Cardiac Patients Psychosocial Needs. Cardiac Patients Psychosocial Needs

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1 Cardiac Patients Psychosocial Needs Implications for Rehabilitation Programs and CACR Guidelines Jaan Reitav and Paul Oh Cardiac Rehabilitation & Secondary Prevention Program Cardiac Patients Psychosocial Needs The INTERHEART study (2004) concluded that: Raised cholesterol, smoking and psychosocial [stress] factors were the most important risk factors [for heart attack] in all regions of the world. p. 943 In Cardiac Rehab (CR), we are now in the post-interheart era : the importance of addressing psychosocial factors in the rehab process is accepted unequivocally So, what psychosocial intervention is provided, to whom, how and when? 1

2 Best Practice at Toronto Rehab Definition of Best Practice: An approach to planning and delivery of patient care that is patient centered, research and outcome-based, refined through quality improvement and benchmarking CACR Guidelines* for Cardiac Rehab 1. Develop routine screening protocols 2. Provide Individual Treatment for Depression & Anxiety 3. Provide Group Treatments for Stress & Self-Management 4. Address return to work issues by providing Vocational Rehab assessments 5. Provide Continuing Education of all Supervisors on the track (front line) * CACR Guidelines, 2 nd Edition (2004) 2

3 CACR Guidelines (2 nd Edition) Advocates screening and treatment for specific psychosocial needs: Depression Anxiety Alcohol and Substance Abuse Chronic Stress Self-Management for Lifestyle and Non-adherence But, how does one set priorities for programming and staffing? Start with the Patient Patient Need Sustain Review Present Practice Evaluate The Process Circle to Develop Best Practices Determine Best Practice Implement and Facilitate Gap Analysis Prepare 3

4 Sustain Evaluate Implement and Facilitate Patient Need The Process Circle to Develop Best Practices What is the range of complaints? Which are seen most frequently? Review Present Practice Range and frequency of disorders will determine Determine Best programming. Practice Need data to decide how to allocate staff and dollars. Gap Analysis Prepare A Patient Centered Review Prospective study of consecutive CR patients Patients were selected by Cardiac Supervisors on basis of inability to meet their exercise prescription Study cohort includes every patient assessed by the psychologist across one full year Files were reviewed for: Chief complaint (1º and 2º presentation) DSM-IV diagnoses (1º and 2º) 4

5 Patient is identified by CRS as needing help Patients assessed by Dr. Reitav to determine their psychosocial needs & status 146 Stroke program n=6 Cardiac program n=118 Diabetes program n=22 24 weeks training FILE REVIEW: (87 CR males 31 CR females) Subjective (Chief) Complaints and Patients Psychiatric Diagnoses Co-Morbid Health Conditions Health Conditions reported by patients: 90 % had had a Cardiac event 23 % had also had a Stroke 19 % had been diagnosed with Diabetes 15 % reported a psychiatric history 15% reported angina Not only Cardiac patients, but patients with multiple health concerns and challenges 5

6 CACR Guidelines (2 nd Edition) Advocates screening and treatment for specific psychosocial needs: Depression Anxiety Alcohol and Substance Abuse Chronic Stress Self-Management for Lifestyle and Non-adherence What conditions do you expect are seen most typically? Results: Chief Complaints People Stress Anxiety & Anger Depression Chronic Stress Sleep Problems Substances and Lifestyle 87 Men 41 % 40 % 29 % 27 % 19 % 15 % 31 Women 32 % 42 % 48 % 13 % 23 % 19 % No significant differences between men and women at assessment 6

7 Chief Complaints Lifestyle 12% 5% Substances 20% 40% People Stress Sleep Problems Chronic Stress 25% 35% 42% Anxiety & Anger Depression 118 consecutive CR Patients (men and women combined) Results: Psychiatric Diagnoses No diagnosis Axis I Conditions Depression Anxiety & Anger Sleep Disorder Adjustment Disorder Substances and Lifestyle Axis IV (People Stress) 87 Men 1% 32 % 35 % 18 % 13 % 12 % 51 % 31 Women 6 % 42 % 23 % 19 % 16 % 12 % 45 % No significant differences between men and women at assessment 7

