The whole is greater than its parts.

Many psychosocial factors have been identified as potential risk factors for ischaemic heart disease, and strong evidence has been put forward for several personality factors such as Type A behavioural pattern, hostility, depression, or social factors such as low socioeconomic status and lack of social support. (Table 1 ) Psychosocial stressors per se increase cardiac vulnerability by altering autonomic tone, and induce increased catecholamines spillover, baroreceptor reflexes inhibition, clotting formation, and angiotensin-II stimulation. All these responses have detrimental effects on the cardiovascular system and may explain the high incidence of adverse cardiac events during follow-up. Associations between depressive symptoms and mortality have been reported in patients without known coronary artery disease, but these reported associations were, in general, weaker than those observed in studies of patients with cardiac disease. On citing how psychosocial factors may impact the development of cardiac disease, it is clear that such factors are not unitary in nature, but rather multifactorial in their own right. Thus, we must consider age, sex, diet, exercise and smoking pattern, obesity, family history, hypertension, and other factors as potential covariates with psychosocial factors at the individual, interpersonal, and environmental levels. The impact that psychological distress may exert on the clinical outcome after a cardiac event is also a complex task, because several factors may interact and have a confounding effect. For instance, patients with cardiovascular symptoms and poor general health are more likely to have depressive symptoms, which reduce the perception of well-being and cause distress. This interaction is particularly stronger in patients with chronic conditions, such as those with chronic heart failure or those who underwent several invasive procedures like coronary angiography, percutaneous transluminal coronary angioplasty (PTCA) after PTCA, or coronary artery bypass grafting (CABG) after PTCA and/or after a previous CABG. Other contributing factors are left venricular function, age, sex, and cardiovascular risk profile. A depressed ejection fraction, age .65, male sex, and multiple cardiovascular risk factors may contribute to aggravate psychological distress and to make difficult the interpretation of its role in the clinical outcome. Another important issue is the time when cardiovascular risk is assessed. In most of the previous studies, depressive symptoms were assessed during or shortly after hospitalization for myocardial infarction (MI), unstable angina, heart failure, cardiac investigations, or cardiac surgery. However, when patients are in hospital, the severity of cardiac disease, available treatment options, and prognosis are likely to have a significant impact on mood. Thus, the administration of a questionnaire to determine the impact of psychosocial profile on outcome should be performed after 5 months from hospital discharge, when the patient has hopefully reached a stable condition. In their study, Ferketich and Binkley examined the burden of psychological distress among individuals with different forms of heart disease. Subjects were screened in the United States with the National Health Interview Survey (NHIS), a yearly interviewer-administered survey performed on an annual basis since 1957 and currently, the primary source of information on health and illness in the United States. Because heart disease primarily affects older populations, the present analysis is limited to the adults 40 years of age. Three self-reported heart disease diagnoses were examined: CHD, MI, and CHF. For each condition, participants who reported being told that they had the condition were compared with those participants who reported having no cardiovascular condition (CHD, MI, CHF, plus angina pectoris, and stroke). The self-administered K6 questionnaire was used to assess how often during the past 30 days the participant felt sad, nervous, restless, hopeless, everything was an effort, and worthless. The responses were scored from 0–4 on a Likert scale with ratings from ‘None of the time’ to ‘All of the time’. The total scores therefore ranged from 0–24 and a score of 13 has been suggested as a cut-point for classifying individuals as having a ‘serious mental illness’. The psychometric properties of the K6 have been examined in men and women who were sampled from the