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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 33-39

Association between behavioral flexibility and psychological distress in patients with cardiovascular disease: Data from the do cardiac health: Advanced new generation ecosystem study

1 Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The, Netherlands
2 Department of Medical and Clinical Psychology, Tilburg University; Department of Cardiology, Elisabeth-TweeSteden Hospital, Tilburg, The, Netherlands
3 ONMI b.v., Eindhoven, The, Netherlands
4 Open Evidence Research Group, Open University of Catalonia; Catalan Health Service, Barcelona, Spain

Date of Submission04-Mar-2021
Date of Acceptance23-May-2021
Date of Web Publication29-Jun-2021

Correspondence Address:
Dr. Mirela Habibovic
Department of Medical and Clinical Psychology, Tilburg University, Tilburg
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_15_21

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Objective: Being able to adapt to a changing environment has been associated with better mental and physical health. This adaptivity can be measured by behavioral flexibility assessment tools. However, the mental health consequences of behavioral flexibility have not been examined in patients with cardiovascular disease (CVD). The current study aims to examine if behavioral flexibility is associated with depression and anxiety in patients with CVD. Methods: A total of n = 387 patients with stable CVD were recruited as a part of the Do CHANGE study. At baseline, 3, and 6 months, data were collected. Depression (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder Scale-7) were assessed at all time points. Results: The mean age of the sample was 61.9 ± 10.23 years, with 274 (71%) being male. An inverse association between behavioral flexibility and depression at baseline, 3, and 6 months was observed. The associations remained significant after adjusting for relevant demographic and medical variables and baseline depression. No longitudinal association between behavioral flexibility and anxiety was found in the multivariate models. Conclusions: Behavioral flexibility is associated with depression in cardiac patients. Future studies should focus on examining the pathways of this association and offering patients with low flexibility levels additional care if needed.

Keywords: Anxiety, cardiovascular disease, depression, distress, flexibility

How to cite this article:
Habibovic M, Widdershoven J, Wetzels M, Piera-Jimenez J, Kop WJ. Association between behavioral flexibility and psychological distress in patients with cardiovascular disease: Data from the do cardiac health: Advanced new generation ecosystem study. Heart Mind 2021;5:33-9

How to cite this URL:
Habibovic M, Widdershoven J, Wetzels M, Piera-Jimenez J, Kop WJ. Association between behavioral flexibility and psychological distress in patients with cardiovascular disease: Data from the do cardiac health: Advanced new generation ecosystem study. Heart Mind [serial online] 2021 [cited 2023 Mar 23];5:33-9. Available from: http://www.heartmindjournal.org/text.asp?2021/5/2/33/319650

  Introduction Top

Living with a chronic medical condition such as cardiovascular disease (CVD) can be very challenging because of the (daily) life changes and adaptations necessary to cope with functional disability, physical discomfort, and cardiovascular risk reduction. Consequently, mental health problems (e.g., depression and anxiety) are more prevalent among patients with CVD as compared to the general population.[1],[2] Within the CVD population, mental health problems have, in turn, been associated with adverse cardiac outcomes and even mortality.[3],[4] In addition, in the general population, higher suicidality rates have been reported among people with mental health problems.[5] Hence, it is of great importance to identify possible predictors of mental health problems in order to prevent these adverse outcomes.

An important factor in experiencing optimal mental health is the ability to successfully adapt to continuously changing environments/situations. Studies show that being flexible, and thus able to adapt, is associated with better mental health, positive emotions, and biological processes associated with better health.[6],[7],[8] In contrast, inflexibility has been associated with depression and anxiety as it may be indicative of rigid thinking patterns (e.g., rumination) and avoidance behavior.[6],[9],[10] However, flexibility is a complex psychological construct encompassing multiple subcomponents within emotional, cognitive, and behavioral domain that cannot be captured in one definition.[6],[11],[12] The subcomponents that have gained the most attention in relation to mental health are “;Psychological Flexibility”[6],[12],[13] (“The ability to contact the present moment more fully as a conscious human being and to change or persist in behavior when doing so serves valued ends”[13]), and “Cognitive Flexibility” (“The ability to modify, or shift between 'cognitive sets' or strategies in response to changes in the environment”[14]). Both Psychological Flexibility and Cognitive Flexibility show a positive association with mental health.[6],[14] While the previously mentioned flexibility components reflect mental processes, a third flexibility component, referred to as “Behavioral Flexibility,” reflects a behavioral component and is characterized by an increased behavioral repertoire.[15],[16] In the current study, behavioral flexibility is defined as the ability to select and display appropriate behaviors in varying situations. As living with a cardiac disease often requires significant adaptations in daily life, having high levels of behavioral flexibility might be an important coping characteristic.

