Shinshu Med J, 68⑵：97～105, 2020

Assessment of Depressive Tendency, Coping Strategies,
and Type D Personality in Japanese Patientswith Coronary Artery Disease
Daisuke Yamaguchi, Atsushi Izawa＊ and Yasuko Matsunaga
School of Health Sciences, Shinshu University

Background : Type D personality, characterized by social inhibition and negative affectivity, is a psychological riskof coronary artery disease (CAD). This study aims to identify self-ratings of depression and its associations withcoping strategies, Type D personality, and with sociodemographic or clinical factors among Japanese patientswith CAD.
Methods : Participants were CAD patients who underwent percutaneous coronary intervention. The Zung SelfRating Depression Scale, the Type D Personality Scale, and the Tri-axial Coping Scale 24 were used to survey
the presence of depressive tendency, Type D personality, and type of coping strategy, respectively. Logistic re‑gression analysis was performed to identify characteristics associated with depressive tendency.
Results : Among 100 respondents who returned fully completed questionnaires (effective response rate : 92.6 ％),59 were found to be depressed, and 44 presented with Type D personality. The self-ratings of depression weresignificantly associated with Type D personality (odds ratio [OR]＝2.78, 95 ％ confidence interval [CI] [1.06, 7.24],
P＝0.037), and inversely associated with full-time work (OR＝0.23, 95 ％ CI [0.08, 0.64], P＝0.005). Analysis of thetypes of coping strategy revealed that abandonment or resignation coping style was significantly associated withdepressive tendency (OR＝1.33, 95 ％ CI [1.07, 1.65], P＝0.010).
Conclusions : CAD patients with higher depressive tendency are significantly more likely to display a Type D
personality, to employ abandonment or resignation coping strategies, and are less likely to be in full-time em‑
ployment. Employment of strategies to prevent negative coping behavior could be beneficial to prevent future
depressive tendency in CAD patients with Type D personality. Shinshu Med J 68 : 97―105, 2020
(Received for publication July 3, 2019 ; accepted in revised form October 25, 2019)
Key words : Type D personality, Depressive tendency, coping strategies, coronary artery disease
Abbreviations : CAD, coronary artery disease ; PCI, percutaneous coronary intervention ; SDS, Self-Rating De‑pression Scalecreasingly high-stress society, a super-aging popula‑

Ⅰ Introductiontion, and the work-centered way of life. While strate‑

The Global Burden of Disease Study has demon‑gies for percutaneous coronary intervention (PCI)

strated that cardiovascular diseases are leading

have been established, interventions for psychosocial

2）

and also in Japan .

stress and illness are still needed to prevent further

Coronary artery disease (CAD), a mainstay of athero‑major cardiovascular events in patients with CAD.

sclerotic cardiovascular disease, could be attributed

The prevalence of depression is strikingly higher

in Japan to the westernization of lifestyles, an in‑among patients with acute myocardial infarction (45causes of death in the world＊1）

Corresponding author : Atsushi Izawa
School of Health Sciences, Shinshu University, 3-1-1
Asahi, Matsumoto, Nagano 390-8621, Japan
E-mail : izawa611@shinshu-u.ac.jp

No. 2, 2020％) than among the general population (2-3 ％ in males,
5-9 ％ in females)3）4）. Importantly, the mortality rate
after two years among depressive CAD patients has
been twice as high as non-depressed CAD patients5）.
97

Yamaguchi・Izawa・Matsunaga

Personality types have been linked to CAD as

PCI, patients who consented to participate were

follows : Type A personality, which is characterized

asked to anonymously complete the survey question‑

by hostility, i.e., anger and animosity, has been asso‑

naires. The exclusion criteria were as follows : (1) de‑6）7）. Type D

compensated heart failure ; (2) prior history of myo‑

personality, characterized by social inhibition andcardial infarction (excluded owing to possible depres‑ciated with greater vulnerability to CAD
8）negative affectivity , has been also associated withsion following the previous infarction episode)3）4）; (3)psychological CAD risks. In fact, approximately 76 ％prior history of cognitive impairment ; (4) inabilityof CAD patients with the Type D personality haveto communicate verbally ; (5) inability to complete theexperienced significant anxiety and depressive

survey questionnaire ; (6) the patient’s consent could

9）

symptoms , suggesting proneness to psychological10）

stress , and thus having higher mortality rates
8）

not be obtained ; and (7) severely diseased patients
who were not able to participate in this study. The
data collection period was July 2016 to June 2017.

when compared to non-Type D CAD patients .

