Depressive Symptomatology and Vital Exhaustion are differentially related to behavioral risk factors for coronary heart disease
Running title: Depressive Symptomatology and Vital Exhaustion
Prof. Maria S. Kopp, M.D., Ph.D., Inst. of Beh.Sci., Semmelweis Univ.of Med.
Dr. Paul R.J. Falger, Maastricht Univ. Med, Dept.of Med. Psychology, Holland
Prof. Ad Appels, Maastricht Univ. Med., Dept. of Med. Psychology, Holland
Sándor Szedmák, M.A., Inst. of Beh.Sci., Semmelweis Univ.of Med.
Published in : Psychosomatic Med.(in press)
Correspondence:
Prof. Maria S. Kopp, M.D., Ph.D., Director
Institute of Behavioural Sciences
Semmelweis University of Medicine
H-1089 Budapest, Nagyvárad tér 4. floor 20.
Hungary
Tel: +36 1 210 2953; Tel/Fax: +36 1 210 2955
E-mail: kopmar@net.sote.hu
This study was supported by the OTKA T-016486,
T0 13423 research grants of the National Research Fund
AbstractObjective:To assess differences in external validity of two psychosocial risk indicators for coronary artery disease(CAD), i.e. depressive symptoms and vital exhaustion. Method: In a representative, stratified, nation-wide sample of the population of Hungary over age 16 (N = 12,64o), we analyzed whether those risk indicators were differentially related to a number of illness behaviors (including history of cardiovascular treatment and cardiovascular sick days), cognitions, mood states, and socio-economic characteristics that may generally be associated with elevated CAD risk. The sample was stratified by age, sex, and composition of the population of all counties in Hungary. Results:Although depressive symptoms and vital exhaustion correlated strongly (r =.6198; p .ooo1), there were clear and significant differences in strenght of association between depressive symptoms, vital exhaustion and a number of variables under study.Dysfunctional cognitions, hostility, lack of purpose in life, low perceived self-efficacy, illegal drug use and several forms of subjective disability complaints and the history of treatment because of congenital disorders, alcohol and drug abuse,chronic skin and haematological disorders were more closely associated with depressive symptoms, while loss of energy, use of stimulants, chest pain related disabilities, history of treatment because of cardiovascular disorders and self-reported cardiovascular sick days were more significantly associated with vital exhaustion. Conclusions: Vital exhaustion and depressive symptomatology have different associations with relevant external criteria. Vital exhaustion has a more important impact on perceived cardiovascular complaints and history of cardiovascular treatment, while depressive symptomatology seems to be more closely connected to alcohol, drug and congenital disorder related disabilities and complaints, and to dysfunctional cognitions and hostility.
Keywords: depressive symptomatology, vital exhaustion, cardiovascular morbidity
Acronyms: MI = myocardial infarction, BDI = Beck Depression Inventory, VE = Vital Exhaustion, MQ = Maastricht Questionnaire, CVSDs = Self-reported cardiovascular sick days in the last year, CV%=percentage of persons with history of treatment because of cardiovascular disordersINTRODUCTION
There is increasing evidence from prospective studies that depression and vital exhaustion constitute strong risk indicators for first and recurrent cardiac events.In a representative community sample, depressive symptomatology derived from the Minnesota Multiphasic Personality Inventory was predictive of myocardial infarction(MI) during 27 years of follow-up(1). Another study showed that those heart patients who suffered an MI and who were depressed according to the Diagnostic Interview Schedule or the Beck Depression Inventory (BDI) during hospitalization, were at elevated risk to die from a new cardiac event within the next 18 months(2). According to 13 years follow-up of the Baltimore cohort of the Epidemiological Catchment Area Study in persons originally free of heart troubles the odds ratio for MI associated with original dysphoria was 2.o7, and the odds ratio associated with a history of major depressive episode was 4.54, independent of other coronary risk factors.(3) Previously, a study on vital exhaustion showed that apparently healthy adult males with elevated scores on the Maastricht Questionnaire(MQ) to assess manifestations of vital exhaustion(VE) were at increased risk of suffering a non-fatal MI during 4.2 years of follow-up(4). Also, it was observed that those heart patients who stayed exhausted after successful percutaneous transluminal coronary angioplasty were at elevated risk for a new cardiac event during 18 months of follow-up (5).
