The use of the implantable cardioverter-defibrillator (ICD) for life threatening ventricular

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1 488 * Eletrophysiology QUALITY OF LIFE AND PSYCHOLOGICAL FUNCTIONING OF ICD PATIENTS QUALITY Correspondene to: Samuel F Sears Jr, PhD, University of Florida, Department of Clinial & Health Psyhology, Box UF Health Siene Center, Gainesville, FL 32610, USA; ssears@hp.ufl.edu Samuel F Sears Jr, Jamie B Conti The use of the implantable ardioverter-defibrillator (ICD) for life threatening ventriular arrhythmias is standard therapy, in large part beause linial trials data have onsistently demonstrated its superiority over medial treatment in preventing sudden ardia death. 1 This suess prompts loser examination and refinement of quality of life (QOL) outomes in ICD patients. Although no universal definition of QOL exists, most researhers agree that quality of life is a generi term for a multi-dimensional health outome in whih biologial, psyhologial, and soial funtioning are interdependent. 2 To date, the linial trials demonstrating the effiay of the ICD have foused primarily on mortality differenes between the ICD and medial treatment. While the majority of the QOL data from these trials is yet to be published, many small studies are available for review and support the onept that ICD implantation results in desirable QOL for most ICD reipients. 3 In some patients, however, these benefits may be attenuated by symptoms of anxiety and depression when a shok is neessary to aomplish ardioversion or defibrillation. This paper reviews the published literature on QOL and psyhologial funtioning of ICD patients and outlines the linial and researh impliations of these findings. OF LIFE AND THE ICD: PATIENT REPORTS Heart 2002;87: Definitive onlusions about QOL differenes between patients managed with an ICD and those treated with antiarrhythmi drugs are diffiult to make in the absene of large, randomised, ontrolled trials. Available evidene indiates that ICD reipients experiene a brief deline in QOL from baseline but improve to pre-implant levels after one year of follow up. 4 The largest linial trial data published in final form is from the oronary artery bypass graft (CABG) Path trial whih randomised patients to ICD (n = 262) versus no ICD (n = 228) while undergoing CABG surgery. 5 In ontrast to May and olleagues, 4 data from this trial indiate that the QOL outomes (mental and physial) for the ICD patients were signifiantly worse ompared to patients with no ICD. Subanalyses revealed that there was no differene in QOL for non-shoked ICD patients versus no ICD patients. These results indiated that the ICD group who had reeived shoks was responsible for the signifiantly worse mental and physial QOL outome sores between the groups. Colletively, these data suggest that the experiene of shok may ontribute to psyhologial distress and diminished QOL. Figure 1 details the psyhologial ontinuum a patient may experiene seondary to shok. Other investigators have examined patients with ICDs and ompared them to patients with permanent paemakers. Very few onsistent differenes an be demonstrated between these two populations. For example, Duru and olleagues 6 found no differenes in QOL sore, anxiety or depression when omparing ICD patients with and without shok experiene and paemaker patients. ICD patients with a shok history were more likely to report limitations in leisure ativities and anxiety about the ICD, but they also viewed the ICD as a life extender. Herbst and olleagues 7 reently ompared the QOL and psyhologial distress of four patient groups: ICD only (n = 24) v ICD plus antiarrhythmi drug (n = 25) v antiarrhythmi drug only (n = 35) v a general ardia sample (n = 73). QOL was assessed using the short form 36 (SF-36) and three supplementary sales examining sleep, marital and family funtioning, and sexual problems. Comparisons were made between ICD groups and drug groups. Results indiated that there were no signifiant differenes on the 11 QOL sales, even after ontrolling for age, sex, disease severity, and duration of treatment. However, signifiant differenes were found in drug groups versus no drug groups, suh that the drug treated group onsistently reported greater impairment in physial funtioning, vitality, emotional, and sleep funtioning, as well as psyhologial distress. Colletively, these results suggest that QOL is maintained in ICD treated groups, while antiarrhythmi drug treatment is assoiated with diminished QOL and inreased psyhologial distress. In ontrast, others have ompared ICD patients to either antiarrhythmi drug treated patients or a ardia referene group and have not found signifiant differenes between these treated groups. For example, Arteaga and Windle 8 ompared three groups: ICD (n = 45), mediation (n = 30), and referene group (n = 29) on QOL and psyhologial distress. No signifiant differenes were Heart: first published as /heart on 1 May Downloaded from on 9 May 2018 by guest. Proteted by opyright.