Behavioral flexibility has not been extensively investigated in relation to mental health in the general population nor in people with chronic mental or physical illnesses. In one study, Nolen- Nolen-Hoeksema et al. showed that psychological inflexibility can lead to behavioral perseveration and thus lower behavioral flexibility.[9] Hence, it could be speculated that behavioral flexibility is the underlying construct explaining the reported relationship between psychological and cognitive flexibility with mental and physical health. In addition, having a limited behavioral repertoire has been associated with personality factors characterized by high trait levels of negative affectivity such as distressed personality (Type D personality).[17] It is therefore important to examine the association between behavioral flexibility with mental health in patients with CVD as it might influence patients' mental and physical health.

For the current study, we hypothesized that behavioral flexibility in cardiac patients (heart failure [HF], coronary artery disease [CAD], or hypertension [HT]) is associated with depression and anxiety both cross-sectionally and longitudinally independent of sociodemographic, clinical, and baseline levels of depression and anxiety. Measures were obtained at baseline, 3, and 6 months.

  Methods Top

Study design

The current study was conducted based on data from the Do Cardiac Health: Advanced New Generation Ecosystem (Do CHANGE) project, which consisted of two randomized controlled trials that was carried out in The Netherlands, Spain, and Taiwan (NCT02946281; NCT03178305). The intervention was developed to enhance lifestyle change in patients CVD using behavior change theory[18] and innovative technology.[19] In the Do CHANGE trials, two groups were compared (intervention vs. control) and assessed at baseline, 3, and 6 months. Our previous results showed that the intervention did not affect behavioral flexibility; hence, the current study will treat these data as longitudinal and combine the data sets of Do CHANGE 1[20] and Do CHANGE 2.[21] Treatment condition will be considered as a covariate in the analyses.

Before participation, all patients signed informed consent. The study was conducted in accordance to the World Medical Association Declaration of Helsinki and was approved by the Medical Ethics Review Boards of the participating institutions with overall approval by the METC-Brabant, Tilburg, The Netherlands (NL57411.028.16/P1621).

Study sample

The study sample consisted of patients with a primary diagnosis of HF, CAD, or HT that requires cardiology outpatient care (HT).

Inclusion criteria

Patients between 18 and 75 years of age, diagnosed with one of the conditions mentioned above (CAD, HT and/or HF), and having at least two risk factors (i.e., high cholesterol, family history of CVD, diabetes mellitus, smoking, psychosocial risk factors, and sedentary lifestyle) were recruited. For patients with HF, a HF diagnosis with reduced or preserved ejection fraction and presence of HF symptoms was an additional required inclusion criterion. Patients with HT had to have “complicated” HT that required clinical care in a cardiology clinic (i.e., not treated in primary care settings). Patients also had to have a smartphone with compatibility for the applications of the study used and an Internet connection at home. Sufficient knowledge regarding smartphone usage was required.

Exclusion criteria

Patients with a life expectancy of <1 year, life-threatening comorbidities such as cancer, significant cognitive impairment such as dementia, psychiatric history (with exception of depression and/or anxiety) were excluded from the study. In addition, inadequate mastery of the local language was also considered as one of the exclusion criteria. Patients with inadequate mastery of the local language were also excluded from the study.


Patients were recruited in three participating centers: Badalona Serveis Assistencials, in Badalona, Spain; Elisabeth-TweeSteden Hospital, in Tilburg, The Netherlands; and Buddhist Tzu Chi Dalin General Hospital, in Dalin, Taiwan. Patients were approached by their health-care professional (cardiologist or cardiac nurse) and were informed both verbally and on paper about the study and participation. An informed consent form was given to patients that agreed to participation. Patients that signed the informed consent and filled in the first set of questionnaires (baseline measurement) were randomization to either the intervention or care as usual group. Afterward, the intervention group received the required equipment and wearables/devices (Fitbit, Beddit, blood pressure monitor, weight scale, and CarePortal) see details in Habibović et al.' study.[19] A research assistant installed the required applications on patients' smartphones. Patients were contacted by the research assistant by phone 1 day later to verify whether all devices were functioning as intended. The intervention was provided for a period of 3 months. The research assistant contacted each patient weekly during the intervention to assess their progress, assess compliance, and answer additional questions.

The Do Something Different (DSD) program,[18] which was the active component of the intervention designed to initiate behavior change (through increase of behavioral flexibility), ended 3 months after baseline. After termination of the DSD program, intervention group patients continued using the equipment and monitoring devices that they received at baseline for another 3 months.

