Download Psychosocial Risk Factors and Cardiovascular Disease

Cardiovascular Innovations and Applications
Vol. 1 No. 4 (2016) 417–431
ISSN 2009-8618
DOI 10.15212/CVIA.2016.0033
REVIEW
Psychosocial Risk Factors and C
­ ardiovascular
Disease: Epidemiology, Screening, and
­Treatment Considerations
Alan Rozanski, MD
Division of Cardiology, Mount Sinai St. Luke’s Hospital, Mount Sinai Heart, and Icahn School of Medicine at Mount Sinai,
New York, NY 10025, USA
Abstract
The recognition that psychosocial risk factors contribute to the pathogenesis of cardiovascular disease has led to the development of a new field of behavioral cardiology. The initial impetus for this field was studies performed in the 1980s
and 1990s that provided epidemiological evidence and a pathophysiological basis for a strong link ­between a number of
psychosocial risk factors and cardiovascular disease, including depression, anxiety, hostility, job stress, and poor social support. In recent years, additional psychosocial risk factors have been identified, including pessimism; other forms of chronic
stress, such as childhood abuse and trauma, and the psychological stress that may be associated with chronic medical illness; lack of life purpose; and the syndrome of “vital exhaustion,” which consists of a triad of exhaustion, demoralization,
and irritability. New research in the last decade has also established that positive psychosocial factors, such as optimism,
positive emotions, a vibrant social life, and a strong sense of life purpose, can have an important health-buffering effect
through their favorable influence on health behaviors and promotion of positive physiological functioning. Patients can
be screened for psychosocial risk factors in clinical practice through either the use of open-ended questions, which can
be integrated into a physician’s standard review of systems, or the use of short questionnaires. Physicians can assist in the
treatment of psychosocial risk factors in various ways, such as screening patients for psychological distress and making
appropriate referrals when indicated, providing patients with practical lifestyle suggestions, and employing office personnel to teach patients behavioral or psychosocial interventions that can promote a sense of well-being and/or reduce stress.
Keywords: stress; psychosocial factors; coronary heart disease; atherosclerosis; behavioral cardiology
Introduction
During the early 20th century, acute infectious illnesses began to recede as the chief cause of death
because of advances in sanitation and safe food
supply, and the development of vaccines and antibiotics. Chronic diseases then began to emerge as
the primary causes of death, with cardiovascular
Correspondence: Alan Rozanski, MD, Division of Cardiology, Mount Sinai St. Luke’s Hospital Center, 1111 Amsterdam Avenue, New York, NY 10025, USA,
E-mail: [email protected]
© 2016 Cardiovascular Innovations and Applications
disease (CVD) as the leading cause of death. In
1948 the famous Framingham Heart Study was initiated. By 1961 most of the major modifiable risk
factors for CVD had been elucidated, including
hypertension, dyslipidemia, diabetes, and smoking.
At that time, interest regarding potential psychosocial risk factors for CVD was minimal. Growth
of interest was sparked by research into “type A
behavioral pattern,” a triad of hostility, impatience/
time urgency, and a highly competitive drive, that
was first proposed by Friedman and Rosenman [1].
In the late 1970s the Alameda County Study uncovered the role of social network size as a risk factor
418
A. Rozanski, Psychosocial Risk Factors
for all-cause death [2], and with increasing studies
the role of depression as a risk factor for CVD began
to delineate. In the 1980s research began to expand
into the role of acute stress in precipitating myocardial ischemia [3–5], and experimental animal
studies delineated pathophysiological mechanisms
by which chronic stress can cause the development
of atherosclerosis [6]. Other epidemiological studies began to elucidate a growing evidence base for
other psychosocial risk factors for CVD, including
anxiety, hostility, and work stress.
These epidemiological studies were complemented by a growing understanding of the complex ways in which psychosocial risk factors are
pathogenic, including both pathophysiological and
behavioral mechanisms (Figure 1) [7, 8]. The most
potent psychosocial stressors such as depression
and chronic stress can lead to persistent activation
of the hypothalamic pituitary adrenal axis as well as
dysregulation of the sympathetic nervous system.
