Keywords
Mental distress, Quality of life, Non-invasive vascular imaging, Asymptomatic adults, Scoping review
Mental distress, Quality of life, Non-invasive vascular imaging, Asymptomatic adults, Scoping review
Cardiovascular disease (CVD) refers to diseases of the blood vessels, and in particular the heart, brain and peripheral vasculature1. CVDs due to atherosclerosis include cerebrovascular events such as stroke, ischaemic heart disease events such as heart attacks, and peripheral arterial diseases causing peripheral claudication1. CVD is the leading cause of death and disability globally1,2 with an estimated 17.9 million people dying from CVDs in 2016, representing 31% of all global deaths. Of these CVD-related deaths, 85% were due to heart attack and stroke or their sequelae2. By 2030, it is estimated that more than 22.2 million people will die annually from CVDs3.
Atherosclerosis before clinical events, or “asymptomatic CVD”, can be easily visualised using a range of imaging methods, with the most common being computed tomography of the coronary arteries to calculate coronary artery calcification (CAC) or carotid ultrasound to identify carotid plaques and assess intimal medial thickness4. Imaging of the arteries to identify asymptomatic CVD is becoming commonplace in medical practice5, and provides asymptomatic individuals with a visible and tangible illustration of an otherwise hidden disease process, even before distinctive symptoms appear6. Such information can improve an individual’s knowledge of the disease which may enable them to increase control over, and improve their health7. Increased knowledge may also lead to personal and social benefits, such as enabling effective community action and contributing to developing one's social capital8,9. However, diagnostic information or results related to a disease (depending on how the situation is evaluated) may also affect an individual’s sense of well-being10 or lead to mental distress6,11,12. For example, previous studies have reported that women who undergo mammography screening may be susceptible to mental distress following the provision of results13–21.
Mental distress is frequently used as an outcome measure in psychological and medical research22. It includes distress expressed inwardly (anxiety, depression and impulsivity) and distress expressed outwardly (psychoticism, impulsivity and aggression)23 or a measure of obsession-compulsion, and interpersonal sensitivity23,24. Whereas, Quality of Life (QOL) encompasses a person’s psychological state, appraisals of physical health, personal beliefs as well as social relationships25. It is often measured in research using physical and mental health summary scores26. These two broad concepts (mental distress and QOL) are the outcomes of interest for this scoping review.
The scoping review was informed by Witte’s27 extended parallel process model (EPPM) and cognitive stress appraisal theory28. Based on the constructs of the EPPM27, the provision of information—in particular, negative information—about a person’s coronary artery calcium and carotid plaque (and the potential implications of this condition) is likely to stimulate subjective ‘threat’ appraisals (i.e., perceived susceptibility to, and severity of, CVD)29. Depending on interactions between that threat appraisal and individuals’ efficacy appraisals, individuals may react to screening information by (a) adopting danger control responses (including attitudes, beliefs, behavioural intentions, and/or behaviours) that align with message recommendations, or (b) adopting fear control processes (such as denial, reactance, and avoidance) intended to reduce fear rather than take protective action30. Behavioural intentions and/or behaviours such as increasing physical activity, health responsibility, good nutrition, and stress management could impact health outcomes31. Behavioural intentions and/or behaviours are also associated with lifestyle related disease burden such as CVD32 which could undermine QOL33. Cognitive stress appraisal theory28 also proposes that individuals primarily evaluate circumstances/situations as ‘challenging’ (i.e., threat that can be overcome or met) or ‘threatening’ (i.e., anticipated loss/harm)28. Positive cognitive stress appraisal (i.e. appraising a situation as a challenge to be resolved and setting goals to achieve that) may contribute to prevention of depression and improved QOL34. Negative appraisals of stress—viewing an issue such as detected atherosclerotic plaque in the arteries as a threat and believing that resolving it is beyond one’s abilities—may, however, lead to mental distress35–37.
