Meeting of Hearts & Minds- The Practice of Cardiac Psychology

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Meeting of Hearts & Minds – The Practice of Cardiac Psychology Written by Jonathan Gallagher, Senior Psycholgist, Beaumont Hospital, Dublin - Dr Elizabeth O'Brien, Senior Clinical Psychologist, St Vincent's University Hospital and Dr Sinead Mulhern, Principal Clinical Levine et al Psychologist, Mater Hospital PSYCHOLOGICAL FACTORS & CARDIOVASCULAR DISEASE (CVD) A cardiac event such as a heart attack can be a psychologically devastating experience, with profound and enduring consequences. Frequently its onset is sudden, distressing and potentially life-threatening.

Even if this is not the case, mere knowledge of this new disease status can trigger strong and frequently long-term emotional reactions as well as prompting significant lifestyle changes.

Jonathan Gallagher

Downloaded from http://ahajournals.org by on March 16, 2022

Dr Elizabeth O'Brien

Perhaps unsurprisingly, psychological distress is highly prevalent in patients with cardiovascular disease (CVD).

Anxiety, depression and insomnia disorder affect approximately one-third of people with CVD, and up to one in four cardiac patients experience clinically significant levels of posttraumatic stress (PTSD)1-4. Furthermore, psychological distress is linked to increased future cardiac events and mortality, poorer quality of life, increased suicide risk, greater healthcare costs and poorer long-term psychological adjustment5. Unfortunately, there is also evidence that during the COVID-19 pandemic psychological distress has increased in cardiac patients and this has been exacerbated by social isolation, treatment nonadherence, physical inactivity, and an increase in unhealthy lifestyle behaviours6,7.

COMMON PSYCHOLOGICAL RESPONSES TO CVD

Dr Sinead Mulhern

In the initial aftermath of a cardiac event, the focus is understandably on the patient’s physical recovery, and many people feel relief or even gratitude for having survived.

However, once a person begins to feel better physically, the emotional distress they have been holding at bay can surface. It may feel safer for this to emerge after things appear to have stabilised medically.

Although this can be a normal part of the recovery process it can be quite frightening if the person hasn’t experienced this kind of emotional vulnerability previously.

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Table 1. Effect Estimates for Associations of Negative Psychological Factors With Cardiovascular Events and Conditions Negative psychological factors

Parameter/ end point

Effect estimates (95% CI)

Depression

Incident MI

RR, 1.30 (1.22–1.40)42

Incident CHD

RR, 1.30 (1.18–1.44)42

Stroke

RR, 1.45 (1.31–1.61)45

Obesity

RR, 1.37 (1.17–1.48)49

Hypertension

RR, 1.42 (1.09–1.86)51

Diabetes

RR, 1.32 (1.18–1.47)52

CVD mortality

RR, 1.41 (1.13–1.76)39

Incident CHD

RR, 1.41 (1.23–1.61)39

Coronary artery spasm

RR, 5.20 (4.72–5.40)40

Incident stroke

RR, 1.71 (1.18–2.50)39

Heart failure

RR, 1.35 (1.11–1.64)39

Work-related stress

Incident CVD events

RR, 1.4 (1.2–1.8)18

Any-cause stress

Incident CHD/CHD mortality

RR, 1.27 (1.12–1.45)19

PTSD

Incident CHD

RR, 1.61 (1.46–1.77)22

Social isolation and loneliness

Incident CVD events

RR, 1.5 (1.2–1.9)18

Pessimism

CHD mortality

OR, 2.17 (1.21–3.89)50 (highest vs lowest quartile)

Anger and hostility

Incident CHD

HR, 1.19 (1.05–1.35)33

Recurrent CHD

HR, 1.24 (1.08–1.42)33

Anxiety

CHD indicates coronary heart disease; CVD, cardiovascular disease; HR, hazard ratio; MI, myocardial infarction; OR, odds ratio; PTSD, posttraumatic stress disorder; and RR, risk ratio.