2 No shoks Normalised fear "The ICD keeps me safe during exertion" Shok phobias (eg. exertion) "The ICD is my reason for not exerting" Shok ontinuum Cumulative shoks Anxiety spetrum Thoughts and behaviours Generalised anxiety "There is very little that I am safe to do with my ICD" observed on measures of QOL and psyhologial distress between the treated groups, although psyhologial distress was assoiated with lower QOL for all groups. Younger patients and patients with greater ardia dysfuntion reported redued QOL. Similarly, Carroll and olleagues 9 ompared ardia arrest survivors who reeived either an ICD or mediations and found no signifiant differenes in QOL. Herrmann and assoiates 10 also ompared QOL between a group of ICD and general oronary artery disease (CAD) patients and found no signifiant differenes on measures of QOL. Moreover, ICD patients reported signifiantly lower levels of anxiety than the CAD referene group. A US national survey of ICD patients and spouses (NSIRSO) parts 1 and 2 11 examined global QOL and psyhosoial issues in 450 patients. Approximately 91% of ICD reipients reported desirable QOL, either better (45%) or the same (46%) following implantation. However, a small group of ICD reipients (approximately 15%) reported signifiant diffiulty in emotional adjustment. Younger patients (50 years of age and under) reported better general health, but worse QOL and emotional funtioning than eah of the other age groups studied. ICD shok history did not have a signifiant effet on any of the global outome ratings. The spouses and partners of these reipients (n = 380) provided onvergent validity of the reipients reports; no signifiant differenes were found between raters on the 10 most ommon onerns. Of note, frequent ICD shoks, younger age, and being female were assoiated with inreased adjustment diffiulty. The results of these two surveys suggest that ICD reipients derive signifiant health related QOL benefits from ICD therapy, although some (approximately 10 20%) experiene diffiulty. This perentage is onsistent with the expeted rates of distress in omparable medial populations. RETURN TO WORK AS A QOL PROXY An objetive index of QOL is the ability to return to work. ICD reipients have favourable return to work rates in urrently available studies. The largest suh study (n = 101) indiated that 62% of patients had resumed employment. 12 Those who returned to work were more eduated and less likely to have a history of myoardial infartion. No signifiant differenes were found between those who returned to work and those who did not on measures of age, sex, rae, funtional lass, ICD storms PTSD "The ICD does not keep me safe" Figure 1 Continuum of implantable ardioverter-defibrillator (ICD) shok response. PTSD, post-traumati stress disorder. ejetion fration, extent of CAD, reason for ICD, or onomitant surgery. Similar results were obtained from a sample of young ICD patients in whih 10 of the 18 were gainfully employed; eight of those had returned to the same job that they held before implantation. 13 These results suggest that the majority of ICD patients who wish to return to work are apable of doing so. INCIDENCE AND IMPACT OF PSYCHOLOGICAL ISSUES The typial ICD reipient must overome both the stress of experiening a life threatening arrhythmia and the hallenge of adjusting to the ICD. Anxiety is partiularly ommon, with approximately 24 87% of ICD reipients experiening inreased symptoms of anxiety after implantation and diagnosti rates for linially signifiant anxiety disorders ranging from 13 38%. 3 The ourrene of ICD shoks is generally faulted for this psyhologial distress, but its ausal influene is onfounded by the presene of a life threatening medial ondition. Depressive symptoms reported in 24 33% of ICD patients are onsistent with other ardia populations. 