Based on the EPPM and cognitive stress appraisal frameworks, we therefore hypothesized that; (a) population screening to detect atherosclerotic plaque in the coronary or carotid arteries can influence QOL, and (b) population screening to detect atherosclerotic plaque in the coronary or carotid arteries can cause mental distress. To date, however, the available evidence that may support (or refute) these hypotheses has not been scrutinised or reported in any coherent manner. Hence, there is a need for a scoping review to synthesize the state of scientific literature on this subject.
Scoping reviews aim to map key concepts, main sources and types of evidence available in a research area and can be undertaken where an area is complex or has not been comprehensively reviewed before38. Previous reviews reported very little evidence relating to QOL or mental distress following provision of vascular imaging results to asymptomatic adults7,39–42. It is important, therefore, to collate evidence relating to the findings available in this field, how studies in this field have been conducted, the key characteristics of studies, and important knowledge gaps. As such, this scoping review will comprehensively map the evidence on mental distress and QOL outcomes following provision of vascular imaging results of the coronary or carotid arteries to asymptomatic adults. We will also report other details of included studies that we deem important in this scoping review (e.g. the information provided during counselling and whether the counselling could reduce distress or any information included in the results that shaped the nature of the response).
There is great interest (and value) in providing people with vascular imaging results of the coronary and carotid arteries to prompt healthful behaviour change and better management of CVD7,40. However, the provision of the imaging results may produce markedly different emotions—and as a result, downstream behaviours—depending upon the way in which they are received and appraised. Also, the uncertainty about a possible future threat (due to coronary artery calcium and carotid plaque) may cause anxiety43. There is theoretical justification to anticipate that information aimed at prompting healthful behaviour change and better management of CVD may stimulate negative psychosocial outcomes or mental distress such as anxiety or depression impairing QOL. Accordingly, it is important to identify which research questions have and have not been addressed in this area. Also, by highlighting the extent of findings on distress and/or QOL, a scoping review could support the development of strategies designed to mitigate or prevent distress during and following such screening exercises.
The aim of this review is to map all available evidence on mental distress and QOL outcomes among participants who were screened for atherosclerosis by non-invasive methods and provided with their own coronary or carotid artery vascular imaging results. This scoping review will address this research question:
1. What is the state of scientific literature on mental distress and quality of life outcomes following provision of vascular imaging results of the coronary and carotid arteries, and what are the gaps in that literature?
Table 1 further clarifies the core elements of the questions guiding the conduct of this scoping review.
QOL, quality of life.
Study design. The framework developed by Arksey and O’Malley44 will be used for this scoping review. The framework involves 5 stages: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing and reporting the results. The reporting of this scoping review will also be guided by the PRISMA extension for scoping review reporting checklist45.
Information sources and search strategy. The main purpose of a scoping review is to comprehensively identify primary studies (published and unpublished) and reviews suitable for answering the review questions. To achieve this, databases such as MEDLINE (Clarivate), APA PsychINFO, EMBASE, Social Work Abstracts, Psychology and Behavioural Sciences Collection, and Cumulative Index to Nursing and Allied Health Literature (CINAHL), will be searched for articles of relevance. Further manual searching of reference lists in identified articles will be undertaken to include other studies of relevance. We will also search relevant grey literature databases such as Open Grey and Open Access Theses and Dissertations (OATD) to identify relevant studies.
Approach to developing search strategy. Different sources (e.g. MeSH headings and thesaurus) will be used to identify terms and synonyms to comprehensively cover the research questions as much as possible46–49. The proposed search strategy was developed in consultation with an academic librarian (Table 2) for MEDLINE using MesH terms such as "Coronary stenosis", "Carotid Stenosis", "Psychological Distress" and "Quality of Life". We also used Boolean operators “AND” to narrow search results to include only relevant results containing required keywords and “OR” to expand search results and combine synonyms. Other keywords such as behaviour, lifestyle, motivation, risk perception, medication adherence and smoking cessation were included to capture all relevant studies as mental health and QOL outcomes are unlikely to be primary or secondary outcomes and thus reported in the title or abstract. This search strategy will be modified for use in other databases. Due to the exploratory nature of scoping reviews and the need to ensure a comprehensive search of relevant literature, an iterative approach to search strategies will be employed44. This implies that the search strategy will be updated as we discover new terms as we work through the review.