The consequence is widespread systemic effects,
such as autonomic dysfunction, inflammation, insulin resistance and diabetes, ovarian dysfunction,
endothelial dysfunction, potential telomere erosion,
hyperreactive heart rate and blood pressure response
to stress, platelet abnormalities, and unfavorable
alterations in brain plasticity, such as enlargement
of the amygdala and reduced hippocampal and prefrontal lobe size.
As understanding regarding the importance of
psychosocial risk factors has expanded, it has led to
a new field of behavioral cardiology, which concerns
Direct
pathophysiologic
mechanisms
(e.g., autonomic dysfunction, insulin resistance,
inflammation, platelet dysfunction, endothelial
dysfunction, telomere erosion)
Psychosocial
risk
factors
Behavior
mechanisms
(e.g., poor diet, overweight, inactivity,
smoking)
Figure 1 Psychosocial Risk Factors Exert their Effects
Through Two Basic Mechanisms.
itself with the epidemiological and pathophysiological study of unhealthy behaviors and psychosocial
risk factors for CVD, as well as the clinical translation of these findings into medical practice. This
review provides an overview of the current established psychosocial risk factors for CVD (Table 1),
as well as practical considerations for screening
patients for these risk factors and treating patients
with these risk factors in clinical practice.
Sleep
Increasing data have established that both sleep
duration and the quality of sleep may increase CVD
risk. With respect to sleep duration, both short sleep
(i.e., ≤5–6 hours per night) and long sleep (i.e., >8–9
hours per night) have been linked to a greater risk
of either developing or dying of CVD, as shown in
a meta-analysis of 15 studies [9]. A meta-analysis
of 13 studies has demonstrated that insomnia is
also associated with an increased risk of developing
CVD or cardiac events [10]. Short sleep has also
been shown to be a risk factor for hypertension and
diabetes [11, 12].
A growing literature has identified several pathophysiological mechanisms by which poor sleep
Table 1 Behavioral and Psychosocial Risk Factors for
Cardiovascular Disease.
1. Behavioral factors
Poor diet
Overeating
Physical inactivity
Smoking
Poor sleep hygiene
2. Depression
3. Anxiety
4. Pessimism
5. Hostility/anger
6. Chronic stress
Job stress
Marital strain
Child abuse and trauma
Chronic illness
7. Poor social support
8. Socioeconomic factors
9. Vital exhaustion
A. Rozanski, Psychosocial Risk Factors
Screening and Treatment
Physicians can use open-ended questions to assess
patients for sleep problems. Alternatively, sleep
questionnaires customarily target a few domains
of sleep difficulty, such as difficulty to fall asleep
within 30 min, waking up in the middle of the night
with difficulty to fall back asleep, or waking up
feeling unrested.
Vulnerable patients who are voluntarily reducing sleep because of stress or difficulties with lifework balance need to be advised as to the health
benefits of adequate sleep and/or provided with
assistance in stress reduction. For patients with
from mild to moderate insomnia, sleep hygiene
measures can be suggested or a trial of a sleeping
medication may be indicated. If sleeping difficulties are substantial, patients can also be referred
to sleep medicine programs accustomed to dealing
with these issues.
Depression
Depression was one of the first psychosocial factors to be strongly linked to CVD. The clinical
presentation of depressive symptoms can range
from mild depressive symptoms to major depressive disorder. Major depressive disorder is defined
as the experience of severely depressed mood, loss
of pleasure and interest in most activities, and the
development of associated clinical symptoms, such
as fatigue, insomnia, and loss or gain of appetite.
Epidemiological studies have consistently demonstrated a strong gradient relationship between the
magnitude of depressive symptoms and the risk of
adverse clinical outcomes [18, 19]. Notably, even
mild depressive symptoms are associated with
increased risk compared with the absence of depressive symptoms (Figure 2).
100
Survival free of cardiac death,
cumulative %
promotes CVD, including abnormalities in neuroendocrine function, inflammation, and hormonal
changes that stimulate increased appetite and weight
gain [13–16]. Nevertheless, work is needed to identify potential factors that may mediate individual
differences in sleep requirements. For example, it
has been postulated but not yet studied whether a
high sense of life purpose offsets sleep needs in
some patients [17].