CAD patients may be further stressed after dis‑Ｂ

Data collection

charge because of increased medical supervisions

１

Sociodemographic and other characteristics

with multiple medications, diet restrictions, and espe‑

A range of data were collected : age, gender, pres‑cially with concerns over the risk for a secondary

ence/absence of employment, co-residents, smoker/

11）

cardiovascular event . These stressors can reduce

non-smoker, presence/absence of cardiovascular risk

the physical and psychological quality of life, andfactors (e.g., hyperlipidemia, hypertension, diabetes,

increase the risk of depressive tendency. It has been

body mass index), and type of CAD.

demonstrated that an increase in depression in CAD

２Type D personality

12）

patients is correlated with negative coping strategies .

The Japanese version14） of the Type D Personality

Although it has been suggested that avoidance-

Scale developed by Denollet15） was utilized. The

oriented coping is associated with depressive symp‑

reliability and validity of this 14-item, two-factor

toms soon after the onset of acute coronary syn‑scale (negative affectivity [Cronbach’s α＝.799] and9）drome, the details are not clear . A key interventionsocial inhibition [Cronbach’s α＝.826]) have been

for mental health care is to instruct in specific positive

verified14）. For each item, responses are made on a

coping strategies, thereby improving an individu‑

5-point scale (0＝false ; 1＝rather false ; 2＝neutral ; 3

al’s cognitive and behavioral practices to reduce＝rather true ; and 4＝true). Scores of 10 or higher on

13）both subscales denote a tendency toward Type D

stressors .

Currently, however, there is little data from Japan

personality. The Cronbach’s α coefficients of theas to specific types of coping strategies and/or types

subscales in this study were .829.

of personalities, which are associated with depression

３

Coping strategy

in CAD patients. This study therefore aims to examine

The Tri-Axial Coping Scale 24 (TAC-24) devel‑

depressive tendency and its relationships between

oped by Kamimura et al16） was utilized. This scale

coping strategies and Type D personality in Japanese

assesses how an individual facing psychologically

CAD patients. The findings are expected to support

stressful circumstances thinks and behaves about

mental care instructions to prevent depression andsurmounting those circumstances. This scale com‑adverse cardiovascular outcomes in Japanese CAD

prises eight subscales and 24 items. The reliability

patients.

(Cronbach’s α＝.65-.84) and validity have been veri‑
Ⅱ

Ａ

Materials and Methods

Participants and procedure

fied16）. Each item is rated on a scale of 1-5 (1＝I’ve
never done this, 2＝I’ve very seldom done this, 3＝
I’ve done this several times, 4＝I’ve frequently done

Participants were inpatients who underwent PCI

this, and 5＝I’ve always done this). Higher scoresat Shinshu University Hospital. The day following

indicate more likely to be performed. The Cron‑

98

Shinshu Med J. 68

Depressive tendency, coping, and Type D personality in CAD

bach’s α coefficient in this study was .813.

excluded because of the incomplete response to４

essential values. The remaining 100 questionnaires

Depressive tendency
17）

The Japanese versionof the Zung Self-Rating
18）

Depression Scale (SDS), developed by Zung , waswere analyzed (effective response rate : 92.6 ％).
Ａ

Descriptive statistics

utilized in this study. The reliability and validity ofParticipants’ median age was 66.0 (quartiles : 58.0,

this scale have been verified. This scale comprises 2072.0). Sixty-four of the participants were employed :items rated on a scale of 1-4 (1＝a little of the time, 255 full-time and 9 part-time. Forty-four (44.0 ％) of＝some of the time, 3＝a good part of the time, and 4

the participants presented with a Type D personality＝most of the time). A total score of 40 or more on all

and 59 participants reached the criteria for depressive

20 items indicates depressive tendency. The Cron‑

tendency. Table 1 shows the distribution of all socio‑

bach’s α coefficient for this study was .715.

demographic and health characteristics.