8 Psychiatric Diagnoses Substances and Lifestyle Adjustment Disorder 19% 14% 12% 50% People Stress Sleep Disorders 33% 34% Anxiety & Anger Depression 118 consecutive CR Patients (men and women combined) Meeting Patient Needs Programming requirements for Cardiac Rehab (CR) patients: 146 of 1650 patients enrolled in CR required diagnostic workup (triage) Of the 118 assessed CR patients, 45% required individual therapy, most for anxiety and depression, and 22% required referral for psychiatric consultation 8

9 Meeting Patient Needs The diversity of patient problems seen clustered in three domains, which would lend themselves to treatment with Group programs focusing on skills acquisition in: Arousal reduction strategies ( Stress Management ) Behavioural skills training to better manage chronic health conditions ( Self-Management ) Social interaction and better understanding of their emotional reactions to their health condition ( Patient Support Group ) People Stress Most (50%) had difficulties in interpersonal relationships. Examples include: Wife has an alcohol problem Son with Schizophrenic has a psychotic episode Husband has Diabetes and heart failure Son makes a suicide attempt Daughter s marriage breaks down and has to move back into family home with two young children 9

10 Mood Disorders (34 %) Optimally, treatment requires both SSRIs and psychotherapy (CREATE study underlines use of SSRIs in management of CR depressed patients) Referral to psychiatrist means rapid identification of patient problem is key Ongoing co-ordination between front-line staff and treating team is very important Mood Disorders tend to be more prevalent among the female CR patients Anxiety Disorders (33 %) Contain a broad range of distinct clinical problems, that require unique treatment strategies Generalized Anxiety Disorder Angina management Angry outbursts Attention Deficit Disorder (4 adult cases) 10

11 Sleep Disorders (19%) Were more prevalent than one might expect and are not fully integrated into the current CACR Guidelines: There are high levels of sleep disturbance among both depressed and anxiety patients Beyond that there are more patients who have sleep disruptions (triggered by surgery, or their heart problems) who need treatment Some patients have co-morbid sleep apnea, which should be investigated in the sleep lab Substances and Lifestyle (7%) Substance abuse problems were underrepresented in this patient cohort Perhaps these patients are less likely to enroll in a Cardiac Rehab program Perhaps they don t reveal their problem to their Supervisor Perhaps they are not ready to identify themselves, or feel too stressed to start Smoking, in particular, is among the most negative risk factors and requires more vigorous follow-up 11

12 Implications for CACR Guidelines Develop routine screening protocols: Cardiac patients present with broad range of needs (10% of all CR patients required psychosocial consultation) Triaging personnel require excellent diagnostic skills in the assessment of: psychopathology, health risks, sleep disorders and readiness to change Provide Individual Treatment for Depression & Anxiety (45% required & 22% referred for SSRIs ) Provide Group Treatment for Stress Management (arousal reduction), Self-Management, and Emotional and Social Support (25% or more are likely to benefit) Limitations: Sources of Bias No guarantee that all appropriate cases were identified (bias in referral) Small sample size from only one setting Determination of conditions is based on the judgment of one clinician Data is based on clinical interview only Further attention to patient needs in Rehabilitation programs would be helpful 12

13 References 1. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries: the INTERHEART study. Lancet. 2004;364: Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention, 2 nd Edition (2004) Chapter 3: Behavioural, Psychosocial and Vocational Issues in Cardiovascular Disease: Lesperance F, Frasure-Smith, Koszycki D et al. Effects of Citalopram and interpersonal psychotherapy on depression in patients with CAD: the CREATE trial. JAMA. 2007; 297(4): Mental Illness in General Health Care: An International Study (WHO). T Ustun and N Sartorius (Eds). 1995; Wiley, New York. 13