design captures psychological status at only one point in time, limiting the ability to assess changes or casual relationships. Third, data collection relied on self-reported measures using the DASS-21 questionnaire, which may be influenced by recall bias or the tendency to under- or over-report symptoms. These limitations should be considered when interpreting the results, and future multi-center, longitudinal studies with larger and more diverse samples are recommended to validate and extend these findings.
CONCLUSION:
Our study suggests that the most common psychological pressures among individuals with cardiovascular disease are stress & anxiety, with depression being the least frequent. There were significant gender variations, with men presenting more typical stress levels & women indicating higher levels of anxiety. Low-income groups & older persons (>75 years) displayed increased susceptibility to severe stress & anxiety. Vegetarian diets and refraining from smoking & drinking were unusually correlated to higher levels of anxiety, demonstrating either underreporting or complex psychological coping methods. Anxiety risks were considerably increased by residing in a rural area and having less education. These results emphasize high-risk categories & support frequent mental health assessment in CVD management. By confronting dietary patterns, occupational challenges, and socioeconomic burdens, integrated approaches may promote cardiovascular outcomes. To optimize patient care, hospitals should apply quick mental health initial evaluation tools for cardiovascular inpatients to detect high-risk individuals requiring urgent evaluation & targeted support.
ACKNOWLEDGMENT: The authors express their sincere gratitude to the faculty members and healthcare professionals who provided valuable guidance and support throughout this study. We are also thankful to the patients who participated in this research. The constructive suggestions from colleagues and peers are deeply appreciated.
REFERENCES
Chetana Joshi, Kunal Jadaun*, Dilip Jain, Narendra Parihar, Assessment of Depression, Anxiety & Stress in Cardiovascular Disease Patients Admitted at Tertiary Care Hospital in Southern Rajasthan, Int. J. of Pharm. Sci., 2025, Vol 3, Issue 11, 229-237 https://doi.org/10.5281/zenodo.17510755
10.5281/zenodo.17510755