Depression and vital exhaustion have important symptoms in common, most notably increased fatigue and irritability, which raises the question whether both constructs may differ in conceptual and external validity.
In order to investigate the conceptual validity of the vital exhaustion construct,the prevalence of various mood states in 12 exhausted and 1o non-exhausted, apparently healthy adult males was studied(6). Using an experience sampling procedure during three weeks of follow-up, exhausted subjects scored significantly higher on self-ratings of excess fatigue and loss of vigour, while none of these exhausted subjects rated themselves as feeling depressed on the respective Profile of Mood States scales.Thus, excess fatigue and loss of vigour rather than depressed mood may be characteristic of vital exhaustion(6).
With regard to the external validity of the vital exhaustion construct, it should be noted that depressed mood appears to bear a life-time elevated risk for MI, while vital exhaustion may be most indicative of elevated short- term risk. That is, neither the Barefoot et al(1), nor the Pratt et al(3) community study showed time-dependent association of depressive symptomatology with incidence of MI during follow-up; by contrast, in the Appels et al (4) prospective study, vital exhaustion predicted best over the last year prior to MI.
In order to obtain more insight into possible differences in external validity between depression and vital exhaustion, it was studied whether both constucts would be differentially associated with perceived illness behaviors, history of treatment because different illnesses, cognitions, and mood states (e.g.,decline in working capacity, self-esteem, and hostility), use of stimulants(e.g.,smoking, coffee), and socio-economic characteristics that may generally be associated with elevated risk for coronary artery disease morbidity. In case that both constructs were found to be equally associated with these external criteria, the law of parsimony of explanation would suggest that the construct of vital exhaustion was redundant.Methods
Sampling of subjects: a National, Representative, Stratified Survey
Analyses are based on data from a national, representative, stratified survey of the population of Hungary over age 16 (N= 12,64o), which was conducted in 1995 by means of personal interviews at home. The sample was composed by combining stratified sampling and multi-step sampling procedures. In the first stratification all settlements with a population over 5.ooo were included in the sample, and a random selection was made of those with a population of less than 5ooo. In the first stratification single households were selected from the Central Satatistical Institute data base according to distribution of the population by region(county) and settlement size. In the next step, the interviewers went to the selected households and made the next stratification within the given households according to age, sex and occupation criteria given in advance.The refusal rate was 19% for the full sample, although there were significant differences, depending on the settlements. In big cities the refusal rate was much higher than in villages.For each refusal, the interviewers selected another person with similar sampling characteristics in the given neigbourhood.The aim of the study was to evaluate the interactive effects of social, psychological and health characteristics in a large sample of the population. In such a large study the sampling bias caused by the refusals cannot be avoided.
Psychological and Socio-Economic Measures
In all, 155 questions were used to assess the current socio-economic status and 27o questions to assess current physical and mental health status of all 12,64o respondents. Due to the limited time to conduct the interview (maximum 2 h), only those items that had been shown earlier to be the most representative of the respective questionnaires were selected. (7) (See appendix).
For answering the research questions of this paper, the following questionnaires were used:
Shortened Beck Depression Inventory (BDI) (7,8,9)This adaptation contained the nine items (symptoms) from the 21 item version of the BDI(7) with the highest Cronbach alphas and showed a strong correlation with the total BDI ( r =. 9254, p .ooo1; n = 1o1) These symptoms were: pessimism, lack of satisfaction, guilt feelings, social withdrawal, being indecisive, inhibition from work, sleep disturbances, fatigue, and somatic preoccupation.The shortened version of BDI can be reliably transformed into a full score, which can be categorized according to the following cut-off points(12):
o-9 points = normal
1o-18 points = mild depressive symptomatology
19- 25 points = moderately severe depressive symptomatology
26 points or higher = severe depressive symptomatology
Shortened Maastricht Vital Exhaustion Questionnaire (4) This adaptation of the original 21-item questionnaire (in Duch) to assess vital exhaustion(4) contained those nine items that were thought most representative of this construct (1o) (See appendix) The original MQ had been included in a case-control study with 133 male patients with first MI, 133 healthy neighborhood controls and 192 hospital controls in which an elevated score on MQ was predictive of MI in both series(11). With these 9 items, Cronbach s alpha was .8261, indicating good reliability; this short version correlated strongly with the original 21 item MQ (r = .9386,p .ooo1; N = 452).