3 ICD related fears are universal and may be the most pervasive psyhosoial adjustment hallenge ICD patients fae. Psyhologial theory suggests that symptoms of fear and anxiety an result from a lassial onditioning paradigm in whih ertain stimuli or behaviours are oinidentally paired with an ICD shok and are thereby avoided in the future. Beause of fear of present and/or future disharges, some patients inreasingly limit their range of ativities and inadvertently diminish the benefits of the ICD in terms of QOL. Pauli and olleagues 14 examined the anxiety sores of ICD patients and found that anxiety was not related to ICD disharges but was highly related to a set of atastrophi ognitions. Patients with high anxiety sores tended to interpret bodily symptoms as signs of danger and believed that they had heightened risk of sudden death. In addition, atastrophi ognitions were assoiated with anxiety sores onsistent with the sores of pani disorder patients and different from the sores of the healthy volunteer sample. These results suggest that psyhosoial interventions that utilise ognitive behavioural protools will likely prevent and/or redue anxiety problems regardless of shok exposure by hanging atastrophi thinking and over-interpretation of bodily signs and symptoms. Figure 2 *489 Heart: first published as /heart on 1 May Downloaded from on 9 May 2018 by guest. Proteted by opyright.

3 490 * Shoks Pain Castastrophi thinking Avoidane behaviour Family fear Figure 2 Hypothesised interrelationship between shoks, psyhologial distress, and quality of life (QOL). Fear/anxiety QOL and funtion illustrates a hypothesised interrelationship between shoks, psyhologial distress, and QOL based on the available researh. Unertainty related to illness has been demonstrated to be important and related to QOL and psyhologial funtioning in ICD patients. 9 The unertainty of life with a potentially life threatening arrhythmia and an ICD may lead patients to resort to a sikness soreboard mentality, by whih they view the frequeny of ICD shoks as indiative of how healthy they are and as preditive of their future health. 3 In general, outomes based on the frequeny of shoks alone are not a valid indiator of health. ICD shoks an be triggered by both ventriular arrhythmias, for whih the devie was implanted, and supraventriular arrhythmias, whih it was not meant to treat. Shoks for either arrhythmia feel the same to the patient but do not neessarily indiate a deline in health. EFFECT OF SHOCK ON QOL Credner and her olleagues defined an ICD storm as > 3 shoks in a 24 hour period. She found that approximately 10% of their sample of 136 ICD patients experiened an ICD storm during the first two years following ICD implantation. 15 Moreover, the mean (SD) number of shoks for this group of storm patients was 17 (17) (range 3 50; median 8). The experiene of an ICD storm may prompt atastrophi ognitions and feelings of helplessness. These adverse psyhologial reations have been linked in initial researh as prospetive preditors for the ourrene of subsequent arrhythmias and shoks at one, three, six, and nine month intervals, leading the researhers to onlude that negative emotions were the ause, rather than a onsequene, of arrhythmia events. 16 Although additional researh fousing on a wide range of potentially identifiable triggers of arrhythmias is needed, this initial researh indiates that reduing negative emotions and psyhologial distress may also derease the hanes of reeiving a shok. The literature defines speifi risk fators for poor QOL and psyhosoial outomes for ICD patients that inlude, but extend beyond, simple shok experiene. ICD patients who are younger defined in the literature as < 50 years of age have inreased psyhologial distress. 17 ICD patients who do not understand their devie and their ondition often experiene diffiulties making lifestyle adjustments. Similarly, ICD patients that have the additional stressors suh as loss of job or loss of role funtioning often experiene psyhosoial diffiulties that warrant additional professional attention and referral. Table 1 details additional suspeted risk fators from the general ardia literature that an serve as markers for psyhosoial attention. Table 1 Additional suspeted risk fators that an serve as markers for psyhosoial attention in patients with ICDs ICD speifi Young ICD reipient (age <50 years) High rate of devie disharges Poor knowledge of ardia ondition or ICD General ardia Signifiant history of psyhologial problems Poor soial support Inreased medial severity or omorbidity CLINICAL AND RESEARCH IMPLICATIONS RELATED TO QOL Psyhosoial and QOL interventions for