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Adults with heart disease living in a rural area, especially those who aren't married, may have more feelings of hopelessness, according to new research that calls for health care professionals to identify and counsel those at greatest risk.

Previous research shows up to half of people with heart disease report having feelings of hopelessness, which can more than triple the risk of death or heart attack. Compared to people in urban areas, people who live in rural communities already experience higher rates of other risk factors for heart disease, including high blood pressure, obesity, physical inactivity and cigarette smoking.

The new study, published Wednesday in the , was the first to explore the impact of rural living on short- and long-term feelings of hopelessness.

"Because we know hopelessness is predictive of death in people with heart disease, health care professionals need to recognize the subgroups who are most at risk and provide guidance and treatment," senior study author Susan Dunn said in a news release. Dunn is an associate professor and department head of biobehavioral nursing science at the University of Illinois in Chicago.

According to national statistics, adults with and without heart disease who live in rural areas have a higher premature death rate than those who live in urban areas.

In the new study, researchers used questionnaires to measure feelings of hopelessness – a negative outlook and sense of helplessness toward the future – as well as depression and the ability to perform daily physical activities, another measure of depression. The 628 participants, adults at two hospitals in South Dakota and one hospital in Michigan, had experienced heart attacks, severe chest pains or procedures such as surgery or the insertion of stents to open clogged arteries.

Researchers used census tract data to determine about one-fourth of participants lived in a rural area. Overall, 1 in 4 participants had been diagnosed with depression.

Nearly 60% who lived in a rural area felt the type of hopelessness associated with a life event, such as a heart attack, compared to roughly 50% who lived in urban areas, the study found. However, where someone lived had little impact on whether they had a hopeless outlook on life overall.

Being unmarried made a difference for rural residents. Hopelessness related to an event affected more than 70% of unmarried people compared to about 50% of their married counterparts.

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