Behavioral Psychology of the Cardiac Patient: Freud Behind the Stethoscope. Disclosures. The Plan. I have no conflicts of interest to disclose.

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1 12 th Annual Oregon Cardiovascular Symposium June 7, 2015, Portland, Oregon Behavioral Psychology of the Cardiac Patient: Freud Behind the Stethoscope Adrienne H. Kovacs, PhD, CPsych Peter Munk Cardiac Centre, University Health Network Associate Professor, Dept of Psychiatry, Faculty of Medicine, University of Toronto Adjunct Scientist, SickKids Research Institute Disclosures I have no conflicts of interest to disclose. The Plan I. Psychological distress & heart disease II. Healthy behaviors & adherence III.How YOU can be psychologists and optimize the psychosocial well-being of your patients 1

2 Psychological Distress & Heart Disease Personomics People have different personalities, resilience, and resources that influence how they will adapt to illness, so that the same disease can alter one individual s personal and family life completely and not affect that of another person at all. Ziegelstein, JAMA Intern Med,

3 Coronary Artery Disease & Depression What percentage of post-mi patients experience major depression? 1) < 10% 2) 10 15% 3) 15 20% 4) > 20% Coronary Artery Disease & Depression What increase in cardiac mortality is associated with depression among CAD or post-mi patients? 1) No increase 2) 1.5 fold increase 3) fold increase 4) fold increase Barth et al, Psychosom Med, 2004; Van Melle et al, Psychosom Med, 2004; Meijer et al, Gen Hosp Psychiatry, 2011 Effect of Potentially Modifiable Risk Factors: INTERHEART Included psychosocial factors in study of primary risk factors for MI worldwide in both men and women Adults from 52 countries Compared 15,152 cases with 14,820 controls Yusuf S, et al. Lancet,

4 Effect of Potentially Modifiable Risk Factors: INTERHEART Where do psychosocial factors fit in? Raised lipids 3.25 Current Smoking 2.87 Hx of diabetes 2.37 Hx of hypertension 1.91 Abdominal obesity 1.12/1.62 Regular alcohol 0.91 Regular physical activity 0.86 Daily fruits/vegetables Yusuf S, et al. Lancet, 2004 What about Anxiety? Higher perceived stress has been associated with an increased risk of incident CAD Results of a 2010 meta-analysis linked post-mi anxiety with a 36% increase in adverse cardiac events Symptoms of anxiety and depression often coexist in patients with CAD or heart failure Richardson et al, Am J Card, 2012; Roest, Psychosom Med, 2010; Dekker et al, Eur J Cardiovasc Nurs, 2014 Rozanski, JACC,

5 36 studies What is the prevalence of depression in adults with heart failure? Clinically significant depression present: 22% Varied by the use of questionnaires (34%) vs. diagnostic interviews (19%) Varied by NYHA Class I (11%) vs. Class IV (42%) Women (33%) had higher prevalence than men (26%) What is the magnitude of the relationship between depression and clinical outcomes in adults with heart failure? Higher rates of death and secondary events (risk ratio: 2.1) Trends toward increased health care use, higher rates of hospitalization and emergency room visits Is there evidence for treatment effectiveness in reducing depression in adults with heart failure? 6 treatment studies were identified Methodological limitations: small sample sizes, brief treatment duration, lack of comparison group Results suggestive of depressive symptom reductions 5

6 Depression & Heart Failure Survival Prospective 12-year observational study of 985 adults with heart failure Patients aged >18 years; mean = 69 years Compared outcomes for patients with Beck Depression Inventory (BDI) scores > 10 vs. those with lower scores during index HF hospitalization Across follow-up, 80% of patients with elevated BDI scores died vs. 73% of those without Adams, Psychosomatics, 2012 Depression & Heart Failure Survival Adams, Psychosomatics, 2012 Depression & Heart Failure Survival Adams, Psychosomatics,

7 ICDs & Quality of Life Compared to patients on anti-arrhythmic medications, how does the quality of life of ICD recipients compare? 1) Worse 2) Better 3) Equal/depends upon many factors ICDs & Psych Distress ADULTS WITH ICDs 11 28% have depressive disorders 11 26% have anxiety disorders Depression is associated with shock occurrence Fear is an understandable and reasonable reaction THE GOAL? Help patients manage this fear and live as rich and full a life as possible Magyar-Russell et al, J Psychom Res, 2011; Whang et al, JACC, 2005; Carroll et al, Cdn J Cardiol, 2012 Adult Congenital Heart Disease Canada & US 28% -35% meet diagnostic criteria for psychiatric diagnosis Prevalence of mood disorders is 3 times that observed in the general population 0 31% adults with CHD with psychiatric disorders receive mental health treatment Horner et al, May Clin Proc, 2000; Bromberg et al, Heart Lung, 2003; Kovacs et al, Int J Cardiol,

