Download Cardiac Rehabilitation

Introduction to
Cardiac Psychology
Honors Psychology Course
March 25, 2008
Rachel Fry, Ph.D.
Overview
 Provide
a background and history of cardiac psychology.
 Introduce
psychosocial factors related to heart disease.
 Discuss
treatment opportunities and challenges within
this population.
 Describe
practice.
the pros/cons of being a psychologist in private
What is Cardiac Psychology?
 Cardiac
Psychology is a specialization focused on
helping patients (and their families) prevent heart
disease, prepare for surgical procedures, and
recover from cardiac events and/or surgery.
Cardiac Psychologists

Prevention
– Help patients identify and modify risk factors associated with
heart disease.

Preparation for Surgery
– Provide patients and their families with educational
information and teach relaxation skills that can ease anxiety.

Recovery Process
– Provide support and education following surgery.
– Help patients develop adaptive coping mechanisms, make
needed lifestyle modifications, work through psychological
distress, and learn how to control stress and anger.
History of Cardiac Psychology
 1950’s
Friedman and Rosenman: Type A
Behavior Pattern (TABP)
 1960’s
Behavioral Risk Factors: Addictive
Behaviors and Health-Related Lifestyle
 1980’s-90’s: Associations
between cardiac
disease and psychopathology
Modifiable Risk Factors
 Tobacco
smoke
 High
blood
cholesterol
 High

Depression

Anxiety

Stress

Hostility
blood pressure
 Physical
inactivity
 Obesity
and
overweight
 Diabetes
mellitus
Depression
 Depression
is the most proven psychosocial risk factor
and consequence of heart disease.
 Estimates
of depression range from 15-65% in cardiac
patients.
14-47% - depressive symptoms
15-20% - DSM criteria
 Some
depression may be expected
– Guilt over lifestyle contributions
– Difficulty adjusting to physical limitations
Prevalence Rates of Major Depression in
Patients with Cardiovascular Illness
15-20%
Unstable Angina-4
14-36%
CHF-3
MI-2
16-20%
CAD-1
15-23%
0%
10%
20%
30%
40%
1-Carney. 1995; Hance, 1996; Gonzalez, 1996; Sullivan, 1999; Connerney, 2001; 2-Schleifer, 1989;
Ladwig, 1991; Frasure-Smith, 1995; Jiang, 2001; 3-Jiang, 2001; Koenig, 1998; Frasure-Smith, 1993;
4-Lesperance, 2000
Depression And
Future Cardiac Problems

Negative mood and depression significantly predicted cardiacrelated deaths independent of the severity of heart disease.1

Depression after an acute MI was found to be a significant
predictor of further cardiac events one year later, especially for
elderly patients. 2

In patients six months after a heart attack, depression was
associated with more than a 400% increase in the risk of
cardiac related death after adjusting for other risk factors,
such as left ventricular dysfunction and previous heart attacks. 3
1) Frasure Smith and Lesparance 2003, Archives of General Psychiatry, 60: 627-36. 2) Shiotani et al. 2002, Journal of
Cardiovascular Risk, 9: 153-60. 3) Frasure-Smith et al. 1993, JAMA, 270: 1819-1825.
How Does Depression
Lead to Heart Disease?
 Unhealthy
Lifestyle Behaviors
 Autonomic
Nervous System Dysregulation
 Hypothalamic
 Diabetes,
Pituitary Adrenal Axis Dysregulation
obesity, and metabolic syndrome
 Inflammation
 Platelet Activity
Depression
 Depression
–
–
–
–
in heart patients is UNDERDIAGNOSED
Patients may be reluctant to share their feelings
Cardiac patients do not display typical depressive
symptoms
Many patients can’t identify depressive symptoms
Symptoms may be confused with medication sideeffects of after-effects of surgical procedures
Anxiety


Very prevalent in heart patients, especially within the first year of
having a heart attack (50-60%).
Anxiety symptoms are very similar to heart attack symptoms.
– Rapid heart rate
– Feelings of fear or strong apprehension
– Trembling, restlessness, and muscle tension
– Light headedness or dizziness
– Perspiration, sweating
– Cold hands or feet
– Shortness of breath
– Excessive worry
– Feelings of having little control over events
Anxiety

Anxiety has been found to be highly predictive of fatal CHD,
even after controlling for other cardiovascular risk factors.1