Ｃ

Table 2 shows the descriptive statistics for the

Data analysis
Associations between depression, sociodemograph‑Type D Personality Scale, TAC-24 subscale scores,

ic, and health characteristics, Type D personality,

and SDS scores. The median score of the Type D

and all eight TAC-24 subscales were assessed via a

Personality Scale was 23.0 (quartiles : 16.3, 30.0), while

two-sample test, a chi-squared test, and Spearman’sthat of the SDS was 41.0 (quartiles : 35.0, 47.8).

rank correlation coefficient. As the presence/absence

Ｂ Comparison of coping strategies between patientsof employment was divided into three variables, thewith and without Depressive tendency

chi-squared test for comparison was used andTable 3 shows comparisons of the sociodemographic

corrected for the multiple comparisons using Bonfer‑and health characteristics between the patients withroni’s method. Multiple logistic regression analyses

and without depressive tendency. Patients with de‑

were performed to identify factors associated withpressive tendency had significantly higher Type D

depressive tendency. Independent variables werepersonality scores (p＝.004) than those without de‑age, gender and factors that were p＜0.1 in univari‑pressive tendency. Significantly larger population of

ate analysis. To clarify the characteristics of thepatients without depressive tendency were full-time

coping strategies of patients with Type D personali‑

employee (p=.009) than those with depressive

ty, a comparative analysis of TAC-24 subscale scorestendency.

between patients with and without a Type D person‑

Table 4 shows comparisons of the TAC-24 subscaleality was conducted using the Mann-Whitney U test.

scores between the patients with and without de‑

The significance level was set at 5 ％, and all analy‑pressive tendency. Patients with depressive tenden‑ses were performed with SPSS Statistics 24.0 forcy had significantly higher scores on abandonment

Windows (IBM Corp., Armonk, NY).

or resignation and responsibility shifting (p＝.001 andＤ.035, respectively) than those without depressive ten‑

Ethical considerations
This study was conducted in accordance with thedency. Meanwhile, participants with non-depressive

Declaration of Helsinki. The protocol of this study

tendencies had higher scores (p＝.010) on planning.

was approved by the Medical Ethics Committee of
Shinshu University School of Medicine (No. 3428).
Ⅲ Results

The independent variables selected for the binomial
logistic regression analysis included presence/absenceof Type D personality, abandonment or resignation,planning, responsibility shifting, BMI and full-time

The design and protocol of this study were ex‑work (Table 3, 4). For the TAC-24 subscales, theplained to 115 eligible patients, and then 108 patients

total score of each item was entered. The chi-squareconsented to participate. The survey question‑

statistic of the model was significant (p＜.01), and thenaires were returned from all participants (response

Hosmer-Lemeshow test was p＜.627. The discrimi‑

rate : 100 ％ ) ; however, eight questionnaires were

nant predictive value was 74.0 ％. The most notable

No. 2, 202099

Yamaguchi・Izawa・Matsunaga
Table 1Sociodemographic and other characteristics
Median(Interquartile range)

Age (years)
30-39
40-49
50-59
60-69
70-79

n

66.0 (58.0, 72.0)
3
6
22
37
32

Sex
Male
Female88
12

LivingWith family
Alone

89
11

Employment
Full-time work
Part-time work55
9Unemployed/retired

36

Type of coronary artery disease
Acute myocardial infarction
Angina pectoris

39
61

Unstable angina pectoris
Stable angina pectoris

12
49

Clinical variables
Smoking
Hypertension
Dyslipidemia
Diabetes mellitus
Body mass index
Body mass index≧25

32
60
71
33
24.2 (21.6, 26.8)
39Type D personality

44

Depressive tendency

59

relationship was observed inversely between depres‑had significantly higher scores on abandonment orsive tendency and full-time work (OR＝0.23, 95 ％ CI

resignation and responsibility shifting subscales (p[0.08, 0.64]). We also found significant correlations＝.002 and .010, respectively) than those with non-between depressive tendency and Type D personality

Type-D personalities. In contrast, participants with

(OR : 2.78, 95 ％ CI [1.06, 7.24]) and between depressive

non-Type-D personalities had higher scores (p＝.004)

tendency and abandonment or resignation (OR＝1.33,

on positive interpretation.