Summary of Findings: Negative Psychological Health and CVD

attacks after a cardiac event After the initial sense of shock and need help understanding subsides, emotional vulnerability why this happens and figuring can manifest in different ways for to respond differently cardiac patients: Calculated RRs for associationsout ofhow negative psychologito the triggers for panic (e.g.  and fear having calAnxiety factors andofcardiovascular risk are given in Table 1, abdominal breathing). another heart attack is very and a summary of key relevant studies on negative  Low mood, depression or common, and this typically hopelessness affects many eases for people as they begin psychological health and CVD patients is provided in the Online with heart disease. to re-engage with their lives.

Data Supplement (Supplemental Table 1A–1E).

Taken This is often accompanied by However, for many their fear can a feeling of grief about what’s be so great that they restrict together, these studies highlight the potential adverse been lost (e.g. a sense of their activities (e.g. avoiding immortality, physical limitations), impact of poor psychological functioning, psychological exercise) to the point where and can lead to a sense of this interrupts their lives and stress, trauma, anger and hostility, andwith mental health disconnect life and its compromises their health. sense Given of purpose meaning. of disorders on cardiovascular health. theor nature  Many people experience panic Depression is common, and

this work, most human studies in this area are observational, with many involving large administrative databases or self-reporting of exposures. The potential thus exists for bias from misclassification and confounding,

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49 patients are afraid to close their eyes at night for fear they may not wake up. Improving one’s ability to unwind and slow down can be important here, and brief psychological treatments for insomnia (CBT-I) are particularly effective.

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natsrednwhich u si sulimits cof ethe ht individual’s ,tneve caidrac a fothis htachallenge. mretfa laSocial itini ehsupport t nI fully revewoHability .devito vru s gengage nivah rin oflife. edutitarg neisvehugely ro feimportant iler leef einlphelping oep tI .ecafrSocial us nacisolation yab ta and/or gnidlolack h neofeb evah cardiac yeht sspatients ertsid latonoadjust itometo perceived support can deepen the impact of depressed mood.

If an individual doesn’t have an emotional connection with Levine et al person to process the another grief they’re experiencing, they may need to look externally to

sometimes multiple lifestyle changes (e.g. exercise, dietary patterns, smoking, alcohol reduction).

 Sleep problems are especially common in newly diagnosed cardiac patients, and many

 Some people may even feel traumatised by their cardiac event. For example, if they nearly died or were shocked on the way to hospital; or if their implantable device (ICD) went off. Or maybe they were very distressed in ICU and were convinced they were going to die. Sometimes in the aftermath of such an experience people develop symptoms of posttraumatic stress disorder (PTSD) which can include reliving the trauma or having flashbacks or nightmares, feeling very alert to future risk and feeling very anxious. These symptoms often resolve but at times can remain very frightening.

Reported Associated Behavioral and Biological Detrimental Processes

Smoking ini a on Physical inac vity Poor ea ng and overea ng Weight gain Medica on noncompliance ------ Ac va on of the hypothalamicpituitary-adrenal axis Dysregula on of the autonomic nervous system Inflamma on Hypercoagulability Increased arterial s ffness Endothelial dysfunc on Inducible myocardial ischemia

 Where stress has been ongoing, people may be placing high demands on themselves which result in an overly demanding lifestyle.

Now, this can lead to feeling overwhelmed by pressures that feel unchangeable, and this may need to be addressed.

 Mental and behavioural habits that perpetuate the stress cycles people are caught in can add additional suffering and impede physical recovery. For example, people often need help getting unstuck from thinking traps that drive automatic or unhelpful behaviour. This may include guilt about previous lifestyle choices made, regrets, self-blame or  People may feel anger if they self-criticism. These common believe their cardiac issue thinking styles can hold was not identified in time, people back and lower mood, or even towards others (e.g.

Psychological Health and the Mind-Heart-Body Connection particularly in those patients employer, family members) who had a lot of negative selfwhom they perceive to have contributed to their high stress talk before their cardiac event.

Nega ve Psychological Health Stress Nega ve outlook Anxiety Anger and hos lity Depression

levels. Personality traits such as hostility place patients at additional cardiovascular risk, and outburst of anger have been shown to serve as triggers of acute cardiovascular events8.