419
BDI score
BDI <5
90
BDI 5 to 9
BDI 10 to 18
80
(n=896)
BDI ≥ 19
70
60
100
365
730
1095
1460
1825
Days after MI discharge
Figure 2 Five-year Survival After Acute Myocardial
Infarction is Shown in Relation to the Measurement of
Depression at the Time of Hospitalization.
Depression was measured by the Beck Depression Inventory
(BDI). There was a progressive decrease in survival according to increasing baseline BDI scores. Even mild elevations
in BDI scores (5–9) were associated with increased incidence
of events compared with normal BDI scores (<5). MI, myocardial infarction. From [18].
Depression is a commonplace symptom in cardiac practice. Whereas major depressive disorder
has a point prevalence of 4–5% in the general population, it is commonly found among 15% of cardiac
patients according to literature study [7]. In addition,
another 15% of cardiac patients tend to have milder
subsyndromal levels of depression. Thus depressive symptoms may be found in nearly one-third
of cardiac patient populations. The reason for this
high frequency appears to be due to a bidirectional
relationship between depression and heart disease:
depression is a direct causative risk factor for heart
disease, but the occurrence of cardiac events may
also drive the development of depressive symptoms
among patients.
Various meta-analyses have confirmed a strong
relationship between depressive symptoms and
cardiac events, both in community cohorts without preexisting heart disease and in patients with
known CVD. The largest of these meta-analyses
involved the study of 146,538 patients among 54
studies [20]. In that meta-analysis, the adjusted risk
ratio for cardiac events was increased by approximately two-fold among depressed versus nondepressed individuals in both community and known
CVD cohorts.
420
A. Rozanski, Psychosocial Risk Factors
Screening and Treatment
Anxiety Syndromes
As with depression, anxiety symptoms can range
from mild feelings of anxiety to well-known psychiatric conditions. With respect to general anxiety
symptoms, a meta-analysis of 20 studies found the
15
HAM-D after treatment
An American Heart Association multidisciplinary council has recommended screening cardiac
patients for depression according to a two-item
subscale of the Patient Health Questionnaire (PHQ2), which asks patients how often they have been
bothered over the previous 2 weeks by (1) little interest in or pleasure in doing things, and (2)
feeling, down, depressed, or hopeless. Both questions are answered according to a four-point scale
(0=not at all; 1=several days; 2=more than half the
days; 3=nearly every day). A positive answer to
either question (i.e., score ≥2) is an indication to
use the full nine-item version of the Patient Health
Questionnaire (PHQ-9) for further screening (see
Appendix 1). In patients with high scores on the
PHQ-9, a more comprehensive clinical evaluation
by a qualified professional is recommended.
The standard treatment of depression includes
either the use of psychotherapy and/or the use of
antidepressant medications. Psychotherapeutic
approaches include the use of either cognitive
behavioral therapy or interpersonal psychotherapy.
Cognitive therapy helps patients to identify distortions in their thoughts and patterns of behavior and
then provide them with assistance in changing these
distortions. Interpersonal therapy attempts to help
patients improve their social interactions, such as
the experience of social isolation and role conflicts.
The first-line medication for treating depression is
the use of a selective serotonin reuptake inhibitor.
Randomized control trials have demonstrated the
safety of selective serotonin reuptake inhibitors
in the treatment of cardiac patients. Considerable
evidence also supports the use of exercise as an
alternative treatment for depression, on the basis
of various epidemiological studies, including the
results of three randomized controlled studies that
found exercise to be comparable to antidepressant
medication in alleviating depressive symptoms
(Figure 3) [21–23].
10
5
Exercise
Sertraline
Placebo
Figure 3 Results from a Prospective Randomized
Involving 101 Depressed Patients with Known CAD.