95 ％ CI [1.07, 1.65]) (Table 5).
Ｃ Comparison of coping strategies between patientswith and without Type D personality

Ⅳ

Discussion

Among 100 CAD patients in this study, 59 patients

Table 6 shows comparisons of the TAC-24 subscale(59 ％) reached the criteria for depressive tendency,

scores between the patients with and without Typeas measured by the SDS. This value was high as

D personality. Patients with the Type D personality

compared with the global prevalence of depressive

100

Shinshu Med J. 68

Depressive tendency, coping, and Type D personality in CAD
Table 2

Descriptive statistics for Type D personality, coping strategy, and depressive tendency
Scoring range

Median(Interquartile range)

Type D personality scale
Negative affectivity
Social inhibition

0-56
0-28
0-28

23.0 (16.3, 30.0)
11.0 (6.0, 14.8)
13.0 (9.0, 17.0)

Subscales of the Tri-Axial Coping Scale 24
Catharsis
Abandonment / Resignation
Information gathering
Distraction
Evasive thinking
Positive interpretation
Planning
Responsibility shifting

3-15
3-15
3-15
3-15
3-15
3-15
3-15
3-15

8.0 (6.3, 11.0)
7.0 (6.0, 9.0)
9.0 (7.0, 11.0)
8.0 (7.0, 10.0)
9.0 (7.0, 10.0)
10.0 (9.0, 13.0)
10.0 (8.3, 12.0)
4.0 (3.0, 6.0)

Zung self-rating depression scale

20-80

41.0 (35.0, 47.8)

Table 3Differences in characteristics between patients with and without depressive tendency
Withdepressive
tendency

Without
depressive
tendency

59

41

Age, mean (SD)61.8 (9.4)

65.0 (10.7)

Sex, n (％)
Male

51 (86.4)

37 (90.2)

Female8 (13.6)

4 (0.8)

Living, n (％)
With family

52 (88.1)

38 (92.7)

7 (11.9)

3 (7.3)26 (44.1)

29 (70.7)

6 (10.2)
27 (45.7)

3 (7.3)9 (22.0)23 (39.0)

16 (39.0)

36 (61.0)

25 (61.0)

18 (30.5)
37 (62.7)n

Alone
Employment, n (％)
Full-time work
Part-time work
Unemployed/retired
Type of coronary artery disease, n (％)
Acute myocardial infarction
Angina pectoris
Clinical variables, n (％)
Smoking
Hypertension

t or χ2pt＝－1.5300.129

χ2＝0.331

0.565

χ2＝0.556

0.456

χ2＝6.8780.009

χ2＝0.000

0.997

14 (34.2)

χ2＝0.147

0.701

23 (56.1)

χ2＝0.441

0.507

2

Dyslipidemia

42 (71.2)

34 (82.9)

χ ＝1.828

0.176

Diabetes mellitus

19 (32.2)

14 (34.1)

χ2＝0.041

Body mass index, mean (SD)25.5 (4.07)

24.0 (4.35)

t＝1.712

0.859
0.090

Personality, n (％)
Type D33 (55.9)

11 (26.8)

Non-Type D

26 (44.1)

30 (73.2)

χ2＝8.315

0.004

No. 2, 2020101Yamaguchi・Izawa・Matsunaga
Table 4 Differences in subscale scores of the Tri-Axial Coping Scale 24 between patients with andwithout depressive tendencynCatharsis
Abandonment / Resignation
Information gathering
Distraction
Evasive thinking
Positive interpretation
Planning
Responsibility shifting