Posi ve Psychological Health

Changes in Behavioral, Psychosocial, and Biological Processes

Smoking cessa on Increased medica on adherence Increased physical ac vity ---- Effec ve emo on regula on Flexible stress management Posi ve social rela onships ---- Decreased inflamma on Lower LDL, VLDL Lower BP

Improved Cardiovascular Health

Reduced cardiovascular risk factors Decreased incident CVD Secondary preven on

Happiness Posi ve affect Emo onal vitality Op mism Sense of purpose Gra tude Psychological well-being Mindfulness

Reported Associated Behavioral and Biological Beneficial Processes

Smoking cessa on Increased physical ac vity Heart-healthy ea ng Weight loss Increased medica on adherence Preven ve screening ---- Blood pressure reduc on Be er glucose control

Figure. Negative and positive associations of psychological health and cardiovascular risk and health and potential biologically plausible mechanisms of how improved psychological health can lead to decreased cardiovascular risk.

Figure concept inspired by Levine,2 Kubzansky et al,54 Rozanski,166 and many other sources. BP indicates blood pressure; CVD, cardiovascular disease; LDL, lowdensity lipoprotein; and VLDL, very-low-density lipoprotein.

in inflammatory markers182 associated with improved cardiovascular prognosis. Although there are conflicting

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 Relationships and sexual health are also significantly impacted in the aftermath of a cardiac diagnosis and individuals need to feel confident in having a safe space to speak openly about these important concerns should they need to.

MECHANISMS: HOW PSYCHOLOGICAL FACTORS AFFECT CARDIOVASCULAR HEALTH The mind and body are inextricably linked, and psychological well-being has direct effects that mediate improvements in cardiovascular health. Better psychological well-being is associated with lower blood pressure, a lower prevalence of metabolic syndrome, a more favourable lipid profile, a lower likelihood of smoking, increased exercise levels and greater adherence to a hearthealthy diet9-11. Conversely, anxiety and chronic stress have been shown to increase inflammation, increase blood pressure and stress hormones such as cortisol which can impact coronary arteries and increase the risk of cardiac events.

Similarly, depression has also been shown to be linked with increased inflammation, reduced physical activity, continued smoking, weight gain and poorer adherence to secondary preventive medications (SPMs). While psychological components are clearly linked with both health behaviours and factors that are directly related to cardiovascular health, improving the psychological wellbeing of cardiac patients is key to optimising their health outcomes.

PSYCHOLOGICAL CARE FOR CARDIAC PATIENTS DURING CARDIAC REHABILITATION (CR) In many respects, cardiac rehabilitation (CR) is the ideal setting in which to address the psychological needs of cardiac patients. CR is a comprehensive, multi-disciplinary chronic disease management programme that incorporates core components such as patient assessment, supervised exercise training with continuous ECG monitoring (telemetry), nutritional counselling, management of cardiac risk factors (lipids, diabetes, blood pressure, weight) and psychological management. To ensure comprehensive cardiac care, some CR programmes have a psychologist on staff as a fully integrated member of the MDT. Systematic reviews demonstrate that the psychological component drives the benefits achieved

by CR, and that psychological interventions not only improve

psychological distress and quality CR programmes also provide In the case of individual therapy of life, but also reduce cardiac (e.g. anxiety, depression, psychological interventions CARDIAC PSYCHOLOGY IN IRELAND: SERVICE EXAMPLES events and hospitalizations12,13. adjusting to adverse life events) delivered by appropriately trained the intention in exploring mental health professionals, and From a psychological Beaumont Hospital: standpoint, psychological distress is to allow that patients with psychological cardiac patients experiencing its expression, to acknowledge it, difficulties are followed in a stepped psychological difficulties present 16-18 to offer the treatment mannerPsychology through toservice remission . is fullyand Beaumont Hospital has a dedicated Cardiac which integrated withpatient its Cardiology to CR in broadly two different strategies to address stress and ways: their distress ‘new’ Department.

