If newly diagnosed heart disease patients who must undergo treatment are optimistic, and expect they'll resume normal activities, do they actually do better than if they're pessimistic about the outcome?
Reporting on their 15-year study in this week's Archives of Internal Medicine, Duke University Medical Center researcherssay they do, raising the issue of whether physicians should go out of their way to accentuate the positive.
"Patients with coronary artery disease who had more favorable expectations about their likelihood of recovery and return to a normal lifestyle had better long-term survival as well as better functional status after their hospitalization," concluded John C. Barefoot and colleagues in the Outcomes Research Group and the Duke Division of Cardiology.
The mortality rate for those in the highest quartile of expectations, that is the most optimistic, was 28.8 deaths per 100 patients during the 10 years after baseline, compared with 56.9 deaths per 100 for those in the lowest quartile.
In a related commentary, Robert Gramling, MD and Ronald Epstein, MD, of the University of Rochester in New York wrote that indeed, "optimism is a powerful 'drug' that compares favorably with highly effective medical therapies" because optimism facilitates contemplation and decision making.
They said the study might prompt physicians to promote the positive when they have to give bad diagnostic news. They might, for example, say "...but I think you'll beat the odds."
Barefoot's study used "extensive controls for clinical disease indicators" as well as a variety of adjustments for psychosocial variables such as depression.
The project enrolled 2,818 patients who were newly diagnosed with clinically significant, at least 75% diameter, coronary artery stenosis between 1992 and 1996. The participants also underwent angiography or coronary artery bypass surgery.
Before the procedures participants were asked to indicate from a panel of 18 statements in the Expectations for Coping Scale, which ones most closely matched their outlook.
For example, they might check "My heart condition will have little effect on my ability to work," or "I expect that my lifestyle will suffer because of my heart condition," or "I doubt that I will ever fully recover from my heart problems."
Scores "indicating positive expectations were associated with reduced mortality risk" for both all-cause mortality and mortality from cardiac causes, "despite extensive controls for clinical disease indicators" plus psychosocial variables, the researchers wrote.
The researchers then compared their responses with their functional status at one year and whether they died within the next 15 years.
"The most novel findings in the present study are the associations between expectations and subsequent survival," they wrote.
Barefoot and colleagues suggested two possible mechanisms to explain the relationship between expectation and mortality. In the first, "Optimists have been found to be more likely to address the demands of a problem rather than withdrawing or focusing on its emotional consequences," a coping predisposition that may be more effective in reducing risk factor levels.
In the second, it's likely that pessimists experience "more tension and negative emotions," which translates to "heightened stress, autonomic dysregulation, and other physiological responses that increase the risk of cardiac events."
In their commentary, Gramling and Epstein noted that unbridled optimism "can be disastrous. Patients with serious incurable illness harboring unchallenged optimistic perceptions to choose burdensome treatments that they might not have chosen if they had a more balanced understanding of their overall prognosis."
Rather, they said, a better strategy would be to view both optimism and pessimism as not mutually exclusive, such as a "hope for the best, prepare for the worst," approach.