Patients were randomized to undergo 16 weeks of aerobic
exercise, to receive treatment with a selective serotonin reuptake inhibitor (sertraline), or to receive placebo. Depression
was measured by the Hamilton Rating Scale for Depression
(HAM-D). Aerobic exercise and treatment with a selective
serotonin reuptake inhibitor resulted in comparable reductions
in the depression scores assessed by the HAM-D versus treatment with placebo. MI, myocardial infarction. From [23].
presence of such symptoms to be associated with
an increased incidence of CVD (hazard ratio 1.48,
95% confidence interval 1.15–1.38) [24]. However,
the analysis also demonstrated considerable variability among the individual studies, with only half
of the studies manifesting a significant association
between anxiety and CVD. A greater and more consistent link with CVD has been observed among
psychiatric-level anxiety syndromes, including
phobias [25, 26], panic disorder [27], generalized
anxiety disorder [28, 29], and posttraumatic stress
disorder (PTSD) [30]. Distinguishing characteristics of these anxiety syndromes are listed in Table 2.
Screening and Treatment
The presence of anxiety can be assessed by use of
a two-item subscale of the Generalized Anxiety
Disorder seven-item scale (GAD-7), which asks
patients how often they have been bothered over
the prior 2 weeks with (1) feeling nervous, anxious,
or on edge and (2) not being able to stop or control
worrying. The two questions are scored on a fourpoint scale (0=not at all, 3=nearly every day). Those
with increased scores can then be assessed with the
A. Rozanski, Psychosocial Risk Factors
421
Table 2 Major Anxiety Syndromes Linked to Cardiovascular Disease.
Syndrome
Symptoms
Generalized
anxiety
disorder
Phobias
Excessive and generally uncontrollable anxiety or worry
Present most days for >6 months
Social and occupational dysfunction
Marked and persistent fear of objects and performance situations
On exposure, produces anxiety and a fear of acting in a dysfunctional manner
Recurrent panic attacks
The disorder may lead to adverse changes and/or persistent concern of having more panic attacks
Occurrence for >1 month of flashback memories or other reexperiencing, avoidance of stimuli
related to original trauma, numbing feelings, and hyperarousal
Impairment in daily life functioning
Panic disorder
Posttraumatic
syndrome
GAD-7 (see Appendix 2). Patients with elevated
scores may benefit from referral to a trained mental
health professional.
A variety of treatment options can be used to treat
anxiety, depending on the preference of patients
and/or the severity of anxiety symptoms. Relaxation
techniques, problem-solving counseling, and various targeted psychotherapies may be used to treat
mild anxiety symptoms. As with depression, the use
of cognitive therapy is often a mainstay of treatment, with modifications of the therapy, as appropriate, for specific forms of anxiety, such as PTSD
or phobias. For those patients with severe anxiety
symptoms, pharmacological interventions can also
be used, including the use of selective serotonin
reuptake inhibitors or benzodiazepines.
Pessimism
A psychosocial parameter that has been increasingly
linked to health is the domain of pessimism versus
optimism. This domain has long been identified by
psychologists as an important determinant of subjective well-being. Optimism tends to be associated
with more positive moods, greater morale, heightened resiliency and perseverance, and greater life
success. Pessimism, by contrast, tends to be associated with less adaptive coping styles. The study of
pessimism as a risk factor for CVD has been relatively recent. The earliest study, reported by Maruta
et al. [31] in 2000, observed an increased risk of
death for pessimists versus optimists during the
30 year follow-up of initially healthy participants.
Subsequently, Kubzansky et al. [32] demonstrated
an increased risk of adverse cardiac outcomes
among pessimists in the Veteran Affairs Normative
Aging Study. Since then, substantial further study
has confirmed the increased risk posed by pessimism for CVD, stroke, and all-cause death [33–37].
In those studies in which it was assessed, there is a
gradient relationship between the degree of measured pessimism/optimism and the likelihood of
adverse clinical events.
Screening and Treatment
The domain of optimism/pessimism has been
measured according to two differing constructs.
One approach termed “dispositional” optimism/
pessimism assesses a person’s general personality
disposition toward expecting positive or negative
outcomes in the future. The alternative approach
is to assess a person’s “explanatory style.” The
explanatory style of pessimists involves the tendency to blame themselves when negative events
occurs, to view negative events as likely to remain
persistent, and to see these events as affecting many
aspects of their lives. Optimists tend to minimize
self-blame and to see negative events as transitory
and limited in scope. Most recent research tends
to use the measurement of dispositional optimism/
pessimism (rather than explanatory style), and is
most commonly assessed according to the Life
Orientation Test-Revised, as developed by Scheier
et al. [38]. The scale consists of a ten-item questionnaire involving the rating of such statements as “in
uncertain times, I usually expect the best” and “I
hardly ever expect things to go my way.”