Patients iscan access psychological care as working required in during phase (Coronary Care) and Psychologists CR the inpatient factors currently contributing to following psychology their recentreferrals cardiacare also received provide a range of CR psychological individual from both the programme and the Failure Service theoutpatient distress. Heart A concurrent aim event; or they’ve had ongoing treatments to meet the needs can be to focus on aspects of life (Supportive Unit). stress priorHeart to their health issues of cardiac patients. Where that are meaningful that can be which is now adding to their possible, a matched or stepped expanded upon, particularly in current distress (e.g. health carethe model is employed During CR, all patients routinely meet with cardiac psychologistallowing at the beginning of the and this the case of programme, existential difficulties anxiety). Many of these patients treatment complexity to be difficulties. experienced following a near enables timely identification of patients at increased risk of psychological As well as affording each patient also have other psychological and matched to patient need. This death experience. the time and space to telland their individual story, patients identify the role of the psychologist as an integral component behavioural problems have allows for simpler low-intensity never a mental health of psychological of CR. encountered This normalises the inclusion psychological issues in cardiac care and ensures high levelsprovided of patientby Additional expertise interventions professional At before. cardiacmotivational psychologists includes initially but also provides for engagement. this juncture, brief individual interventions (e.g. supportive counselling, interviewing) psychological preparation specialist mental health care to Participating in CR is a process are also delivered as appropriate. for cardiac surgery, weight be available to those patients of recovery where patients grow management, psychosexual requiring it. This model has been together in their confidence to counselling, insomniainto treatment, All patients are to attend group psychoeducational which are incorporated the CR shown to be both accessiblesessions to re-engage withinvited their lives afterweekly small medication adherence, family and associated with adjustment programme.

TheseBecause sessions are a CBT-framework and address to heart disease, health-related a cardiac event. theybased onpatients support (e.g. caregiver burden in increased satisfaction with are monitored exercise,coping. Additional lifestyle changes,during and adaptive group sessions address sleep,heart weight management, managing failure), neuropsychological cardiac care19. they feel safe to push themselves depressed mood, stress and heart disease, overwork & exhaustion, treatment adherence, the psychology of lifestyle eating assessment, maintaining physically and this helps them Inevent. parallel with exercise training changes, training of cardiology and resuming sexualof activity to restore a sense trust after in a cardiac (ET), many patients during CR team members, research, clinical their bodies and the expectation benefit psychologically from brief audit and quality improvement, that they will recover well This interventions such as supportive and advocacy. process is reinforced by targeted counselling, motivational education on behavioural risk CARDIAC PSYCHOLOGY IN interventions to assist with factors (e.g. diet, medications, IRELAND: SERVICE EXAMPLES changing health behaviours and/ smoking) which enhances the or targeted psychoeducational Beaumont Hospital: patient’s understanding of their group sessions (e.g. adjusting heart condition and their sense to adverse life events, managing Beaumont Hospital has a of control over their health. The depressed mood, resuming sexual dedicated Cardiac Psychology group context has a normalising activity after a cardiac event, service which is fully integrated effect as it enables people to managing fatigue). with its Cardiology Department. share their experiences with Patients can access psychological others. This allows patients to Stress management training care as required during the both benefit from the support (SMT) - when fully integrated with inpatient phase (Coronary Care) of their peers and to learn that CR - not only helps patients to and individual psychology they are not the “only ones” to reduce stress but is proven to referrals are also received from feel this way. CR can also be a deliver an incremental benefit on both the CR programme and the good time for people to pause cardiac outcomes (e.g. recurrent outpatient Heart Failure Service and re-evaluate what’s important events, hospital readmissions) (Supportive Heart Unit). to them in life and where they when compared to CR alone. wish to spend their time and Similarly, many psychologists During CR, all patients attention going forward. Cardiac are also trained in the delivery of routinely meet with the cardiac patients are often acutely aware mindfulness-based interventions psychologist at the beginning of of the opportunity to review and (MBI) which can help CR patients the programme, and this enables improve their quality of life that to learn an effective coping timely identification of patients at is not afforded to those who die strategy for managing stress increased risk of psychological suddenly. This can sometimes and a way of approaching difficulties. As well as affording come to be seen as a ‘silver psychological distress differently. each patient the time and space to lining’ that accompanies a recent For patients with insomnia, tell their individual story, patients realisation of life’s fragility.