At 3 and 6 months, all patients were invited to fill in the follow-up questionnaires online. Patients were instructed to fill in the questionnaires within 10 working days after receiving the online link. Patients who failed to fill in the questionnaires within this period were contacted by telephone, up to three times, to remind them to complete the questionnaires. Patients randomized to the intervention group received an additional invitation to fill in an usability and acceptance of the devices/Do CHANGE service survey.


Demographic and clinical variables

Demographic variables were collected through self-report (purpose designed questionnaire) and patients' medical record. Demographic variables included age, sex, level of education, and partner status. Clinical variables included primary diagnosis, Charlson Comorbidity Index, diabetes mellitus, and medication use.


Behavioral flexibility

To assess behavioral flexibility, the DSD questionnaire[20] was administered. The DSD questionnaire contains thirty brief descriptions of behaviors [Appendix 1] for the questionnaire]. The descriptions are organized such that behaviors that oppose each other (e.g., being firm and being gentle) form a pair. The scale reflects thus a total of 15 pairs. Patients were required to pick the behaviors that describe them best. The results were entered in the following formula:

As can be derived from the formula, a higher number of behaviors selected results in a higher score. It is important to note that selecting both behaviors of a pair – which are opposites – also increases the total score as this reflects an increased behavioral repertoire. The total score for behavioral flexibility ranges from 0 to 100.

Depressive symptoms

The Patient Health Questionnaire-9 is a questionnaire that assesses the severity of depressive symptoms by evaluating each criterion for major depressive disorder according to the DSM-IV.[22] The answers can be indicated on a 4-point Likert scale from 0 “;not at all” to 3 “nearly every day” in the past 2 weeks. The total score can vary between 0 and 27 with higher scores indicating higher levels of depressive symptomatology. A cutoff value of ≥10 is used as an index for the probable presence of major depressive disorder.[22]


The Generalized Anxiety Disorder Scale (GAD-7) was used in the current study to measure anxiety. Each item is rated using a 4-point Likert scale from 0 “not at all” to 3 “nearly every day,” resulting in a score range of 0–21 with higher scores indicating higher anxiety symptomatology.[23] A score of ≥10 indicates the probable presence of generalized anxiety disorder. The GAD-7 has an internal consistency of Cronbach's α 0.92 and a test–retest reliability with a correlation of 0.83.[23] The procedural validity of the instrument has been assessed by comparing the agreement between the GAD-7 administration by a clinician and the self-report version.

Statistical analysis

Continuous variables were compared using independent t-tests and are presented as means and standard deviations. Discrete variables were compared using Chi-square test and are presented as numbers and percentages. Four bivariate and four multivariate linear regression analyses were performed to examine: (1) the association between baseline behavioral flexibility with depression and anxiety and (2) the association between baseline anxiety with subsequent depressive and anxiety symptoms at 3- and 6-month follow-up. Multivariate models were used to adjust for a priori selected variables based on literature: age, sex, having a partner, education, group allocation, site of recruitment, main diagnosis, Charlson Comorbidity Index, use of psychotropic medication, and diabetes mellitus. In addition, the models also included baseline levels of depressive and anxiety symptoms as covariates (i.e., the models for depression adjusted for baseline depression and those for anxiety for baseline anxiety levels). All tests were two tailed and an alpha of. 05 was used to indicate statistical significance. All data were analyzed using IBM SPSS statistics software 24.0 (IBM, Armonk, New York, United States).

  Results Top

Sample characteristics

A total of n = 387 patients were included in the two trials (n = 149 in Spain; n = 88 in Taiwan, and n = 150 in The Netherlands). Fifteen patients were excluded from the current analysis due to missing data between baseline and 3-month follow-up (n = 372 were included in the first analysis). An additional n = 8 were lost to follow-up between 3 and 6-month follow-up and were also excluded (n = 364 were included in the second analysis).

[Table 1] provides an overview of the baseline sample characteristics. Overall, the mean age of the sample was 61.9 ± 10.23 years and consisted of mainly male patients (n = 274/372; 71%). The reported depression and anxiety levels at baseline were low and far below the suggested cutoff of ≥10 to indicate the presence of clinical symptomatology. The mean score on the flexibility scale was 26.0 ± 14.25 indicating relatively low levels of behavioral flexibility.
Table 1: Baseline sample characteristics stratified by do cardiac health: Advanced new generation ecosystem 1 and do cardiac health: Advanced new generation ecosystem 2 samples

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Cross-sectional association of behavioral flexibility with depressive and anxiety symptoms

Bivariate analysis showed an inverse relationship between behavioral flexibility with depressive symptoms at baseline (β = −0.228; P < 0.001). This association remained significant after adjusting for age, sex, having a partner, education, group allocation, site of recruitment, main diagnosis, Charlson Comorbidity Index, diabetes mellitus, and use of psychotropic medication (β = −0.193; P < 0.001).