422
A. Rozanski, Psychosocial Risk Factors
The promotion of optimism represents a new
focus in the arena of positive psychology. One
approach involves the tailored use of cognitive
behavioral techniques that are traditionally used to
treat depression, anxiety, and other negative psychological conditions. In addition, recent psychological
interventions that have been developed, such as the
“best possible self exercise” [39, 40], deserve further evaluation.
Hostility and Anger
The study of anger and hostility as CVD risk factors was an outgrowth of initial interest in the type
A behavioral pattern. Interest in this behavioral pattern, which initially was linked to CVD in epidemiological studies, later waned because of negative
findings. However, interest in anger/hostility has persisted. Overall, however, the relationship appears to
be modest. In a meta-analysis of published studies,
Chida and Steptoe [41] observed that the presence
of anger or hostility increased the risk of coronary
heart disease by approximately 20% among 25 studies involving community cohorts and by 25% among
19 studies involving patients with known coronary
heart disease. Various studies have also linked hostility to the progression of atherosclerosis and various
pathophysiological determinants of CVD.
stress have been garnered from studies of the effects
of chronic stress in experimental animals. A popular model in this regard is the study of cynomolgus
monkeys (Macaca fascicularis), for three reasons:
cynomulgus monkeys develop atherosclerosis in a
manner that is similar to humans; they have quantifiable social characteristics; and their social environment can be readily modified to create a condition of
chronic stress. For instance, when male cynomolgus
monkeys are placed in constantly changing social
groups, a chronically stressful environment is created
for “dominant” (versus “submissive”) monkeys since
these monkeys continually attempt to reestablish their
dominance within each new social group. Dominant
male monkeys within unstable groups develop sufficiently greater atherosclerosis than counterparts that
are placed in stable unchanging groups [6].
The epidemiological study of chronic stress has
been extensive. Among these studies, the internationally conducted INTERHEART study observed
a proportional relationship between the chronicity of stress and the risk of myocardial infarction
(Figure 4). Moreover, the relationship between stress
and myocardial infarction was found to be consistent across countries and continents (Figure 5) [42].
The role of chronic stress has also been evaluated
across multiple life situations, such as job, marital,
and caregiving stress, and the chronic stress that
Screening and Treatment
Odds ratio for MI
2.5
Chronic stress has been strongly linked to CVD on
both a pathophysiological and an epidemiological
basis. Important insights into the effects of chronic
2.1
1.4
1.5
1
1
0.95
(1.7–2.6)
(1.2–1.6)
(0.8–1.1)
0.5
Never
B
2.5
Some of
the time
1.5
1
Several periods
Stress at home
1.5
1
Permanent
2.1
2
1.1
(1.7–2.7)
(1.3–1.7)
(0.97–1.1)
0.5
0
Chronic Stress
Stress at work
2
0
Odds ratio for MI
Assessment of hostility can be performed with the
Cook-Medley hostility scale, but the scale is not
practically used in clinical practice. While patients
can be screened for most psychosocial risk factors
by use of open-ended questions, a problem with the
use of open-ended questions to screen patients for
anger/hostility is the frequent lack of sufficient selfrecognition as to this character tendency among
those who have it. However, when undue anger has
been identified, it can be successfully treated by
participation in anger management programs.
A
Never
Some of
the time
Several periods
Permanent
Figure 4 The Odds Ratio for Myocardial Infarction (MI)
in the INTERHEART Study According to Measurements of
the Amount of Stress at Work and Stress at Home.
For both, the odds ratio increased with increasing frequency
and chronicity of stress.
A. Rozanski, Psychosocial Risk Factors
423
Figure 5 Adjusted Odds Ratio for Acute Myocardial Infarction in the INTERHEART Study for Participants with Moderate/
Severe Stress, Shown by Geographic Region and by Ethnic Group.
Stress was associated with an increased odds ratio in all regions and ethnic groups. CI, confidence interval. From [42].