ICD patients Table 2 details eah of the studies available that used psyhosoial intervention for ICD patients. General methodologial problems are onsistent aross studies. Firstly, the studies report on very limited sample sizes and inur a resulting low statistial power. Seondly, most of the studies were onduted using a support group format, whih typially involves a partiipant led, unstrutured approah rather than a professional led, strutured approah. Although the partiipant led approah has some merit, suh as a high level of involvement for some members, this approah often does not involve suffiient fatual and objetive information to produe measurable hange. Instead, this approah tends to fous predominantly on the emotional aspets of the illness. In ontrast, professional led groups tend to fous more on strategy and skill building rather than simply the expression of emotion. Taken together, the methodologi flaws of most of these interventions limit their utility in gauging the potential of professional led, strutured ognitive behavioural psyhosoial intervention. Support groups are a popular adjuntive treatment for ICD patients beause they provide an effiient onduit for patient eduation spanning the biopsyhosoial domains. 2 The ative ingredients of support groups probably entre on the universality of many patient onerns and the sharing of information and strategies to deal effetively with these onerns. We suggest that support groups are a valuable but not neessarily suffiient means of providing psyhosoial are for all ICD patients. Some patients will need more individualised, tailored ognitive behavioural or pharmaologial interventions to address more ompletely their psyhosoial needs. As noted above, professional led groups are preferable beause a systemati presentation of information via seleted expert speakers and a broad based urriulum ould be designed for maximal benefit for the majority of partiipants. Certainly patient stories or testimonials an also play a regular role, but that is a proess that an our both formally and informally during the meetings among group members. The majority of the groups are maintained by ICD health professionals with a strong ommitment to psyhosoial are. There is no formula on how to struture support groups for maximal effetiveness, but they remain important in the are of ICD patients as one of a set of strategies to improve the psyhosoial are of ICD patients. The most signifiant study of psyhosoial interventions for ICD patients involved a randomised ontrolled methodology to redue psyhologial distress. 18 Individual ognitive behavioural therapy was used to redue psyhologial distress in newly implanted ICD patients to determine if suh Heart: first published as /heart on 1 May Downloaded from on 9 May 2018 by guest. Proteted by opyright.

4 Table 2 Psyhosoial intervention studies with ICD reipients Study n Duration of treatment Summary of results and ritique of findings Badger and Morris (1989) Molhany and Peterson (1994) Sneed et al (1997) non-strutured support group sessions treatment would also redue arrhythmi events requiring shoks for termination. These investigators randomised 49 ICD patients to ative treatment versus no treatment. The treatment onsisted of an individual therapy session at pre-implant, pre-disharge from the hospital, onseutive weeks for four weeks, and then sessions at routine ardia lini appointments at one, three, and five months postimplantation. They found that ative treatment patients reported less depression, less anxiety, and less general psyhologial distress than the no treatment group at nine month follow up evaluations. These results suggest that more systemati interventions for new ICD patients would likely produe optimal psyhologial and QOL outomes. Although this study did not inlude information about the ost effetiveness of the intervention, it is reasonable to assume Purpose: support group intervention v no treatment ontrol group. Results: no signifiant between group differenes. Trends were reported towards improvement in the treatment group 11 Not speified Purpose: support group intervention v no treatment ontrol group. Results: no signifiant between group differenes. Qualitative analyses demonstrated