Behavioral flexibility was also inversely associated with anxiety (β = −0.232, P < 0.001), which remained significant in multivariate adjusted models (β = −0.221, P < 0.001).

Longitudinal association of baseline behavioral flexibility with depressive and anxiety symptoms at 3- and 6-month follow-up

Behavioral flexibility at baseline was associated with depressive symptoms at 3 months (β = −0.141; P = 0.006) and 6 months (β = −0.175; P = 001) follow-up. The results of the multivariable analysis are displayed in [Table 2]. The model accounted for age, sex, having a partner, education, group allocation, site of recruitment, main diagnosis, Charlson Comorbidity Index, diabetes mellitus, use of psychotropic medication, and baseline depression levels (model fit 3 months: F(12,359) =3.35; P < 0.001; model fit 6 months: F(12,351) =3.70; P < 0.001). The current findings show that behavioral flexibility at baseline was associated with depressive symptoms at 3 (β = −0.101; P = 0.054) and 6 months (β = −0.144; P = 0.007) follow-up even after adjusting for the abovementioned covariates. These findings indicate that higher levels of behavioral flexibility were associated with lower levels of depression. The analyses further showed that group allocation site of recruitment and psychotropic medication use were associated with depression at 3- and 6-month follow-up. In addition, diabetes mellitus was associated with depression at 6-month follow-up [Table 2].
Table 2: Multivariate linear regression analysis results for depression

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For anxiety, the bivariate analysis showed an inverse association between behavioral flexibility with anxiety at 3 (β = −0.028; P = 0.012) but not at 6 months (β = −0.015; P = 0.17) follow-up. Adding covariates age, sex, having a partner, education, group allocation, site of recruitment, main diagnosis, Charlson Comorbidity Index, diabetes mellitus, use of psychotropic medication, and baseline anxiety levels to the model (model fit 3 months: F(12,359) =3.66; P < 0.001; model fit 6 months: F(12,352) =3.09; P < 0.001), resulted in nonsignificant associations between flexibility and anxiety at both follow-up moments [Table 3]. The current findings also showed that female sex and baseline anxiety levels were associated with anxiety at both 3- and 6-month follow-up, while group allocation (active intervention) was only associated with lower anxiety at 6-month follow-up.
Table 3: Multivariate linear regression analysis results for anxiety

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  Discussion Top

The current results showed an association between behavioral flexibility with depression at baseline, as well as 3- and 6-month follow-up. Higher behavioral flexibility scores were associated with lower depressive symptoms. With respect to anxiety, the analyses revealed an inverse association between behavioral flexibility with anxiety at baseline and 3 months but not at 6-month follow-up. After adjusting for demographic, clinical, and psychological variables (including baseline depression or anxiety), the association between behavioral flexibility with depressive symptoms remained significant at 3- and 6-month follow-up. Regarding anxiety, results showed a significant cross-sectional association, while no significant association between behavioral flexibility and anxiety during follow-up was observed in the adjusted multiple regression models.

The current findings are to some extent in line with previous studies. With respect to depression, similar results are observed as previously reported by other studies focusing on (other definitions of) flexibility.[9],[24],[25] Being behaviorally inflexible means also having a narrow behavioral repertoire and thus less opportunity to encounter new situations and new people which could alter an individual's mood in case of depressive symptoms.[17] In addition, it refers to living in accordance to habits.[16] If unhealthy habits are developed and one is, due to inflexibility, not able to change these, this might results in adverse mental (e.g., depression) and physical health outcomes.[24] Behavioral flexibility has also been linked to the ability to learn (problem-solving tasks) as one is easily adapting to a changing environment.[15] In this sense, the association with depression could be explained by better problem-solving skills which can help alleviate depressive symptoms.

The results regarding anxiety are not in line with previous studies.[10],[26] This discrepancy can mainly be explained based on the different flexibility subcomponents that have been addressed in previous studies. The current study has tapped into the behavioral subcomponent, while the previous studies focused on the mental subcomponents of flexibility. In addition, in the current study, we have adjusted for various demographic, clinical, and psychological variables which can be related more strongly to anxiety than behavioral flexibility.

