Supporting your patient s mental health. March 2019

Transcription

1 Supporting your patient s mental health March 2019

2 Emotions after a cardiac event Acute response Adjustment, new normal change in role/ dependence, new meds etc overwhelmed, anger, denial, grief, anxiety, cardiac blues Down the track Depression 80% want to have a conversation with H Prof about their emotional condition (Murphy et al, Austrian Family Physician, 2015) Can help normalise their feelings

3 Overview today Heart health and mental health are closely related. Stress and psychosocial factors Cardiac blues and depression Screening tools Tips and resources What s happening in real life practice?

4

5 Stress and the heart Different triggers for each person Stress response Sympathetic Nervous System rhythm, HR, BP adrenaline (catecholamines) cortisol (glucocorticoids) glucose, lipids immune system: inflammatory cytokines atherosclerosis, obesity, diabetes CV Risk

6 Effects of stress Can negative habits dietary choices, physical activity, smoking, alcohol Disturbed sleep & racing mind (can affect the above too) Palpitations & rhythm disturbances

7 2003 Position statement Heart Foundation Psychosocial risk factors and coronary heart disease No strong or consistent evidence for a causal association between chronic life events, work-related stressors (job control, demands and strain), Type A behaviour patterns, hostility, anxiety disorders or panic disorders and CHD. Strong and consistent evidence of an independent causal association between depression, social isolation and lack of quality social support and cause and prognosis of CHD Increased risk contributed by these psychosocial factors is of similar order to the more conventional CHD risk factors eg smoking, dyslipidaemia, hypertension. Psychosocial risk factors should be identified during individual CHD risk assessment and management,

8 Psychosocial risk factors for CHD A consensus statement from the National Heart Foundation of Australia Authors: Nick Glozier, Geoffrey H Tofler, David M Colquhoun, Stephen J Bunker, David M Clarke, David L Hare, Ian B Hickie, James Tatoulis, David R Thompson, Alison Wilson, Maree G Branagan Med J Aust 2013; 199 (3): Perceived chronic job strain and shift work associated with small absolute increased risk of developing CHD. Limited evidence regarding their effect on CVD prognosis. Inconclusive evidence regarding CHD and job (in)security, job satisfaction, working hours, effort reward imbalance and job loss is inconclusive. Social isolation after MI associated with adverse prognosis. Acute emotional stress may trigger MI or takotsubo ( stress ) cardiomyopathy, but absolute increase in transient risk from an individual stressor is low. Psychosocial stressors have an impact on CHD, but clinical significance and prevention require further study

9 NHMRC levels of evidence 1 NHMRC evidence hierarchy: designation of levels of evidence Level Intervention I A systematic review of level II studies II A randomised controlled trial III-1 A pseudorandomised controlled trial (i.e. alternate allocation or some other method) III-2 III-3 IV A comparative study with concurrent controls: non-randomised, experimental trial cohort study case-control study interrupted time series with a control group A comparative study without concurrent controls: historical control study two or more single arm study interrupted time series without a parallel control group Case series with either post-test or pre-test/post-test outcomes Grade of recommendation A Description Body of evidence can be trusted to guide practice B C Reference 1. National Health and Medical Research Council (NHMRC). Accessed December application D Body of evidence can be trusted to guide practice in most situations Body of evidence provides some support for recommendation(s) but care should be taken in its Body of evidence is weak and recommendation must be applied with caution

10 National Heart Foundation of Australia evidence statements regarding psychosocial stressors and CHD 1,2 Reference 1. National Health and Medical Research Council (NHMRC). Accessed December Glozier N, et al. Med J Aust 2013; 199 (3): Chronic stressors Risk factors for onset of CHD (aetiology) Grade of evidence* Level of evidence 1. High job strain increases the risk of CHD C I 2. Shift work increases the risk of CHD C I 3. There is limited evidence that social isolation is a risk factor for CHD Outcome of CHD (prognosis) *Clinical impact is unclear Using NHMRC aetiology hierarchy Using NHMRC prognostic hierarchy 1 1. There is limited evidence that high job strain increases the risk of a poor CHD prognosis D I D II 2. Social isolation increases the risk of a poor CHD prognosis B I

11 National Heart Foundation of Australia evidence statements regarding psychosocial stressors and CHD 1,2 Acute stressors Grade of evidence Level of evidence 1. Myocardial infarction can be precipitated by negative emotional states B III-3* 2. CHD events can be precipitated by bereavement B II* 3. There is no consistent evidence that involuntary job loss causes CHD D II* 4. Takotsubo cardiomyopathy can be precipitated by acute emotional stress 5. Acute population stressors (such as earthquakes, missile attacks, and stressful sporting events) may transiently increase cardiovascular events *Using NHMRC aetiology hierarchy Recommendation 1. Wider public access to defibrillators should be available where large populations gather, such as sporting venues, airports, and as part of the response to natural and unnatural disasters C C Grade of recommendation B III-3* III-2* Level of evidence III-2*

12 Cardiac blues: Have you watched the excellent webinar? Heightened emotions (inc anxiety) at time of cardiac event Traumatic event Normal coping mechanism, like a grief response Often resolves with time and reassurance, often by 2-3 months Cardiac blues & depression can appear the same

13 lth.org.au/

14

15

16

17 Clinical depression at is Depression What is Depression More than sadness or a low mood 5% prevalence in the general community (non cardiac pop) One in five experience depression during their lifetime persistent sadness loss of interest in enjoyable activities plus inability to carry out daily activities at least two weeks.