Job demand
High
Low
High
Low
Job latitude
may ensue from childhood abuse and trauma. The
most studied of these situational stressors has been
chronic job stress. A leading model in this regard has
been the study of “job strain,” as first proposed by
Karasek et al. [43]. According to that model, individuals are assessed for the amount of work demand
and the latitude they are afforded in their job situation. Job strain is present when individuals experience work that is highly demanding but associated
with low job latitude (Figure 6). A similar model
has evaluated individuals for job demand versus the
“reward” (fiscal or nonfiscal) received from working. A meta-analysis by Kivimäki et al. [44], however, found only a modest 1.23-fold increased risk
of incident CVD among individuals with job strain.
It may be insufficient though to reduce the nature of
job stress to just these two variables. Rather, other
factors that may potentially impact the relationship
between job stress and CVD outcomes deserve further study, including the chronicity of stress, the
impact of socioeconomic conditions, and the meaningfulness experienced in one’s work.
Job
strain
Figure 6 Model of “Job Strain” as Proposed by Karasek
et al. [43].
Work is evaluated according to the amount of demand of the
job, and according to the amount of latitude that is afforded
to workers. Job strain is present when highly demanding
work is associated with little job latitude.
Another potential manifestation of stress is the
inability to unwind after work. Some studies have
observed an increased risk of clinical events among
individuals who report difficulty in unwinding after
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A. Rozanski, Psychosocial Risk Factors
work [45, 46], but overall, research in this arena is
quite limited. An interrelated arena is the study of
burnout [47] and vital exhaustion [48, 49], two syndromes that are each characterized by a triad of symptoms, as shown in Figure 7. To date, there has been a
paucity of studies examining the relationship between
burnout and CVD outcomes, although one large follow-up of 8838 healthy individuals assessed for burnout found that those who scored in the highest quintile
for burnout symptoms had a higher risk of developing
coronary heart disease (hazard ratio of 1.79, 95% confidence interval 1.05–3.04) [47]. By contrast, there
has been substantial epidemiologic study that now
links vital exhaustion to CVD outcomes [50–53]. For
instance, in the Copenhagen City Heart Study, which
involved the follow-up of 8882 individuals who
were initially free from CVD, vital exhaustion was
observed to be a strong independent risk factor for the
development of CVD, with manifestation of a strong
risk-adjusted gradient relationship [53].
Lesser study has suggested a link between marital strain and CVD [54], and divorce is also associated with an increased risk of death [55]. Similarly,
childhood abuse has been found to be associated
with an increased risk of CVD and other adverse
medical outcomes in adulthood according to a
meta-analysis of 24 studies [56]. More recently,
study has begun to focus on the stress associated
with medical illness and its impact on subsequent
CVD risk. For instance, in a meta-analysis of 24
studies in which PTSD was assessed among acute
coronary syndrome patients, a 12% prevalence
of PTSD was found [57]. Among three of these
studies, there was a doubling of subsequent risk
Vital exhaustion
Exhaustion
Demoralized
Irritability
Burnout
Exhaustion
Depersonalized
Low selfefficacy
Figure 7 Two States that are Associated with Exhaustion
are Depicted: Vital Exhaustion and Burnout.
Each consists of a triad of symptoms.
of death among those acute coronary syndrome
patients who had PTSD.
Screening and Treatment
There is no formal approach to screening patients
for stress in clinical practice. A practical approach
involves the use of open-ended questions such as
“what kind of pressure have you been under at work
or at home?” and “do you have difficulty unwinding after work?” Alternatively, there are a variety
of scales that can be used to assess factors such as
general perceived stress, job strain, burnout, and
vital exhaustion. However, these scales are primarily used for epidemiological study rather than in
routine clinical practice.
Physicians can often undertake an important and
often unappreciated role in helping patients to deal
with chronic stress. Physicians often underestimate
their potential “bully pulpit” (i.e., their ability to
suggest recommendations that patients will take
seriously because their physician thinks they are
important). Physician management of stress first
begins with the physician becoming attuned to recognizing high stress levels in patients. Physicians
can then take the following steps when they sense
patients have a high burden of stress.