The association between behavioral flexibility and mental health in cardiac patients is worthwhile examining in future studies. Particularly, the focus on the association with depression is important as the current findings show an association even after controlling for relevant covariates including baseline depressive symptoms. As the underlying mechanisms are largely unknown, future studies could focus on disentangling how this association could be explained. Is it related to actual behavior (e.g., low behavioral activation) or to underlying mental processes (e.g., low ability to learn new skills and adapt to situations, extreme sensory processing patterns)? In addition, to better understand the observed association, it would be worthwhile to examine whether behavioral flexibility relates to sensory processing patterns which have shown to be associated with mental health problems such as depression and helplessness.[27] Whether, and how, other flexibility components (psychological and cognitive) are related to mental health problems in cardiac patients should also be examined in future. Particularly, it would be worthwhile to examine the role of behavioral flexibility in this association and shed light on possible causality between the components. Furthermore, studies should also explore the possibilities to assess behavioral flexibility in real time. As it reflects a behavioral process, the potential of[6] Global Positioning System (GPS) to capture behavioral flexibility in a nonobtrusive, real-time manner might be worthwhile examining. Being able to predict depressive symptomatology based on GPS-captured behavioral flexibility data would be the next step forward and add great value to the current clinical practice. The nonobtrusive, low-burden assessment of behavioral flexibility would particularly been advocated for patients with CVD as they are already dealing with often complicated disease management that requires most of their time. Finally, the association between behavioral flexibility and disease-related outcomes (e.g., adverse cardiac events and prognosis) should be examined in future studies.

Clinical practice could benefit from new measurement tools and novel interventions to targeting behavioral flexibility. One could think about components of cognitive behavioral therapy such as “behavioral activation.” This has shown to be an effective treatment for depression.[28] However, it has not been examined in relation to behavioral flexibility and whether that is the underlying mechanism of this therapy. The DSD that has been applied in the Do CHANGE project is an intervention that aims to increase behavioral flexibility by giving behavioral prompts to participants.[18] It triggers participants to do something different every day (e.g. take a different route to work today). The intervention shows positive effects on behavioral flexibility (assessed with questionnaire) in some but not all studies. Hence, it is unclear what the underlying mechanism between the intervention and outcomes is and whether the behavioral repertoire increases, or perhaps other factors are modified. Using GPS to assess behavioral flexibility and evaluate intervention effects could provide more insight in this matter.

Regarding the cardiology practice, it would be important to identify patients with low behavioral flexibility, by administering the DSD questionnaire during outpatient visits, and offer additional support if needed. These patients might be particularly at risk to develop depressive symptoms and consequently suffer the associated adverse outcomes.

The current findings should be interpreted in light of the study limitations. The DSD questionnaire, which was used in the present study to assess behavioral flexibility, was purpose designed for the DSD program. Although the questionnaire has been used in other studies,[18],[29] it has not been validated on its psychometric properties in a large-scale survey. Nevertheless, to the best of our knowledge, it was the only available questionnaire to tap into this subcomponent of flexibility during the Do CHANGE study. In line with this perspective, a more objective measure, as previously suggested (e.g., GPS), would be advocated for futures studies as it might be less subject to recall bias and socially desirable answers. Second, data from two different trials were combined in the current sample. However, the inclusion criteria were the same for both trials and the intervention did not have an effect on flexibility scores on any of the follow-up measurements. Third, patients from three different cultural backgrounds were included. Whether flexibility varies between cultures is unknown, in our analysis, we have accounted for this by including “site of inclusion” as one of the covariates. Nevertheless, our study comprised a large sample where adjusting for relevant variables was possible. This is the first study to examine the association between behavioral flexibility and mental health, adding significantly to the existing literature.

The present results showed that behavioral flexibility is associated with depression at 3- and 6-month follow-up even after accounting for baseline depression levels. It is therefore advocated for future studies to examine through which pathways this construct is associated with depression and to identify patients with low behavioral flexibility in the (cardiology) clinical practice in order to possibly prevent the onset of depressive symptoms and subsequently reduce the associated adverse outcomes.


The Do CHANGE Study was funded by the European Commission's Horizon 2020 program (grant number: 463735) awarded to Dr. A. van Berlo and consortium. We would like to thank all patients who have participated in the Do CHANGE trials and provided their data for the current study. We would like to thank the health-care professionals who have helped with patient recruitment during the study. A special thanks to Dr. E. Broers who has organized the data collection and data management of the patient-reported outcomes in the Do CHANGE study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]

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