Juhász Neurosis Scoring Scale (12) This 1o item questionnaire examines a number of important neurotic symptoms: anxiety, prolonged(at least 2 weeks) mood disturbances, sleep problems, being exhausted at waking up, diminished working capacity, impatience, headache, cardiac and gastric complaints without organic disorder.
Shortened Dysfunctional Attitude Scale (13) This 35 item questionnaire examines seven value systems and corresponding attitudes. These are: need for external recognition, need to be loved, need for achievement, perfectionism, need for return for a kindness (entitlement), omnipotence and external control versus autonomy. The items with highest Cronbach s alphas for each attitudes were recorded during the interviews. All of these 7 items (See Appendix) were analysed separately.
Shortened Hostility (Cynicism) (13) Based on the results of Barefoot et al (14), who employed the full Cook-Medley scale, a short (6 item) questionnaire to assess hostility was constructed (See appendix). All of these items were analysed separately, because according to Barefoot et al(14), and according to our earlier studies(13) the relative predictive values of different hostility items are different.
Shortened Purpose in Life Questionnaire (13) A 4 item shortened version of the 2o item questionnaire of Crumbaugh and Macholick (15) was constructed to assess subjective feelings of meaningfulness and purposes in life.(See Appendix)
Perceived Self-Efficacy The single item with the highest Cronbach s alpha of the Hungarian version of Schwarzer s (16) 1o item Generalized Perceived Self-Efficacy questionnaire was used.
Disabilities questionnaire (13) Disabilities, ranging from mild impairment to complete inability to ensure self-support according to 28 symptoms of different severity.
Illness Questionnaire(13): In this questionnaire, all subjects answered two questions with respect to 26 disease categories about
a., whether they had ever been treated for the respective disease at some time in their lives. The percentage of persons who have had a history of treatment because of different disorders was calculated, in this study the percentage of persons with history of treatment because of cardiovascular disorders(CV%) was especially important.
b., how many days they had been sick (i.e.,unable to work) due to illness during the past year. The total number of self-reported sick days during the past year for each subject was calculated by summing up the number of sick days for all disease categories. The total number of sick days due to cardiovascular disorders (hypertension and disorders of the heart ) (Cardio Vascular Sick Days: CVSDs) were also calculated separately.
Use of stimulating or sedative substances This 7 item questionnaire included questions about (amount of) daily smoking, daily coffee consumption, and daily alcohol consumption and use of illegal drugs.
Socio-economic characteristics: fathers employment, (manager to unskilled worker), level of education, employment status, housing situation (below standard situation to luxury), access to car, and own property (summer residence)
Statistical methods
The SPSS statistical program system was used for data analysis.(17) Hierarchical log linear analyses were performed to investigate the interactive effects for analysing the structure of discreet variables with not normal distribution. A special class of statistical techniques, called loglinear models, has been formulated for the analysis of categorical data ( 18,19). These models are useful for analysing the complex relationships among the variables in multiway crosstabulations. 1 footnoote
Footnote 1:Loglinear models are similar to multiple regression models. In loglinear models, all variables that are used for classification are independent variables, and the dependent variable is the number of cases in the cell of the crosstabulation.The regression analysis examines the relationship between a dependent variable and a set of independent variables. Analysis-of-variance techniques provide tests for the effects of various factors on a dependent variable. But neither technique is appropriate for categorical data, where the observation are not from population that are normally distributed with constant variance.The test of the hypothesis that the loglinear model fit the observed data can be based on the Pearson chi-square statistic. An alternative statistic is the likelihood-ratio chi-square. For large sample sizes, these statistics are equivalent. The advantage of the likelihood -ratio chi square statistic is that it, like the total sums of squares in analysis of variance, can be subdivided into interpretable parts that add up to the total. The difference between the two likelihood-ratio chi-squares values, sometimes called the partial chi-square, also has a chi-square distribution and can be used to test the hypothesis that the effect is 0.The partial chi-square can be used as an association measure that is proportional to the partial information between the two variables.(Footnote vége)
The test of hypotheses that the loglinear models fit the observed data are based on likelihood-ratio chi-squarq statistics. The likelihhod-ratios are proportional of the mutual information ( information difference ) that is a measure of stochastic dependencies betwen pairs of variables.(2o,21) The parameters of the analysis are LR = Chi square Likelihood ratio, df = degree of freedom, p = probability. The likelihood ratios can be regarded as a measures of the strenght of partial associations in the case of identical degrees of freedom(df). (2o,21)Results
Table 1. shows the percentage of persons with a history of treatment because of cardiovascular disorders (CV%), means and standard errors of depression scores, vital exhaustion scores, and the number of persons according to gender, age, level of education and employment status.