improved ability to ope and inreased satisfation with life in group partiipants 2 inpatient individual sessions, 2 support group sessions, and 12 telephone ontats over a 16 week period. Kohn et al (2000) 49 9 sessions (pre-implant, pre-disharge, 7 routine follow up visits) Table 3 Purpose: support group intervention v no treatment ontrol group. Results: no signifiant between group differenes at 4 month follow up. Results indiated that tension/anxiety redued for both groups Purpose: ompared individual ognitive behavioural treatment to usual are. Results: individual treatment group reported less depression, less anxiety, less general distress, (p<0.05), despite reeiving a higher level of shoks (p<0.07) Poket guide to key interview questions for the psyhosoial are of ICD patients Very small number of patients were studied. No systemati treatment protool was delivered. This was a patient led methodology Very small number of patients were studied. No known systemati treatment protool was delivered. Duration of treatment is unknown but may not have been suffiient to detet differenes Small number of patients were studied. Systemati treatment protool was delivered but group format was patient led. Longer duration of treatment was a signifiant improvement in methodology but the ontent of the follow up phone ontats was not well speified Suffiient sample size. Most omprehensive and well doumented treatment protool study available. Effets were robust enough to detet differenes. Used an expensive and time intensive, individual therapy protool that psyhologial intervention delivered in this manner would likely be at least ost-neutral if it prevented more expensive hospitalisations, additional mediations, and unneessary aessing of are. Future researh on psyhosoial interventions should provide further information about the osts of their interventions for loser ost effetiveness analysis. Cliniian readiness for psyhosoial interventions The realisti probability of pratising ardiologists and nurses having the time or skills neessary to provide suh extensive psyhosoial interventions is small. We surveyed physiians and nurses (n = 261) to rate their views of speifi ICD patient outomes, ommon daily life problems for ICD patients, and their own omfort in managing these onerns. 19 The majority Key onept Sample interview question Interpretation Affetive funtioning depression Depressed mood question: during the past month, have you often been bothered by feeling down, hopeless, or depressed? Anhedonia question: during the past month, have you felt less interested in or gotten less pleasure from doing the things you typially enjoy? If either of these questions sreen positive, the presene of depression should be pursued via additional interview or referral to a mental health professional. If both of these questions are negative, the patient is unlikely to have major depression Anxiety Generalised anxiety: are you generally a nervous person? A positive response to general anxiety indiates a ondition that is unlikely to be responsive to lini based intervention by a Behavioural funtioning avoidane behaviour Cognitive funtioning attention and memory Speifi anxiety: do you have regular and ontinuous fears of ICD shoks? Avoidant behaviour: do you avoid doing anything simply beause of your fear of shoks? Attention and memory hange and pereived impat: have you notied any signifiant hanges in your attention or memory sine ICD implantation? Have these hanges presented any problems in your daily funtioning? ardiologist and should be referred. Speifi anxiety, however, is likely to be improved by a lini based disussion from a ardiologist. However, referral may still be neessary if eduation and reassurane related to the speifi ardia onerns are not suffiient Confirmed avoidane behaviour inreases the probability of a signifiant anxiety problem and warrants referral for additional work up by a mental health professional Cognitive hanges are a reognised part of signifiant ardia illness Neuropsyhologial evaluation is indiated if the hanges have presented any problems or onerns for the patient or family members *491 Heart: first published as /heart on 1 May Downloaded from on 9 May 2018 by guest. Proteted by opyright.