Cognitive Behavioural Therapy identify the role of the psychologist for Insomnia (CBT-I) is the as an integral component of CR. THE ROLE OF THE recommended first-line treatment, This normalises the inclusion of PSYCHOLOGIST IN CR is highly effective, and its benefits psychological issues in cardiac care The psychological benefits of are proven to persist at 10-year and ensures high levels of patient exercise training (ET) are wellfollow up20-22. engagement. At this juncture, 14 established and ET is proven to be brief individual interventions Frequently, certain cardiac patients a highly cost-effective intervention (e.g. supportive counselling, (e.g. survivors of sudden cardiac for improving depressed mood motivational interviewing) are also 15 arrest, SCAD) present with unique in cardiac patients . This can be delivered as appropriate. and complex psychological needs particularly effective when allied to (e.g. device-related shock anxiety, All patients are invited to the social support received by staff PTSD) that are best delivered by attend weekly small group and/or peers during CR. However, an experienced clinician familiar psychoeducational sessions international guidelines continue to recommend that comprehensive with cardiology. which are incorporated into the

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CR programme. These sessions are based on a CBT-framework and address adjustment to heart disease, health-related lifestyle changes, and adaptive coping.

Additional group sessions address sleep, weight management, managing depressed mood, stress and heart disease, overwork & exhaustion, treatment adherence, the psychology of eating and resuming sexual activity after a cardiac event.

As part of Beaumont’s steppedcare pathway, patients can also access a comprehensive Stress Management Training (SMT) Programme specifically designed for cardiac patients.

This multicomponent intervention combines psychoeducation, group support and cognitive behaviour therapy for groups of 10-12 patients. Here patients acquire an extensive repertoire of relaxation techniques and psychological skills targeting stress, anxiety, sleep and anger/hostility.

Beaumont Hospital have also developed a comprehensive Heart Failure Self-Management Programme to support patients living with HF, including those unable to participate in exercisebased CR. The ‘UPBEAT’ programme targets the health of both patients and their caregivers (e.g. caregiver burden) and has been shown to be effective in improving HF self-management, psychological distress and medication adherence in patients living with HF. All patients completing the CR programme are also followed up by the cardiac psychologist.

For patients requiring additional support at this point, treatment options are discussed with the patient and onward referrals are made as appropriate (e.g. referral for stress management, individual therapy, GP, community mental health team and/or Irish Heart Foundation patient support group).

For sensitive treatment-related issues (e.g. erectile dysfunction), a referral to the cardiology clinic is facilitated on the patient’s behalf.

Psychological support is also provided to partners of patients where appropriate.

St Vincent’s University Hospital (SVUH): The Cardiac Psychology service at SVUH has evolved over time and currently employs both a senior clinical psychologist (1.0 WTE) and a psychotherapist (0.3 WTE). SVUH also provide a stepped care model delivering a service for patients across the spectrum of cardiac disease.

Lower intensity and group-based interventions are offered for mild to moderate distress, and higher intensity interventions (e.g. individual psychological therapy) are offered where there is greater complexity to the presenting difficulties and more severe distress. All psychological interventions are evidencedbased in accordance with best clinical guidance, and encompass cognitive behavioural therapy (CBT), interpersonal therapy, mindfulness-based interventions (MBI), compassion-focused therapy, short term Kleinian psychotherapy and integrative approaches (depending on the clinical presentation).

SVUH’s Cardiac Psychology service provides input to the CR programme, and consultation is provided as required, on both an inpatient and outpatient basis. Patient assessment and individual input (e.g. formulation and intervention) can be initiated at any point of a patient’s care journey. All patients attending the CR programme can benefit from two psycho-educational group sessions where participants learn about stress, depression, how these difficulties can impact heart health, coping strategies and signposting to further help, and planning for post-CR behaviour maintenance. Mindfulness based interventions (MBI) such as mindfulness-based stress reduction (MBSR) and mindfulness based cognitive therapy (MBCT) are 8-week group interventions run by the SVUH Psychology Department and are also available to these patients. MBI have been shown to reduce stress, depression, improve quality of life and help individuals manage ongoing chronic conditions23.

Patients living with heart failure (HF) are at increased risk of psychological problems such as depression and anxiety, which can in turn negatively impact cardiac outcomes. Patients with HF can access SVUH’s Cardiac Psychology service at different stages of their illness from diagnosis to episodes of acute decompensated HF, disease progression through to end of life.