According to Table 1, women scored significantly higher on depression (F=58,5124, df=1,p .oooo) and vital exhaustion(F=271,4811, df=1, p .oooo). There was an increased depression score (F=341,5581,df=6, p .oooo) and vital exhaustion(F=4o7,52o2, df=6,p .oooo) dependent on age. BDI and VE were dependent on socioeconomic situation in very similar extent. In respect of connections with sex, age and socioeconomic characteristics there was no significant difference in the strength of the association between these characteristics and respectively the severity of depressive or vital exhaustion symptomatology.Among poeple who had been treated because of cardiovascular disorders during their life, the self-reported cardiovascular sick days in the last year (CVSDs) increased significantly with age, according to the results of the Kruskal-Wallis test (chi-square: 17,2791, p .oooo, cases:2441) and decreased according to level of education(Kruskal-Wallis chi-square:9,4121, p .ooo6, cases: 243o).In CVSDs there were no sex differences(t: o.731o, p .3926).
As might be expected, the interrelation between depression and vital exhaustion score was highly significant (r=0.6198) because both measures share a substantial amount of common variance (r2=0.3841). Table 2. shows the distribution of persons according to VE and BDI (below and above popolation average values).
The rate of people who were exhausted above mean exhaustion score, but not above mean depression score(18,1 %) were significantly more than people who were depressed but not exhausted(8,6 %).(chi square = 2697,84, df=1, p .oooo)
The results also show clear differences in the strength of the association between different psychosocial characteristics and respectively the severity of depressive or vital exhaustion symptomatology.
Table 3. and 4. show the most important discriminating factors of vital exhaustion and depressive symptomatology.
Table 3. shows those characteristics which are more closely connected to vital exhaustion than to depressive symptomatology analysed by hierarchical loglinear method(19-21). The likelihood ratios can be regarded as measures of the strength of partial associations in the case of identical degrees of freedom. The likelihood ratio in the case of smoking is 7 times higher, in the case of coffee consumption is three times higher and among the neurotic symptoms the feeling of loss of energy and being exhausted at waking up the likelihood ratios are six, and three times more closely connected to vital exhaustion than to depression.
Among the disability symptoms chest pain and chest discomfort are more closely connected to vital exhaustion than to depression. The history of being treated because of cardiovascular disorders was also more closely connected to vital exhaustion, than to depression.
Table 4. shows those characteristics which are more closely connected to depressive symptomatology than to vital exhaustion. These are the purpose in life questions, the dysfunctional attitudes, that is the dysfunctional cognitive patterns, the hostility score and all of the hostility items, and low perceived generalised self- efficacy. The likelihood ratio of no goals in life is 24 times, of general boredom from Purpose in Life questionnaire is 25 times more closely connected to depression, than to vital exhaustion. The connection of depressive symptomatology with hostility score is 11 times higher, with the dysfunctional attitudes are at least eight times higher, than with vital exhaustion. Illegal drug consumption, history of treatment because of drug and alcohol abuse, non peptic ulcer gastrointestinal disorders, hematological, dermatological and congenital disorders and several forms of disabilities are more closely connected to depression than to vital exhaustion. The above differences between depression and VE remained valid after correction according to age and sex.