5 492 * of ICD patients experiene desirable QOL, emotional wellbeing, and family funtioning post-implantation, as viewed by health are providers. However, healthare providers reported that approximately 10 20% of ICD patients were signifiantly worse in these areas post-implantation. The most ommon problems for ICD reipients in daily life inluded driving restritions/limitations, oping with ICD shoks, and depression. Health are providers generally reported the most omfort handling traditional medial issues (that is, 92% of the sample reported omfort in managing patient adherene onerns), and the least omfort in managing emotional wellbeing issues (for example, only 39% of the sample reported omfort in managing depression and anxiety symptoms). These results are somewhat disonerting when we onsider that our previous work also showed that ICD patients were equally likely to seek disussion about emotional issues with health are providers (37%) as they were with family and friends (36%). 11 Our survey of health are providers also found that the majority believed that their ICD patients wanted more information to help them ope with or adjust to their ICD (91%) and that they believed that eduation as an intervention would be effetive (83%). Disomfort while addressing psyhosoial issues for ardiology pratitioners is not surprising and most likely reflets lak of training and experiene in behavioural mediine and psyhology. We have suggested the Four A s heklist to detet and manage psyhosoial issues in ICD linis: ask, advise, assist, and arrange referral The first step is to ask the patient about their ICD related onerns in an effort to define aurately their pereived problem. In table 3, we have provided sample diagnosti questions that an assist the liniian and yield suffiient diagnosti preision. 21 Seondly, the healthare provider an advise the ICD patient on the ommon hallenges that lie ahead and how to manage these onerns via supportive ommuniation. The healthare provider should take are to respet the oping style and adjustment diffiulties of eah patient. Thirdly, the provider an assist the patient by addressing the immediate onerns of the patient, normalising the most ommon hallenges, eduating the patient about their devie, and provide brief problem solving. Finally, the health are provider should arrange a onsultation for those reipients who would benefit from speaking with a mental health speialist. ICD reipients should be told that anxiety and depression are ommon and expeted side effets for many medial patients inluding ICD patients, and for that reason, attending to the psyhosoial aspets of adjustment is part of the overall treatment strategy. This rationale of a stress management based approah is broadly aeptable to most patients. CONCLUSIONS The ICD is the treatment of hoie for life threatening arrhythmias. The QOL data from these trials, whih foused primarily on mortality, now warrants equal srutiny. All available data suggest that the ICD will ahieve omparable if not better QOL than alternative treatments. Future researh must plae greater emphasis on ICD speifi and arrhythmia speifi measures that may be more sensitive to more hanges in outome. Measurement and interventions should fous on patient aeptane of the devie. Interdisiplinary studies that inlude ardiology, psyhology, nursing, and ardia rehabilitation speialists are needed to guide best linial pratie. The reputation of the ICD as a shok box is a signifiant soure of anxiety to potential patients. Today, third generation ICDs QOL and psyhologial funtioning of ICD patients: key points Inidene of psyhologial diagnosis anxiety 13 38% depression 34 43% Risk fators for maladjustment young age frequent shoks women Four A s ask advise assist arrange Multidisiplinary are team ardiologist nurse mental health professional rehabilitation are muh improved in their sensing and tiered therapy options to redue shoks and their resulting distress. Despite improvements in therapy suh as antitahyardia paing, ICD patients are likely always to need some attention to psyhologial adjustment. We suggest that routine onsideration of psyhosoial needs be integrated into the linial are of ICD patients worldwide. REFERENCES 1 Glikson M, Friedman PA. The implantable ardioverter defibrillator. Lanet 2001;357: This artile provides a thorough review of the details of devie funtioning and linial trial data for health are professionals. 2 Engel GE. The need for a new medial model: a hallenge for biomediine. Siene 1977;196: Sears SF, Todaro JF, Saia TL, et al. Examining the psyhosoial impat of implantable ardioverter defibrillators: a literature review. Clin Cardiol 1999;22: All psyhosoial literature is reviewed and interpreted inluding speifi psyhologial and behavioural theory posited about the development and manifestation of distress in ICD patients. 