MeSH, Medical Subject Headings; CAC, Coronary Artery Calcium.
These terms will be searched as keywords in the title and abstract headings and no date limits will be applied. Search results will be downloaded, imported and saved as Microsoft Word and PDF documents. Database outputs will be compared to check for the existence of any duplicates.
Databases and records will be screened using the eligibility criteria (see below) and studies not meeting the criteria will be excluded. The process for identification, screening, eligibility and studies to be included is displayed in Figure 1. The process of searching and selection will be reported in the main review using a PRISMA flowchart50.
The screening will begin with title and abstract screening by two investigators (RA and JRL) who will independently screen the titles and abstracts for all retrieved records for inclusion and to agree on exclusions. This process will be piloted using a sample of abstracts to ensure that this approach will be efficient enough to capture all relevant articles. Any articles that meet the inclusion criteria or that cannot be excluded will be retained for full text review. For the second stage, two investigators (RA and JRL) will each independently screen the full text of articles to determine if they meet the inclusion criteria and conflicts will be resolved by an independent reviewer (LCB).
Data from included studies will be extracted. There will be no critical appraisal of quality of studies, but we will comment on key methodological issues within the studies. We are not critically appraising results as this scoping review (and scoping reviews in general) will not produce critically appraised and synthesised data but an overview of existing evidence51.
Inclusion criteria
The following inclusion criteria will apply:
Studies must be of adults who are 18 years and over and asymptomatic (not screened due to clinical symptoms such as chest pain or angina) and without pre-existing CVD (e.g. stroke, myocardial infarction, peripheral arterial disease or transient ischemic attack). Studies must report follow-up assessment and a mental distress or QOL outcome after participants received information related to their own coronary artery calcification or carotid stenosis/plaque.
Study types that will be included for this scoping review are empirical studies of any type. No year of publication and language restrictions will be applied.
Concepts
Information regarding the state of arteries, extent of stenosis, extent of coronary artery calcification, or carotid/atherosclerotic plaques, coronary calcium score, arterial wall irregularities or obstructive artery walls conveyed to study participants.
Studies must report mental distress expressed inwardly (anxiety, depression and impulsivity), distress expressed outwardly (psychoticism, impulsivity and aggression), obsession-compulsion or interpersonal sensitivity.
Studies must report QOL as an outcome or should include QOL as an outcome measure.
This scoping review will include studies conducted in any geographical location among any racial/ethnic group and gender. Studies will be included irrespective of their settings.
Exclusion criteria
Studies in symptomatic patients undergoing invasive imaging for diagnostic purposes will be excluded. Other studies that will be excluded are studies providing imaging results of other vascular diseases/conditions such as Aneurysm or Endoleak; Angiodysplasia; Angioedema; Angiomatosis (Bacillary Angiomatosis, Klippel-Trenaunay-Weber Syndrome, Sturge-Weber Syndrome, von Hippel-Lindau Disease); Arteriovenous Malformations; Capillary Leak Syndrome; Ischemic Colitis; Compartment Syndromes; Diabetic Angiopathies; Hand-Arm Vibration Syndrome; Hemorrhoids; Hemostatic Disorders; Hyperemia; Hepatic Veno-Occlusive Disease; Hypotension; Peliosis Hepatis; Ischemic Optic Neuropathy; Pulmonary Veno-Occlusive Disease; Scimitar Syndrome; Retinal Vein Occlusion;Pulmonary Vein Stenosis; Splenic Infarction; Superior Vena Cava Syndrome; Telangiectasis; Varicocele; Thoracic Outlet Syndrome; Varicose Veins; Vascular Fistula; Vascular Neoplasms; Vascular System Injuries; Vasculitis as well as Vasoplegia and Venous Insufficiency.
Studies without outcomes considered as mental distress will be excluded. We will also exclude studies where mental distress/psychiatric assessments were performed only before vascular imaging procedure and not after provision of imaging results. Studies that did not report QOL as an outcome will also be excluded.