Higher levels of anxiety have been associated with sudden
cardiac death.2

Associated with increased rates of in-hospital complications
(having another heart attack, recurrent ischemia, and ventricular
tachycardia and fibrillation.3

Anxiety has been shown to predict recurrent cardiac events
over a 12-month period following a heart attack.4
1) Haines et al. 1987 British Medical Journal 295: 297-99 2) Kawachi et al. 1994 Circulation, 89: 1992-97.
3) Moser et al. 1996, Psychosomatic Medicine, 58: 395-401. 4) Frasure-Smith et al. Health Psychology, 14: 388-98.
Treatment
 Cognitive
behavioral therapy, stress management,
relaxation therapy, problem solving therapy, and selfcontrol therapy are especially effective in treating
depression and anxiety.
 Counseling
programs effective at not only reducing
anxiety and depression, but also for reducing various
underlying biologically related risk factors.
Stress

Chronic stress can play a role in the development and progression of
heart disease.

Stress can decrease immune system functioning and cause inflammation1

Stress hormones can increase LDL and decrease HDL levels1

Stress can increase the odds that artery wall linings will accumulate clots
that harden, causing artherosclerosis.1

Chronic stress can affect the hypothalamus, causing blood pressure to rise.2
1)Kop, Psychosomatic Medicine 61 (4) 1999: 476-487. 2) Pandya, Comprehensive Therapy 24 (5), 1998: 265-271.
Chronic Stress and Heart Disease

Chronic stress can increase the risk of experiencing a heart
attack, ischemia, or sudden death.1

Chronic stress impairs the heart’s ability to pump blood to the
lungs for oxygen and then propel the oxygenated blood throughout
the body, causing the heart to pump harder and faster.2

Can contribute to high blood pressure, reduced blood flow,
increased blood clotting, heart rhythm problems, and
increased plaque buildup in the arteries.3
1) Tofler et al., American Journal of Cardiology, 66, 1990: 22-27. 2) Wright, American Psychologist, 43, 1988:
1-14. 3) Pandya, Comprehensive Therapy 24 (5), 1998: 265-271.
The Holmes-Rahe Life Events Scale






















LIFE EVENT
Divorce
Marital Separation
Jail Term
Death of a close family member
Personal Injury or Illness
Marriage
Fired at Work
Marital Reconciliation
Retirement
Change in health of family member
Pregnancy
Sexual Difficulties
Gained a new family member
Business Readjustment
Change in financial status
Death of a close friend
Change to a different line of work
Change in # of arguments with spouse
Mortgage or loan of more than $100,000
Foreclosure of mortgage or loan
Change in responsibilities at work
MEAN VALUE
73
65
63
63
53
50
47
45
45
44
40
39
39
39
38
37
36
35
31
30
29






















LIFE EVENT
MEAN VALUE
Son or daughter left home
29
Trouble with in-laws
29
Outstanding personal achievement
28
Spouse began or stopped work
26
Began or ended school
26
Change in living conditions
25
Revision of personal habits
24
Trouble with boss
23
Change in work hours or conditions
20
Change in residence
20
Change in schools
20
Change in recreation
19
Change in church activities
19
Change in social activities
18
Mortgage or loan less than $100, 000
17
Change in sleeping habits
16
Change in number of family get togethers
15
Change in eating habits
15
Vacation
13
Christmas
12
Minor law violations
11
Hostility

Hostility can lead to the development and exacerbation of heart disease.

Hostility can increase stress hormones, elevate fat levels in blood, and
heighten physical reactions (i.e., increase blood pressure, constrict arteries).

Hostility can also lead to destructive behavior (i.e., caffeine, nicotine, alcohol,
drugs, unhealthy eating habits, and impulsivity).

Intense episodes of anger have been found to trigger heart attacks.

High levels of hostility have been linked to recurrent cardiac events and
mortality.
Treatment
Cognitive Behavioral anger management programs
Significant reductions in blood pressure and hostility levels.