4 May CD, Smith PR, Murdok CJ, et al. The impat of the implantable ardioverter defibrillator on quality of life. Paing Clin Eletrophysiol 1995;18: Namerow PB, Firth BR, Heywood GM, et al. Quality of life six months after CABG surgery in patients randomized to ICD versus no ICD therapy: findings from the CABG Path trial. Paing Clin Eletrophysiol 1999;22: This randomised ontrolled trial data impliated the speifi role of ICD shok in the quality of life outomes of ICD patients. 6 Duru F, Buhi S, Klaghofer R, et al. How different from paemaker patients are reipients of implantable ardioverter-defibrillators with respet to psyhosoial adaptation, affetive disorders, and quality of life? Heart 2001;85: These authors were the first to use generi quality of life indies to ompare implantable devie patients on measures of quality of life and adaptation. 7 Herbst JH, Goodman M, Feldstein S, et al. Health related quality of life assessment of patients with life-threatening ventriular arrhythmias. Paing Clin Eletrophysiol 1999;22: Arteaga WJ, Windle JR. The quality of life of patients with life threatening arrhythmias. Arh Intern Med 1995;155: Carroll DL, Hamilton GA, MGovern BA. Changes in health status and quality of life and the impat of unertainty in patients who survive life-threatening arrhythmias. Heart Lung 1999;28: Herrmann C, von zur Muhen F, Shaumann A, et al. Standardized assessment of psyhologial well-being and quality-of-life in patients with implanted defibrillators. Paing Clin Eletrophysiol 1997;20: Sears SF, Eads A, Marhefka S, et al. The U.S. national survey of ICD reipients: examining the global and speifi aspets of quality of life [abstrat]. Eur Heart J 1999;20: Kalbfleish KR, Lehmann MH, Steinman RT, et al. Reemployment following implantation of the automati ardioverter defibrillator. Am J Cardiol 1989;64: Dubin AM, Batsford WP, Lewis RJ, et al. Quality of life in patients reeiving implantable ardioverter defibrillators at or before age 40. Paing Clin Eletrophysiol 1996;19: Heart: first published as /heart on 1 May Downloaded from on 9 May 2018 by guest. Proteted by opyright.

6 14 Pauli P, Wiedemann G, Dengler W, et al. Anxiety in patients with an automati implantable ardioverter defibrillator: what differentiates them from pani patients? Psyhosom Med 1999;61: This study provided speifi examination of the role of ognitive appraisal proesses in the development of psyhologial distress in ICD patients by omparing their responses to both anxiety populations and healthy same aged populations. 15 Credner SC, Klingenheben T, Mauss O, et al. Eletrial storm in patients with transvenous implantable ardioverter defibrillators. J Am Coll Cardiol 1998;32: These authors defined a riteria for ICD storm and provided data regarding its inidene in a linial sample of ICD patients. 16 Dunbar SB, Kimble LP, Jenkins LS, et al. Assoiation of mood disturbane and arrhythmia events in patients after ardioverter defibrillator implantation. Depress Anxiety 1999;9: This study provided prospetive examination of psyhologial fators and the inidene of shok that allowed for predition of shok by psyhologial distress. 17 Sears SF Jr, Burns JL, Handberg E, et al. Young at heart: understanding the unique psyhosoial adjustment of young implantable ardioverter defibrillator reipients. Paing Clin Eletrophysiol 2001;24: Kohn CS, Petrui RJ, Baessler C, et al. The effet of psyhologial intervention on patients long-term adjustment to the ICD: a prospetive study. Paing Clin Eletrophysiol 2000;23: This study was the first randomised ontrolled trial of a omprehensive psyhosoial intervention programme for ICD patients. 19 Sears SF, Todaro JF, Urizar G, et al. Assessing the psyhosoial impat of the ICD: a national survey of implantable ardioverter defibrillator health are providers. Paing Clin Eletrophysiol 2000;23: This study provided US physiian and nurse data and indiated the speifi psyhosoial onerns that ICD patients report to health are providers and their degree of omfort managing these onerns. 20 Sotile WM, Sears SF. You an make a differene: brief psyhosoial interventions for ICD patients and their families. Minneapolis, Minnesota: Medtroni In, This book provides a omprehensive review and set of linial strategies of the ommon psyhosoial hallenges for ICD patients and families for nurses and physiians. 21 Whooley MA, Simon GE. Managing depression in medial outpatients. N Engl J Med 2000;343: *493 Heart: first published as /heart on 1 May Downloaded from on 9 May 2018 by guest. Proteted by opyright.