First, physicians can make practical suggestions regarding positive health practices to support
patients with chronic stress. This is important in
light of work by Thayer [58], who demonstrated that
patients tolerate stress better when they feel more
energetic. The same problem that seems manageable when one feels energetic can loom large when
one feels tired. Thus promotion of energy management can often assist patients in managing stress. A
principal recommendation in this regard is to promote exercise. Exercise has the benefit of elevating
mood, improving cognitive function, and reducing
the negative pathophysiological effects of chronic
stress [17]. Other important energy tips include
obtaining adequate sleep and having a healthy diet.
Second, physicians can recommend relaxation
techniques when appropriate. This can include simple
measures such as breathing exercises and progressive
relaxation techniques that could be demonstrated by
trained ancillary office personnel, or the referral of
patients to structured programs, such as mindfulnessbased stress reduction classes, yoga, or Tai Chi.
A. Rozanski, Psychosocial Risk Factors
Third, physicians can also make practical lifestyle suggestions to help patients reduce stress or to
unwind, such as creating better boundaries around
work, taking more vacation, or spending more time
with their family or in leisure pursuits.
Fourth, physicians can suggest referral of appropriate patients for behavioral interventions, including traditional psychotherapies, for patients who are
apparently overwhelmed by chronic stress.
Social Isolation and Poor Social
­Support
The need for social attachment is a basic psychological need. Its absence may lead to both negative
psychological sequelae and poor health. The study of
the social determinants of health has been extensive
and multidimensional, including study of the size
and frequency of contact within one’s social network,
the quality of emotional support, and the quality of
tangible forms of social support. Each of these determinants has been shown to be an important health
predictor. Even among social animals, the induction
of social isolation can induce potent pathophysiological disturbances [59, 60]. For example, among experimental female cynomulgus monkeys that were all fed
the same atherogenic diet, those that were placed in
single cages developed substantially greater atherosclerosis than those that were placed in groups [60].
A recent extensive meta-analysis of 148 studies,
involving 308,849 individuals, found that an index
of social integration had a moderate to large effect
size with respect to diminishing the subsequent risk
of all-cause death [61]. The nearly two-fold odds of
increased survival with good social integration noted
in this analysis is comparable to that noted with many
cardiac interventions, such as cardiac rehabilitation.
Another important social index is socioeconomic
status, which is commonly assessed as a composite
of factors, such as education, occupational status,
and income. A consistent inverse gradient has been
observed between socioeconomic status and the
likelihood of both all-cause death and cardiac events
[62, 63]. Low socioeconomic status increases the
likelihood of overall chronic stress because of its
common association with poor income, job insecurity or unemployment, poorer housing conditions,
decreased public safety, and other factors.
425
Screening and Treatment
While numerous scales have been developed to
assess social support, there is no standard scale
that has gained widespread acceptance for clinical
practice. Instead, patients can be screened for poor
social support according to open-ended questions,
such as “who do you turn to for social support?”
Further questions may follow according to practical circumstances, such as inquiring whether an
infirm patient has adequate tangible social support
or resources.
Physicians can undertake practical steps to support
patients who appear to be lonely or have poor social
support. One step is to become cognizant of the various support groups, social services, and community resources that are available to aid patients with
their social needs and to then encourage patients to
use these resources. In addition, physicians can also
encourage patients to be more socially active and let
them know that they will follow-up on this advice at
subsequent visits. This may inspire some patients to
become more socially active. For example, among
elderly retirees who feel socially isolated, volunteering may be a meaningful and useful way to improve
social contact. Volunteering has been shown to have
practical health benefits, including extension of longevity [64, 65]. Finally, when needed, a physician
can refer patients who have difficulty in constructing a healthy social life to an appropriate behavioral
specialist.
Positive Psychosocial Factors
In the last decade increasing focus has been
placed on the health-mediating effects of positive psychological factors. This focus grew out of
research that explored the role of positive psychological factors in improving overall well-being
and resiliency. In essence, all of the negative psychological factors noted in previous sections have
their positive counterparts, and when assessed,
these positive factors promote health and longevity [17], just as the negative factors promote
disease and reduce longevity. In an initial metaanalysis of epidemiological studies that studied
positive psychological factors, Chida and Steptoe
[66] found that the presence of positive psychological well-being reduced mortality in both
426
A. Rozanski, Psychosocial Risk Factors
community cohorts and diseased populations.