A draft data extraction chart will be developed and piloted with a selection of identified studies. The diagrammatic or tabular form of presentation or charting will be used for this study. The potential chart categories may consist of authors information (names, year of publication, study location), participant characteristics (age, gender), research design, methods, instruments/techniques/clinical assessments used to gather data coronary artery calcification, carotid plaque/stenosis, mental distress, and quality of life and aims/purpose of the extracted studies (Table 3). We will also extract data on how vascular imaging results were provided and whether there was additional counselling or support mechanisms.
QOL, quality of life.
EndNote X9 will be used as a reference management tool and to avoid duplications. Microsoft Excel and Word will be used to manage data within the review team.
This review will employ thematic and numeric approaches to summarise studies. A thematic approach will be used to summarise the main and sub-themes that will emerge after the scoping exercise. A numeric approach will also be used to summarise results of the scoping review by presenting the quantity of each emerging concept (e.g. worry was used interchangeably with anxiety (n=2) or most of the studies (n=25) measured depression using the Center for Epidemiological Studies Depression (C-ESD) instrument). The scoping review will not produce a pooled estimate of the impact of vascular imaging results on mental distress and quality of life as we aim to preliminary assess the potential size, scope and gaps in available literature.
Results on the state of scientific literature will be reported and the gaps in the literature will be identified. There will be further discussion on the implications of the results for practice and future research.
Start date of search: August 2020; anticipated date of completing review: December, 2020
Current study status:
Preliminary searches: Yes
Piloting search strategy: Yes
Pilot screening of search results: Yes
Study selection process piloting: Yes
Formal screening of search results against eligibility criteria: Not started
Data extraction: Not started
Data analysis and interpretation: Not started
The purpose of this protocol is to describe the methodological considerations that will guide the completion of a scoping review that will summarise the extent, range and nature of studies on mental distress and quality of life outcomes reported among asymptomatic adults following the provision of vascular imaging results. This comprehensive review will help advance knowledge about potential negative effects of screening for asymptomatic CVD to elicit healthful behaviour changes. It could also possibly enable the development of strategies to prevent distress. The results of this review will help advance knowledge in this field and will be useful for future medical practice when providing vascular imaging results to patients, cardiovascular research, and future clinical trials providing vascular imaging results to participants. This scoping review will be limited to studies reporting coronary or carotid artery plaque screening only as these are the commonly used structural vascular imaging modalities for large screening initiatives of asymptomatic individuals.
There will be no formal ethical application and ethical review as no primary data will be collected.
Views | Downloads | |
---|---|---|
F1000Research | - | - |
PubMed Central
Data from PMC are received and updated monthly.
|
- | - |
Is the rationale for, and objectives of, the study clearly described?
Yes
Is the study design appropriate for the research question?
Partly
Are sufficient details of the methods provided to allow replication by others?
Partly
Are the datasets clearly presented in a useable and accessible format?
Not applicable
References
1. Levac D, Colquhoun H, O'Brien KK: Scoping studies: advancing the methodology.Implement Sci. 2010; 5: 69 PubMed Abstract | Publisher Full TextCompeting Interests: No competing interests were disclosed.
Reviewer Expertise: Psychosocial Epidemiology; Evidence-based Mental Health; Mental Health Policies and Systems
Alongside their report, reviewers assign a status to the article:
Invited Reviewers | ||
---|---|---|
1 | 2 | |
Version 3 (revision) 09 Nov 21 |
read | |
Version 2 (revision) 28 May 21 |
read | read |
Version 1 26 Nov 20 |
read |
Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list:
Sign up for content alerts and receive a weekly or monthly email with all newly published articles
Already registered? Sign in
The email address should be the one you originally registered with F1000.
You registered with F1000 via Google, so we cannot reset your password.
To sign in, please click here.
If you still need help with your Google account password, please click here.
You registered with F1000 via Facebook, so we cannot reset your password.
To sign in, please click here.
If you still need help with your Facebook account password, please click here.
If your email address is registered with us, we will email you instructions to reset your password.
If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance.
Comments on this article Comments (0)