Relaxation training
– Reduced blood pressure reactivity to anger-instigating situations.1

Psychosocial counseling program with Type A behavior men who had a
previous heart attack.
– Significant reductions in type A behavior and anger
– Improved medical outcomes and fewer recurrences of negative cardiac
events.2
– Recurrent Coronary Prevention Project, patients received CB counseling
and experienced marked reductions in type A behaviors, but also lower
rate of coronary recurrence.3
1) Davison et al. 1992, Journal of Behavioral Medicine, 14: 453-68. 2) Burrell et al. 1994, International Journal of Behavioral Medicine,
1:32-54. 3) Thoreson and Brake, 1997, Geroup Therapy for Medically Ill Patients, J.L. Spira, Guilford.
Social Support
 Social
support has been shown to predict psychological
distress (i.e., depression), development of medical
problems, as well as mortality in different populations.
 Low
perceived social support [i.e., having (or at least
believing one has) no one to confide in, no one with
whom to share love and affection, and no one to provide
emotional support when confronting difficult challenges
or decisions] has been shown to predict adverse medical
or psychiatric outcomes in cardiac patients.
Psychologist in Rehab Setting

Initial screening appointment
– Assess patient’s overall psychological functioning

Follow-up appointments
–
–
–
–
–



Psychotherapy
Lifestyle Modification
Stress Management
Anger Management
Relaxation Training
Group Education
Support Groups
Psych consults with inpatients
– Meet with patients following medical procedures


Help recruit patients for the cardiac rehab program
Collaborate with physicians and other health care professionals
Depression Screening in Cardiac
Rehabilitation
AACVPR Position Statement
 Assess for depression using a valid and reliable
screening tool as part of the intake assessment.
 Communicate findings of possible clinical
depression to referring physician and facilitate
referral for appropriate treatment.
 Reassess therapeutic progress.
Herridge et al, J of Cardiopulm Rehabil, 2005
Screening Measures

Beck Depression Inventory-II (BDI-II)
– Assessed at enrollment & completion of CR; 1 year follow-up

Herridge Cardiopulmonary Questionnaire (HCQ)
– Hostility
– Depression
– Anxiety
– Stress
– Social Support
– Self-efficacy
– Motivation
HCQ

Cardiac Patient
Caucasian Male
 Age: 62


BDI Score: 10
HCQ
 Cardiac
Patient
 African American
 Age:
42
 BDI
Score: 16
Male
A Current Look at Depressive Symptoms
Men
24%
n=360
Women
30%
4%
11%
Minimal (0-13)
9%
n=180
8%
11%
Mild (14-19)
Mod (20-28)
76%
11%
70 %
Severe (29-63)
BDI-II Score Categories
Baseline scores of UAB enrolled patients (n=540) with CAD 1/96- 8/04
Cardiac Rehab Improves Depression
n=338; Prevalence of depression: 20% (n = 69);
Phase II Rehab: 12 weeks, 36 sessions
Change in Depression by Initial Severity
% of Patients
60
Entry
Final
50
40
30
20
10
0
Moderate
Severe
Milani RV, et al. Am Heart J 1996;132:726-732
Challenges
 Lack
 No
of Infrastructure
direct proven benefits
 Funding
 Determining
 Improving
best screening and treatment methods
the gap between psychologists and physicians
Cardiac Psychologist in Private Practice
 Work
–
–
–
–
with cardiology clinics in Birmingham
Individual and Family Therapy
Support Group Meetings
Provide in-service workshops to staff
Work as a liaison between the patient and physician
Benefits to Private Practice
 Flexibility
 Ability
to see a variety of patients
 Opportunity
to work in many different settings (rehab,
inpatient, and outpatient clinics)
 Potential
to make a good living
Challenges Faced In Private Practice
 Building
up caseload (estimated to take 5 years)
 Marketing
to target audience
 Balancing
cases
 Benefits
Recommended Books
 Molinari,
E., Compare, A., & Parati, G. (2007). Clinical
psychology and heart disease. Springer.
 Kligfield,
P. (2006). The cardiac recovery handbook.
Hatherleigh.
 Sotile,
W. (2003). Thriving with heart disease: A unique
program for you and your family. Free Press: New York, NY.
 Maximum, A.,
Stevic-Rust, L., & Kenyon, L.W. (1997). Heart
therapy: Regaining your cardiac health. New Harbinger:
Oakland, CA.
Contact Information
 Dr.
Rachel Fry:
– E-mail: [email protected]
– Phone (205) 870-3520
 Practice
Website: Pitts and Associates
– www.drbertpitts.com
 Cardiac
Psychology Website
– www.cardiacpsychology.com