With depressive tendency

Without depressive tendencyp59
8.0 (6.0, 11.0)
8.0 (6.0, 9.0)
8.0 (7.0, 10.0)
8.0 (7.0, 10.0)
9.0 (7.0, 10.0)
10.0 (9.0, 13.0)
10.0 (8.0, 12.0)
5.0 (3.0, 6.0)41
9.0 (6.5, 11.0)
6.0 (4.0, 8.0)
9.0 (8.0, 12.0)
8.0 (7.0, 10.0)
8.0 (7.0, 10.5)
10.0 (9.0, 14.0)
11.0 (9.0, 14.0)
4.0 (3.0, 5.0)

.554
.001
.099
.581
.798
.371
.010
.035

Data are shown as median (interquartile range) and analyzed by the Mann-Whitney U test.
Table 5Characteristics associated with depressive tendency
Univariable

Multivariable

OR

95 ％CIpOR

95 ％CIp

Type D personality

3.46

1.46 - 8.19

.005

2.78

1.06 - 7.24

.037

Subscales of coping strategy
Catharsis
Abandonment / Resignation
Information gathering
Distraction
Evasive thinking
Positive interpretation
Planning
Responsibility shifting

0.96
1.36
0.89
0.97
1.04
0.93
0.82
1.37

0.84 - 1.09
1.12 - 1.65
0.78 - 1.03
0.82 - 1.14
0.89 - 1.21
0.81 - 1.07
0.71 - 0.96
1.05 - 1.80

.958
.002
.107
.688
.614
.319
.012
.021

1.33

1.07 - 1.65

.010

Age
Sex
Full-time work
Part-time work
Living with family
Acute myocardial infarction

1.03
1.45
0.30
0.67
0.59
0.99

0.99 - 1.07
0.41 - 5.18
0.12 - 0.75
0.14 - 3.23
0.14 - 2.42
0.44 - 2.26

.131
.566
.010
.615
.460
.997

0.23

0.08 - 0.64

.005

Table 6 Differences in subscale scores of the Tri-Axial Coping Scale 24 between patients withType D and non-Type D personalitynCatharsis
Abandonment / Resignation
Information gathering
Distraction
Evasive thinking
Positive interpretation
Planning
Responsibility shifting

Type D

Non-Type Dp44
8.0 (7.0, 11.8)
8.0 (6.3, 9.0)
9.0 (7.0, 11.0)
9.0 (6.3, 10.0)
9.0 (7.0, 10.8)
10.0 (8.0, 12.0)
9.5 (8.0, 11.8)
5.0 (3.0, 6.8)56
8.0 (6.0, 11.0)
6.0 (5.0, 8.0)
9.0 (7.0, 12.0)
8.0 (7.0, 10.0)
8.0 (7.0, 9.8)
11.5 (9.0, 14.0)
11.0 (9.0, 13.0)
4.0 (3.0, 5.0)

.489
.002
.680
.535
.129
.004
.050
.010

Data are shown as median (interquartile range) and analyzed by the Mann-Whitney U test.
102

Shinshu Med J. 68

Depressive tendency, coping, and Type D personality in CAD

tendency : approximately 45% among CAD pati­
3）
4）
19）

bilitation, stress management training with coping. The presence of depressive tendency ininstructions has produced significant reductions in

CAD patients was significantly correlated with Typestress and greater improvements in medical out‑

D personality and abandonment or resignation

comes26）. These results, taken together, suggest that

coping strategy, and inversely related with full-time

positive coping strategies are beneficial for CAD

employment.

patients with the Type D personality.

ents

The association observed in this study between

A prospective study has shown that unemployment

depressive tendency in CAD patients and Type D

status among outpatients with cardiovascular diseases

20）

personality was consistent with a previous report .

was independently associated with depression andSince Type D personality is a stable personality

the risk of major cardiovascular outcomes27）. In ac‑

category that undergoes minimal change21）, it tends

cordance with the previous study, the present study

to enhance the risk of depressive tendency in CAD

indicated that full-time work was inversely associat‑

patients. Type D patients had a higher frequency ofed with depressive tendency. Mental health carestressful life events and had more mental disorders,should therefore focus predominantly on part time

including depression and anxiety disorders, thanworkers and/or unemployed and retired patients.