This initial meta-analysis included a broad variety
of positive psychological factors, such as positive
mood, optimism, and life satisfaction. Since then,
epidemiological studies have continued to support the benefits of positive psychological factors,
while physiological studies have helped to delineate mechanisms by which positive psychosocial
factors are physiologically beneficial, such as by
reducing activation of the neuroendocrine and
immune systems, and increasing the likelihood of
positive health behaviors [17].
As this research has expanded, an area of specific
interest has centered around the basic psychological need of having a sense of purpose, as proposed
by many theorists. While this line of investigation
has only been recent, a meta-analysis of ten studies
found a consistently lower risk of adverse clinical
Figure 8 Unadjusted (top) and Adjusted (bottom) Risk Ratios for All-cause Death According to High versus Low Purpose in
Life.
Squares represent the risk ratio of the individual studies, while the diamond represents the pooled risk ratio or the overall
­effect. CI, confidence interval; RR, relative risk. From [67].
A. Rozanski, Psychosocial Risk Factors
events among individuals with a strong sense of
life purpose in these studies (Figure 8) [67]. Other
studies have found a reduced risk of stroke [68],
dementia [69, 70], and future physical disability
[71] among participants reporting a higher sense of
life purpose at the baseline.
Screening and Treatment
No formal approach to screening patients for
positive psychosocial functioning has yet been
developed, but one practical approach is to assess
patients for their reported sense of vitality (i.e., to
what extent they feel energetic). Those reporting
low energy can then be evaluated as to physical or
psychological factors that may potentially diminish
their sense of vitality.
Promoting positive psychological well-being is
not merely the result of reducing negative psychosocial factors. Rather, for those individuals seeking
a “positive prescription,” a baseline of promoting
exercise and healthy nutrition can be coupled with
a tailoring from other integrative health practices,
such as yoga and meditative practices, the performance of appreciation and gratitude exercises,
promoting volunteering or other meaning-based
activities, the use of positive cognitive therapy,
and other approaches. The future will likely see the
427
development of programs that offer such services
within health care systems.
Summary
The study of psychosocial risk factors has led to the
development of a new field of behavioral cardiology. This field concerns itself with the identification
of health behaviors and psychological and societal
factors that contribute to the pathogenesis of CVD
and the clinical translation of these findings into
practical methods to help patients reduce psychological distress and improve health behaviors. The
epidemiological evidence linking negative psychosocial risk factors to CVD is both consistent and
strong. The last decade has also seen a marked
growth in the examination of psychological factors
that promote overall health, longevity, and individuals’ sense of well-being. This article has also
reviewed practical means for screening patients for
psychosocial risk factors as well as practical interventions that can be used to manage psychosocial
risk factors in clinical medical practice.
Conflict of Interest/Disclosures
The author declares no conflict of interest.
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Appendix 1. Nine-Item Patient Health Questionnaire
Over the last 2 weeks, how often have you been bothered by any of the following
­problems?
Not at all
Several
days
More than
half the days
Nearly
every day
1. Little interest or pleasure doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself – or that you are a failure
or have let yourself or your family down
7. Trouble concentrating on things, such as reading the
newspaper or watching television
8. Moving or speaking so slowly that other people could
have noticed? Or the opposite – being so fidgety or
restless that you have been moving around a lot more
than usual
9. Thoughts that you would be better off dead or of
hurting yourself in some way
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
0
1
2
3
0
1
2
3
0
1
2
3
If you checked off any problems, how difficult have these problems made it for you to do your work, take
care of things at home, or get along with other people?
Not difficult at all
□
Somewhat difficult
□
Very difficult
□
Extremely difficult
□
A. Rozanski, Psychosocial Risk Factors
431
Appendix 2. Generalized Anxiety Disorder Seven-Item Scale
Over the last 2 weeks, how often have you been bothered by any of the following
­problems?
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it’s hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
Not at all
Several
days
More than
half the days
Nearly
every day
0
0
0
0
0
0
0
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
If you checked off any problems, how difficult have these problems made it for you to do your work, take
care of things at home, or get along with other people?
Not difficult at all
□
Somewhat difficult
□
Very difficult
□
Extremely difficult
□