8 Why? How? MEDICAL FACTORS Diagnosis Treatment Illness Behavioural Mechanisms Adherence Diet Physical activity Tobacco/alcohol use Sleep Physiological Mechanisms Blood pressure responses Electrical instability Elevated platelet activity Increased inflammation HPA axis dysfunction Decreased heart rate variability Endothelial dysfunction PSYCHOLOGICAL FACTORS Depression Anxiety Depression in cardiac disease is common, persistent, under-recognized, and deadly. Does this mean we should screen for depression in cardiology clinics? Yes No I don t know Huffman et al, Cardiovasc Psychiatry & Neurology, 2013 Screening for Depression? Lichtman et al, Circulation,

9 AHA Screening Guidelines Patient Health Questionnaire (2 items) Over the past 2 weeks, how often have you been bothered by any of the following problems: 1) Little interest or pleasure in doing things 2) Feeling down, depressed. or hopeless Based on answers, refer for more comprehensive clinical evaluation by a professional qualified in the diagnosis and management of depression or screen with PHQ-9 AHA Screening Guidelines For patients with mild symptoms, follow up during a subsequent visit is advised. In patients with high depression scores, a physician or nurse should review their answers with the patient. Patients with screening scores that indicate a high probability of depression should be referred for a more comprehensive clinical evaluation. AHA Screening Guidelines Although there is currently no direct evidence that screening for depression leads to improved outcomes in cardiovascular populations, depression has been linked with increased mortality, poorer risk-factor modification, lower rates of cardiac rehabilitation, and reduced quality of life. Lichtman et al, Circulation,

10 Systematic Review re. Screening Depression treatment with medication or CBT in patients with CV disease is associated with modest improvement in depressive symptoms but not improvement in cardiac outcomes. No clinical trials have assessed whether screening for depression improves depressive symptoms or cardiac outcomes Thombs et al, JAMA, 2008 Updated Systematic Review How do depression screening measures perform? Challenges exist with sensitivity and specificity in screening tools Do RCTs show that depression treatments work? Modest symptom reductions Do RCTs show that depression screening works? No eligible RCTs Thomsbs et al, PloS ONE, 2013 Trial of Routine Screening Screened 217 patients across 2-month period 26% had elevated depressive symptoms (of whom 50% perceived little or no need for help) 42% had elevated anxiety symptoms (of whom 65% reported little or no need for help) Screening also would have serious consequences in terms of the number of referrals and treatment capacity. Luttik et al, Eur J Cardiovasc Nurs,

11 Screening Recommendations United States Preventative Services Task Force. Screening for Depression: Recommendations and Rationale recommended that screening for depression occur in clinical practices with: 1) Accurate measures 2) Appropriate resources and mechanisms to provide feedback of results 3) Appropriate resources for treatment Ann Intern Med, 2002 Pitfalls to Screening Unknown acceptability of screening to stakeholders Cost effectiveness is unknown Positive screening might increase distress False positives False negatives Patients might better be served by improving the care of individuals already identified as depressed. Palmer & Coyne, J Psychsom Res, 2003 When to Screen.. You have buy-in from stakeholders You have a strong screening measure (depression only?) You have the resources (time, personnel) to administer surveys and to interpret surveys You have mental health professionals to whom to refer patients with elevated distress and who are interested in treatment 11

12 Healthy Behaviors & Adherence Audience Question Do you do all of the following? Exercise most days of the week Eat a healthy diet Sleep 7-8 hours per night and have a consistent sleep routine (bedtime and waking time) Follow the recommended guidelines for medical and dental check-ups (and screening) Effectively manage stress at home and work Avoid excessive alcohol use Avoid tobacco Take all medications as prescribed Show of hands not needed! Sometimes a cigar is just a cigar But it s still unhealthy! Sigmund Freud 12

13 Canadian Diabetes Association 2013 Clinical Practice Guidelines Achievement of each of these aims requires patient adherence Compliance Adherence COMPLIANCE Patient follows provider s recommendations Patient is passive recipient of medical information ADHERENCE Patient performs recommended and agreedupon health behaviour Patient is given more active and collaborative role in health care Places responsibility on clinician to foster therapeutic alliance Meta-analysis: Adherence Rates DiMatteo et al, Medical Care,

14 What Impacts Adherence? MEDICATION FACTORS Complexity Inconvenience Side effects Cost CLINICAL ALLIANCE Communication, trust ILLNESS FACTORS Degree to which it is lifethreatening Duration Illness symptoms Impact of illness on vision, energy, mobility, cognitive functioning Clinic environment What Impacts Adherence? PATIENT FACTORS Potential barriers: language, cognitive functioning Resources: transportation, finances, family support Perceptions of the health behaviour: effectiveness of behaviour, adherence self-efficacy, negative reminder of health problem Psychosocial factors: depression, anxiety, life stressors, substance use Depression & Adherence Meta-analysis of 47 independent samples Depression is significantly associated with nonadherence with diabetes regimen Effect sizes greatest for (i) missing medical appointments, and (ii) composite measures of self-care (medication, diet, exercise, glucose monitoring, foot care, clinic attendance) A collaborative care approach has been associated with lower depression and higher adherence Gonzalez et al, Diabetes Care, 2008 Huang et al, MBC Psychiatry,