In accordance with the literature (22-23) significant relationships were found between the socio-economic factors and the percentage of persons with history of treatment because of cardiovascular disorders. With the help of hierarchical loglinear analysis the interactive effects of socio-economic factors, depressive and vital exhaustion symptomatology and cardiovascular sick days were analysed separately.While the interaction between socioeconomic characteristics and BDI and VE respectively were the same, the connection between the severity of depressive symptomatology and cardiovascular sick days is weaker, compared to the effect of vital exhaustion. According to Figure 1. vital exhaustion very effectively mediates between the socio-economic factors and the cardiovascular sick days. In the cases of level of education, accessibility to car, housing conditions, employment status and owning summer residence vital exhaustion mediates between the given socio-economic factor and cardiovascular sick days. The only socio-economic factor, where the direct connection also remained significant was the fathers employment, but in this case this direct interaction was much lower (LR= 59,6, p .oo59), than the mediating effect of vital exhaustion (LR (fathers employment-VE) = 76o,6, p .oooo, LR(VE-CVSDs) = 244,5, p .oooo) These interactive effect of VE remained the same after correction according to age and sex.Discussion
These results indicate that vital exhaustion and depressive symptomatology have different associations with relevant external criteria and especially vital exhaustion has a more important impact on cardiovascular self report history of treatment because of cardiovascular disorders and on self-reported cardiovascular sick days on population level than depressive symptomatology. Self-report health status has been found to be an important predictor of mortality in longitudinal studies (24), therefore CVSDs and CV% can be regarded important health indicators. Dysfunctional cognitions are more characteristic for depressive symptomatology, in accordance with cognitive theory (25), such as increased need for external recognition, love and achievement, and lower self-efficacy. Hostility score and all of the hostility items are more closely related to depressive symptomatology than to vital exhaustion. The feeling of lack of goals in life and boredom are central features of depressive symptomatology, and less characteristic of vital exhaustion. Contrary to the importance of these psychological features in depressive symptomatology, in vital exhaustion the symptoms of loss of energy and the use of stimulating substances, such as daily smoking and increased coffee consumption are the central features.
Both depressive symptomatology and vital exhaustion were significantly related to socio-economic factors. This agrees with the literature (26) that depression is higher in lower socio-economic strata of the population. Additionally to our earlier findings (7), that depressive symptomatology mediates between the socio-economic factors and sickness absence rates in the population, in the case of perceived cardiovascular sick days the mediating effect of vital exhaustion seems to be a more important factor. A vicious circle might be hypothethesized between vital exhaustion and a socially deprived situation, which might play a significant casual role in higher perceived cardiovascular illness rate in lower socio-economic groups.
The observed link between vital exhaustion and smoking might mean that the higher cardiovascular risk of exhausted persons is the result of higher smoking level. However, step by step regression for cardiovascular sick days for vital exhaustion, smoking and duration of working hours pro week shows that vital exhaustion is the most important background variable of cardiovascular sick days among these examined variables.
Both concepts have been connected with increased probability of history of different disorders, vital exhaustion with increased probability of cardiovascular disorders, depressive symptomatology with increased risk for alcohol, illegal drug related treatments and congenital disorders. Among the different types of perceived disabilities depression was more closely connected to most of the disabilities, which limit daily activities, thus vital exhaustion cannot be regarded as identical with symptoms of disabilities. Among the disabilities only the chest pain related complaints were more closely connected to vital exhaustion than to depressive symptomatology.
The limitation of the study is that both the BDI and the MQ were shortened. The abbreviated versions of the BDI have been used widely(27) and they can be reliably transformed into the full score.
Vital exhaustion and depressive symptomatology share a common variance of 38%. However they seem to be distinct features. Vital exhaustion is a broader concept. Most depressed people (77%) are exhausted but fewer of those who are exhausted are simultaneously characterised by cognitive and mood disturbances. Both concepts are meaningful to understand the bridges between social inequalities and health. Relatively deprived persons living in undesirable social conditions might feel helplessness, loss of control and energy due to inability to improve their situation. This might be the best human equivalent of the learned helplessness model, which is more closely related to unsolvable, uncontrollable environmental situations. On the other hand, persons with dysfunctional cognition might blame themselves for their low achievements, or blame others, especially if they have a hostility attitude which means the lack of trust in others, and feeling of frustration by hearing the success of others. This state is related to the cognitive model of mood disorders. Both concepts are meaningful in a different way for a deeper understanding of the impact of adverse socio-economic conditions on health. Because depressive symptomatology and vital exhaustion were found to be differentially associated with behavioral risk factors for cardiovascular disorders, it is important for future preventive and rehabilitation interventions to consider vital exhaustion and depressive symptomatology as distinct psychosocial risk factors.
Footnote: The authors would like to thank Jancis Long and Pamela Falger for their valuable advices to improve the grammatical structure and the language of the paper.
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11. Falger P:
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Shortened Vital Exhaustion Questionnaire
0 no
1 uncertain
2 yes
Do you often feel tired?
Do you often have trouble falling asleep?
Do you wake up repeatedly during the night?
Do you feel weak all over?
Do you lately feel more listless than before?
Do little things irritate you more lately than they used to?
Do you sometimes feel that your body is like a battery that is losing its power?