CR is proven to be effective with this patient population, and the Cardiac Psychology Service also contribute to the 8-week multidisciplinary CR programme for patients with HF. A clinic also runs from the Heart Failure Unit offering individual therapy for those with more moderate to severe distress.

MBI is a helpful follow-on for those appropriate who are discharged from CR or individual therapy, and patients with HF are accepted to this programme.

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Patients with arrhythmias or an implantable cardiac device attending SVUH can also avail of the Cardiac Psychology service.

Although most patients receiving an implantable cardioverter defibrillator (ICD) or pacemaker adjust without psychological difficulties, a significant proportion of patients can experience specific psychological challenges.

Some patients with an ICD can develop problems with body image due to the implant, or anxiety in response to either cardiac symptoms or due to the device delivering therapy (i.e. an electric shock). Some will develop post-traumatic stress problems such as hypervigilance or feeling on edge, avoiding things that cause distress or re-living distressing experiences (e.g. nightmares). Notably, the prevalence of PTSD in patients with an ICD has been shown to be greater than that for Gulf War veterans24. The Cardiac Psychology service contribute to a multidisciplinary group education session for those who have been recently fitted with a device to help support patients’ awareness and independent selfcare. In addition, psychological therapy, in particular CBT and trauma-informed cognitive therapy are available to patients requiring individual support.

As well as direct clinical work with patients, SVUH’s Cardiac Psychology service collaborate with colleagues in other settings (e.g. the Irish Heart Foundation) to highlight the psychological needs of cardiac patients and to advocate for optimum service provision. Research and the provision of training to colleagues which is cognisant of the psychological needs of patients is also core business of the service.

Mater Misericordiae University Hospital (MMUH): In the Mater Hospital Cardiac Rehabilitation programme (CR) there is a principal clinical psychologist (WTE 0.4) appointed to the 8-week programme. All patients are invited to the 2-hour stress management talk given by the psychologist. During this talk, all patients are invited to take part in a mindfulness exercise and are then invited to participate in an 8-week mindfulness group.

Mindfulness-based interventions (MBI) have been associated with improvements across a range of physical and mental health outcomes, including improved depressive symptoms, anxiety, stress, quality of life, smoking cessation, healthy eating and physical activity25-27. In line with these findings, evaluations of MMUH groups have demonstrated

this to be an effective coping strategy for CR patients in terms of reducing anxiety and depression.

A pre-pandemic snapshot of the Cardiac Psychology service over 6 months showed that approximately 65 patients attended the stress management talk at the beginning of CR, and just over half of these patients (33) went onto to attend one of the 2 mindfulness groups run during this time. Feedback from the evaluation of the mindfulness programme has shown that patients viewed this an effective method to both manage stress and approach psychological distress differently. Additionally, patients indicated some improvements in mindfulness skills and self-compassion.

During the same 6-month period, 24 patients were seen for individual therapy sessions, and the average number of sessions received by patients was 4 (range 1 – 8 sessions). Areas of distress that were explored frequently included anxiety and depression and difficulties with adjustment to the cardiac event. In addition stress management, social and relationship difficulties were also addressed.

ACCESS TO PSYCHOLOGICAL CARE FOR CARDIAC PATIENTS IN IRELAND As we have seen, psychological factors are strongly linked with cardiac prognosis, and there is firm evidence underpinning psychological support for patients with heart disease. Furthermore, the need for psychological support has intensified during the recent pandemic. However, psychological services for cardiac patients in Ireland are poorly resourced nationally and characterised by inequitable access.

The recent National Survey of CR services28 conducted by Irish Heart Foundation (IHF) and the Irish Association of Cardiac Rehabilitation (IACR) showed that 80% (28/35) of CR centres had no access to psychological support for their patients. Yet, access to psychology was the highest rated service required (50% of CR Centres) to improve the quality of CR. Similarly, the IHF have deemed psychology a priority area and added: “the lack of psychological services and supports is emerging as one of the issues of greatest concern to the people in our patient advocacy network”.

CR programmes in Ireland are anxious to provide their patients with access to this essential service. The multidisciplinary team (MDT) for each CR centre should include dedicated and adequate psychology staffing. Our patients deserve nothing less.

References available on request