15 Cognitive Impairment CHALLENGES Memory Attention Processing speed Concentration Judgment Usual tasks Personality change ASSOCIATED FACTORS Advancing age Medications Nutritional deficiencies Dehydration/fluid shifts Infection Depression Heart failure Riegel et al, Am J CritCare, 2002 Cognitive Impairment & Heart Failure Adults with heart failure Approximately one-third to one-half of adults with heart failure experience cognitive impairment Most common symptoms: Memory impairment Concentration difficulties Likely reflects hypoperfusion Bauer et al, J Am Acad Nurs Pract, 2011 Cognitive Impairment & Heart Failure Reduced ability to: Attend to and understand patient education (verbal instructions and written materials) Manage complex treatment regimens (eg, medications, fluid restrictions, appointments) Assess and self-manage symptoms Readmissions often due to patient difficulty following complex treatment regimens & recognizing worsening symptoms Bauer et al, J Am Acad Nurs Pract,

16 How YOU can be Psychologists 16

17 Self-Management Behaviours to encourage in providers: Positive verbal reinforcement for small changes Work with patient to prioritize goals/changes Motivational interviewing: Consider level of readiness for change Discuss pros and cons of changing and not changing behaviours Acknowledge ambivalence Facilitate problem-solving Help Patients Set SMART Goals Specific Less Helpful I want to be healthier More Helpful I want to begin an exercise program Measurable I want to feel better I want to lose 20 pounds Achievable Relevant Time-bound I want to lose 20 lbs in the next month My doctors says I need to change I will quit smoking I want to lose 20 lbs in the next year I want to have more energy to enjoy time with my grandchildren I will quite smoking on October 1st Communica on to Adherence Initial discussion: Tailored patient education Specific, consistent instructions provided verbally and in written format Discuss readiness to begin treatment/behaviour Direct discussion of patient beliefs about medication/behaviour (eg, side effects, pros and cons) 17

18 During this visit, we ve talked about the importance of physical activity. It sounds like you are really committed to this goal. Shall I make a note of this goal in the chart so that we remember to follow-up on it during the next visit? Communica on to Adherence Follow-up discussions: Direct inquiry into adherence Non-threatening questioning Address patient (and family) concerns about medication/behaviour, side effects, options Assist with problem-solving barriers to adherence Some people find it challenging to take their medication every day as prescribed. How often do you nottake your medications? In what situations are you least likely to take your medications? Most likely? 18

19 Facilitate Communication Encourage patients to ask questions: Write a list of questions ahead of time Keep an ongoing list of questions (daytimer, phone) Take the list and a pen to clinic appointments (with space to write down the answers) Consider taking a family member or friend as official note-taker Prioritize questions Facilitate Communication Encourage open communication: Ask patients to be prepared to describe their symptoms Explain that the more information patients give their health providers (even about sensitive and risky behaviours), the better guidance you can provide to them Facilitate Communication Help patients become active listeners: Ask patients to repeat an understanding of what was said in their own words This reduces the chance of misunderstanding (and helps to avoid mind-reading) Ask patients to communicate when they agree and also when they disagree with recommendations 19

20 Some final communication tips INSTEAD OF Do you have any questions or concerns? TRY What are you questions and concerns? INSTEAD OF Do you understand the information I m giving you? TRY Am I explaining this clearly? Promote Physical Activity Physical activity & mood: Meta-analysis of 30 studies of impact of exercise on clinically-depressed individuals: mean effect size of (not moderated by exercise duration, intensity, frequency, type) Meta-analysis of 14 RCTs: mean effect size of Benefits of physical activity equivalent to other forms of mental health treatment Craft et al, J Sport Exer Psychol, 1998 Lawlor et al, BMJ, 2001 Promote Physical Activity How do we encourage depressed or anxious (or stressed out ) patients to exercise? Emphasize mental health benefits Reduce focus on exercise frequency, duration, intensity Promote choice in type of physical activity Provide closer follow-up, verbal reinforcement 20

21 Meta-Analysis: Mental Health Treatment & Cardiac Rehab Outcomes: Reducing secondary cardiac events and/or improving depression Mental health treatments: showed a medium effect size for reducing depression & showed moderate efficacy for reducing cardiac events, but did not reduce mortality Cardiac rehabilitation: had similar impact on depression and cardiac events, but was also associated with reduced cardiac mortality Rutledge et al, Psychosom Med, 2013 Focus on Quality of Life Questions to ask patients: How has your (quality of) life changed since developing heart disease? What things are most important in your life that we should consider when talking about your health and treatment options Liaise with mental health professionals: Develop strong referral links Conclusions As a group, approximately 1 in 4 adults with heart disease will face the additional challenge of clinically significant depression or anxiety Screening for depression is likely an inefficient use of resources Two simple strategies to optimize the psychosocial well-being of your patients: GET TALKING AND GET MOVING! 21

22 Adrienne Clarkson, Former Canadian Governor General I have a tricky heart. I believe now that the important thing in life is not knowing how many heartbeats you are going to live, but deciding how best to live in between those heartbeats. Heart Matters, th Annual Oregon Cardiovascular Symposium June 7, 2015, Portland, Oregon Behavioral Psychology of the Cardiac Patient: Freud Behind the Stethoscope Thank you. Questions? Comments? 22