Do you feel dejected?
Do you ever wake up with feeling of exhaustion and fatigue?
Shortened Dysfunctional Attitude Scale
0 totally disagree - 3 totally agree
My value as a person depends greatly on what others think of me (need for external recognition)
If a person I love does not love me, it means I am unlovable (to be loved)
If I fail at my work, than I am a failure as a person (achievement)
I should be upset if I make a mistake (perfectionism)
If I do nice things for someone, I can anticipate that they will respect me and treat me just as well as I treat them (entitlement)
I must try to help everyone who needs it (omnipotence- altruism)
My happiness is largely dependent on what happens to me (external control)
Shortened Hostility Questionnaire
0 Not characteristic at all - 3 totally characteristic
People are honest because they fear from the exposure
My every relative is well meaning with me
Nobody takes care of the others
The best is if you distrust anybody
If I have heard the success of a friend of mine, I feel I am frustrated
People are generally dishonest and selfish and they want only take advantage of others
Shortened Purposes in Life Questionnaire
0 Not characteristic at all - 3 totally characteristic
I am reliable
I have no goals in life
Every single day is new and different
I am generally bored
Disability questionnaire (questions connected to cardiological symptoms)
0 Not characteristic at all - 3 totally characteristic
Have you ever felt pain or an unpleasant feeling in your chest?
Have you ever felt a pressure in your chest?
Table 1. % of persons who have been treated because of cardiovascular disorders(CV%), means and standard errors of BDI and VE in the Hungarian population in 1995 according to sex, age,level of education and employment (N:12596)
CV%
BDI
VE
Number of cases
In population
26.6
%
8.2
±
0.1
7.7
±
0.1
12596
Sex
Men
24.9
%
7.4
±
0.1
6.8
±
0.1
5706
Women
28.0
%
8.7
±
0.1
8.4
±
0.1
6890
Age
<20
4.6
%
4.2
±
0.2
4.2
±
0.1
959
20-29
6.1
%
4.6
±
0.1
5.1
±
0.1
2629
30-39
12.3
%
6.3
±
0.2
6.6
±
0.1
2520
40-49
27.8
%
8.0
±
0.2
8.3
±
0.1
2578
50-59
42.3
%
10.6
±
0.3
9.6
±
0.2
1613
Level of education
Less or equal eight years of primary scool
45.8
%
12.5
±
0.2
10.3
±
0.1
2289
Primary + course
35.7
%
12.4
±
0.4
9.1
±
0.2
636
Skilled
27.8
%
9.1
±
0.2
8.1
±
0.1
2759
Technician
26.8
%
6.8
±
0.3
6.7
±
0.2
809
Secondary graduation
15.2
%
5.9
±
0.2
6.2
±
0.1
2358
Secondary + vocational training
19.7
%
6.4
±
0.2
7.1
±
0.1
1633
University degree
19.8
%
5.3
±
0.2
6.5
±
0.1
2024
Employment status
Manager
17.8
%
4.6
±
0.2
6.4
±
0.1
1408
Non-manager white collar
18.2
%
6.1
±
0.2
7.0
±
0.1
1931
Skilled workers
25.8
%
8.2
±
0.2
7.5
±
0.1
2394
Unskilled workers
33.5
%
13.0
±
0.4
9.3
±
0.2
718
Table 2. Percentage of people in the subgroups according to the mean levels of BDI and VE in the Hungaian population in 1995 (N:12437)
Vital exhaustion (Mean:7,7)
Depression score (mean:8,2)
Below mean value
Above mean value
Sum
Below mean value
5518
44,4%2253
18,1%7771
62.5%Above mean value
1073
8,6%3593
28,9%4666
37.5%Sum
6591
53.0%5846
47.0%No: 12437
Chi square:2697.84389 Df:1 p .00000
Table 3.
Characteristics more closely connected to vital exhaustion than to depressive symptomatology
Use of stimuling subtances
BDI
Likelihood Ratio (probability, df )exhaustion
Likelihood Ratio (probability, df )Daily smoking
7.7(.1021, 4)
58.7(.0000, 4)
Coffee consumption
54.8(.0000, 4)
155.5(.0000, 4)
Loss of energy
BDI
Likelihood Ratio (probability, df )exhaustion
Likelihood Ratio (probability, df)Do you wake up in the morning feeling rested?