18 What s the difference? Cardiac Blues Depression Time period Transient Persistent Trajectory Improving Worsening Red flags Absent Present Incidence 75% 20% Prognosis Good Poor

19 Loss of energy What is Depression Change in appetite Sleeping (increase or decrease) Anxiety Reduced concentration Indecisiveness Restlessness Common Signs and Symptoms Symptoms Feelings of worthlessness Guilt or hopelessness Thoughts of self-harm or suicide.

20 The National Heart Foundation Consensus Statement: guidelines for screening, referral and treatment for depression in patients with coronary heart disease (2013) Screening for depression in cardiac patients is likely to produce a higher yield owning to the higher prevalence of depression in cardiac patients A number of self-report screening tools exist for detecting depression. The Patient Health Questionnaire (PHQ-9; PHQ-2) and the Cardiac Depression Scale have been validated in Australian samples The PHQ-2 is recommended by the AHA for initial depression screening. The NHF recommend that the PHQ-2 or Short CDS (5 items) be incorporated into routine screening of patients for all patients on first presentation and again on subsequent visits.

21 Screening for Depression Screening Routine screening in all CHD patients recommended when patient first presents, and at the follow up appointment. Follow-up screen at 2 3 months after CHD event. Consider ongoing screening yearly Screening, referral and treatment for depression in patients with coronary heart disease consensus statement, 2013 Red flags for depression: PMH depression (>4x more likely) Socially isolated Smoker Younger (<55yrs) Diabetes Financial strain, other bereavement etc

22 PHQ - 2

23 g.au/images/uploads/publicati ons/depression-screeningsupport-tool.pdf

24 Treatment Responds similarly to standard treatments as in general pop: Cognitive Behaviour Therapy (CBT) Interpersonal Psychotherapy (IPT) Collaborative care Exercise Drug therapies antidepressants Selective serotonin re-uptake inhibitors (SSRIs) well tolerated Tricyclic antidepressants may worsen CHD outcomes and should be avoided in patients with CHD. 7

25 Exercise Cochrane Review: exercise as a treatment for depression concluded exercise improves depression with a similar efficacy to CBT. 2 Dose response benefit need >30mins mod aerobic activity x 5 days per week. 3. References 1. Colquhoun D, et al. Med J Aust 2013; 198 (9): Rimer J, et al. Cochrane Database Syst Rev 2012; (7):CD Dunn AL, et al. Am J Prev Med 2005; 28:1 8.

26 Helpful Tips Avoid isolation stay connected Accept help and support Talk to someone with heart disease to share experiences Join a local Cardiac Rehabilitation Program Physical activity Healthy diet Sleep 8 hours each night Attend GP appointments Take medication as prescribed Allow time to relax

27 More helpful tips! Relaxation response, importance of down time Use the breath to lower the heart rate & BP (Yoga, meditation ) Mindfulness (stop to smell the roses!) Visualisation (calm scenes) Useful Apps Release positive endorphins Laughter Exercise Social support, connectiveness

28

29 Handy?

30 Heart Foundation: Further Health Professional Resources Information Heart Foundation: Patient Information fter-my-heart-attack/heart-attackrecovery/managing-your-emotionaland-social-life Beyondblue

31

32

33

34

35

36 Act, Belong, Commit

37 Their GP Other useful resources non-acute Mental Health Assessment pathway lists services: some need GP referral, most Medicare subsidised, some free (Health care card). Chronic Disease Support Services pathway includes WAPHA s Integrated Chronic Disease Care (ICDC) program, care coordinators link to other WAPHA funded mental health services. GP referral and care plan required Eligibility requirements, differ between regions. Suicide Prevention Coordinator in each region. details on attachment

38 Rural Link after-hours service clients call with on-referral to local mental health services if required Mental Health Commission User friendly websites with 24/7 support lines

39 Useful Apps Headspace Smiling Mind

40 In summary Mental health is a significant issue and can underpin a patient s recovery (and risk for heart disease in the first place) Many benefits of CR and physical activity for +ve mental health Health professionals can assist and every step forward helps Screening tools and effective treatments available Several resources to refer patients to

41 Case studies Sue 59yrs MI 4 weeks ago Attending physio Very teary PMH post natal depression Bob 76yrs CABG 2 yrs ago At GP surgery Low mood, lack of interest in activities Questions for you Do you screen? Other challenges? Useful tips for colleagues? Other resources? Conversation starters?

42 Thank You