22）

non-Type D patients . Type D personality has been
23）

The possible protection against depressive tendency

associated with symptoms linked to stress , whichamong full-time workers can be explained, at least in

could result in the development of depression. In fact,part, by their opportunities for annual health screen‑

the risk of depression in patients with a Type Ding, which has been required by the Japan’s Industri‑personality increases by 3.69 times after a 10-year

al Safety and Health Law28）. Moreover, enterprises

period24）. Importantly, 44 ％ of CAD patients in thiswith 50 or more employees are required to employ astudy presented with the Type D personality, indi‑

physician specializing in occupational health andcating a substantial need for CAD patients to besafety, perform stress check-ups, and carry out

screened for the Type D personality, as they areinterviews with workers whenever necessary. Despite

more likely to develop depressive tendency subse‑

the presence of these occupational health interven‑quently.

tions, patients do not always recognize and take care

Abandonment or resignation, a negative copingof their mental burdens. Particularly, in the case of

strategy, was also associated with depressive tendency

patients at the onset of acute coronary syndrome,in CAD patients in this study. In addition, patientsthe emergent PCI and major cardiovascular burdens

with the Type D personality, compared with thosecan be overwhelming, and thus, assessment andwith non-Type D personalities, resorted moreinterventions for mental stressors are often delayed

frequently to abandonment or resignation, and lessand insufficient. Hence, mental health assessment

frequently to the positive interpretation strategy. It

and optimal interventions should be timely and suffi‑

has been reported that depressive tendency in CAD

ciently provided to CAD patients before discharge.

patients is correlated with negative coping strategies,

Based on the results of this study, mental health9）and inversely related with positive coping strategies .

screening and identification of the Type D personality

In addition, cardiac rehabilitation patients with per‑in CAD patients would be warranted to prevent thefectionistic Type D personality are likely to havedevelopment of depressive tendency. Patients with25）

maladaptive coping . The abandonment or resignation

the Type D personality are potential candidates who

strategy provides a temporal escape from psychosocial

should receive positive coping instructions to copestressors, but does not change reality or resolvewith stressors. Post-discharge mental health carestressors. This negative coping, over time, possibly

should also focus predominantly on part-time work­

12）

leads to a vulnerability to depression . According to

ers and/or unemployed and retired patients. Futurea recent report on patients engaging in cardiac reha‑longitudinal studies are expected to determine effec‑

No. 2, 2020103

Yamaguchi・Izawa・Matsunaga

tive coping strategies that CAD patients could inde‑sonalities, patients with the Type D personality werependently practice in their daily lives to prevent de‑more prone to use the abandonment or resignationpression.

strategy. Assessment of personality types and im‑provement of coping strategies could suggest pre‑Limitations

venting the development and/or progression of de‑This study has some limitations. First, a single-cen‑ter, cross-sectional study could not elucidate causalpressive tendency in CAD patients with Type D
personality.

relationships between types of personalities, de­Ｖ Acknowledgmentspressive tendency, and coping strategies. Second,
there could be sampling biases due to the small

The cooperation of all the participants who took

population of females and part-time workers. Third,

part in this study is gratefully acknowledged. In

the presence of depressive tendency was based on the

addition, the authors are grateful to all staff at the

SDS score of 40 or more, but not on clinical diagnosis

Department of Cardiovascular Medicine, Shinshu

by psychiatrists.

University Hospital. This study was presented as aposter presentation at the 5th International Nursing

Conclusions

Research Conference, held in Bangkok, Thailand,

The prevalence of depressive tendency among
Japanese CAD patients in this study was 59 ％, andthe Type D personality was 44 ％. Depressive ten‑during October 20-22, 2017.
Funding
This work was supported by JSPS KAKENHI Grant

dency was significantly correlated with Type D per‑Number JP18K17457.

sonality and abandonment or resignation coping

Disclosures

strategy, and inversely correlated with full-timework. In contrast to patients with non-Type D per‑

The authors declare that there is no conflict ofinterest.

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