352.7(.0000, 8)
2361.5(.0000, 8)
Have there been periods of at least a week when your capacity for work declined but no concrete illness could be diagnosed?
386.9(.0000,12)
1060.9(.0000,12)
Disability Questionnaire
BDI
Likelihood Ratio (probability, df )exhaustion
Likelihood Ratio (probability, df)Have you ever felt pain or an unpleasant feeling in your chest?
238.3(.0000,12)
1370.9(.0000,12)
Have you ever felt a pressure in your chest?
275.4(.0000,12)
1309.9(.0000,12)
History of treated because of different disorders
BDI
Likelihood Ratio (probability, df )exhaustion
Likelihood Ratio (probability, df)e
e
hypertension
111.0(.0000,4)
375.1(.0000,4)
e
heart complaint
94.7(.0000,4)
403.5(.0000,4)
e
e
e
e
e
Table 4.
Characteristics more closely connected to depressive symptomatology than to vital exhaustion
Dysfunctional attitudes
BDI
Likelihood Ratio
(probability, df)exhaustion
Likelihood Ratio ( probability, df)My value as a person depends greatly on what others think of me.
351.4(.0000,12)
42.8(.0001,12)
If a person I love does not love me, it means I am unlovable.
552.7(.0000,12)
51.5(.0000,12)
If I fail at my work, then I am a failure as a person.
206.0(.0000,12)
27.8(.0059,12)
Purpose in life
BDI
Likelihood Ratio
(probability, df)exhaustion
Likelihood Ratio (probability, df)I am reliable.
432.9(.0000,12)
193.3(.0000,12)
I have no goals in life.
2081.2(.0000,12)
85.6(.0000,12)
Every single day is new and different.
460.6(.0000,12)
227.5(.0000,12)
I am generally bored.
1916.0(.0000,12)
75.2(.0000,12)
Perceived self efficacy
BDI
Likelihood Ratio (probability, df)exhaustion
Likelihood Ratio (probability, df)I can manage any situation.
819.6(.0000,12)
185.5(.0000,12)
Hostility
BDI
Likelihood Ratio (probability, df)exhaustion
Likelihood Ratio (probability, df)People are generally dishonest and selfish and they want to take advantage of others.
867.8(.0000,12)
281.9(.0000,12)
People are honest because they fear from the exposure.
441.6(.0000,12)
100.8(.0000,12)
My every relative is well meaning with me.
294.6(.0000,12)
109.7(.0000,12)
Nobody takes care of the others.
672.9(.0000,12)
150.2(.0000,12)
The best is if you distrust anybody.
816.2(.0000,12)
138.0(.0000,12)
If I have heard the success of a friend of mine , I feel I am frustrated.
903.6(.0000,12)
85.1(.0000,12)
Do you use any drug or narcotic?
68.7(.0000, 4)
15.9(.0031, 4)
d
Disability Questionnaire
BDI
Likelihood Ratio (probability, df )exhaustion
Likelihood Ratio (probability, df)Difficulty hearing someone talking in a quiet room.
438.4(.0000,12)
139.6(.0000,12)
d
Difficulty going outside the house or garden without help.
689.4(.0000,12)
86.7(.0000,12)
d
A sore, blemish or deformity which limits daily activities.
348.1(.0000,12)
146.2(.0000,12)
d
Difficulty being understood by other people.
491.9(.0000,12)
101.7(.0000,12)
d
Difficulty understanding what other people say or what they mean.
25.7(.0000,12)
122.3(.0000,12)
d
Frequently getting confused or disorientated.
718.7(.0000,12)
199.9(.0000,12)
d
Mental handicap or other severe learning difficulties.
310.9(.0000,12)
99.2(.0000,12)
d
History of treatment because of different disorders
BDI
Likelihood Ratio (probability, df )exhaustion
Likelihood Ratio (probability, df)e
e
e
e
e
e
e
e
hematological disorders
56.1(.0000,4)
27.3(.0000,4)
d
non peptic ulcer gastric and intestinal disorders
112.0(.0000,4)
29.5(.0000,4)
d
chronic skin disorders
40.0(.0000,4)
6.2(.1822,4)
d
congenital disorders
47.0(.0000,4)
8.0(.0896,4)
d
alcohol abuse
69.7(.0000,4)
11.9(.0176,4)
d
drug abuse
81.4(.0000,4)
20.9(.0003,4)
d