Psychosocial Issues in Cardiac Rehabilitation 7

A Regional Psychology Service for Cardiac Patients Enrolled In Cardiac Rehabilitation George T. Kaoukis, PhD Cardiac Psychology Service, St. Boniface General Hospital and Winnipeg Regional Health Authority

There is a growing body of research indicating that it is important to include psychological interventions in

cardiac rehabilitation (CR). Negative emotional states such as stress, anxiety, depression and anger have been linked to pathophysiologic processes associated with the development and progression of cardiovascular disease.1-3 They have been shown to have a direct impact on traditional cardiac risk factors and pathologic precursors such as decreased heart rate variability, impaired hemodynamic recovery and increased platelet aggre-gation. They also have an indirect influence on these factors via their link to unhealthy lifestyle patterns and poor adherence to treatment recommendations. Moreover, negative emotions have been associated with an increased risk of experiencing an initial or a recurrent cardiac event as well as cardiac death.4-6 This increase in risk often follows a dose-dependent relationship.

A significant number of cardiac patients experience clinically significant adjustment problems following their event, which places them at higher risk for poor medical outcomes and increased rates of cardiac morbidity and mortality.7 Up to 25% of cardiac patients experience clinical depression and up to a third suffer from anxiety disorders. Increased irritability and marital problems are also quite common. Research has shown that including psychological interventions in CR programs to address these problems can improve cardiac patients’ medical risk factor profile, adherence to lifestyle and medication regimens, return to pre-morbid levels of psychosocial functioning and quality of life to a greater extent than usual CR care.8,9 In addition, a

number of studies have found that adding these interventions to standard cardiac care can potentially reduce the risk of cardiac morbidity and mortality in the years following a cardiac event. However, there has been conflicting evidence with regard to these hard medical outcomes.10

The above body of research has prompted cardiologists to recommend that cardiac patients be screened for anxiety and depression and that these disorders be addressed in the comprehensive care of the cardiac patient.1 Similarly, the Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention outline how patients participating in CR should be assessed for these factors and appropriately treated with evidence-based procedures.11

In 2002, the Clinical Health Psychology Program (CHPP) of the Winnipeg Regional Health Authority (WRHA), in

collaboration with the two CR centres in the Winnipeg area, the Wellness Institute at Seven Oaks General Hospital and the Manitoba Cardiac Institute (Reh-Fit Centre), developed a psychological screening and treatment program for cardiac patients enrolled in CR. The two rehabilitation sites offer a four-month educational program that includes instruction in nutrition, exercise and stress management, information on cardiovascular disease, and supervised exercise sessions. They deliver services to approximately 900 patients per year and have a catchment area that includes Winnipeg, Eastern Manitoba and Northwestern Ontario. The CHPP of the WRHA has a Cardiac Psychology Service that provides psychological interventions to post-MI and CABG patients as well as other cardiac populations. As a result of the aforementioned collaboration, the Cardiac Psychology Service based at St. Boniface General Hospital in Winnipeg started conducting weekly outpatient clinics at the two CR sites and integrated psychological interventions into the operations of the sites’ CR program. All costs for psychological services offered by these clinics are covered by provincial health insurance.

Figure 1: Psychological Screening Process for Patients Entering CRThe psychological screening process (Figure 1) involves administration of the Beck Depression Inventory (BDI-2)12 and Brief Symptom Inventory13 to all cardiac patients entering the CR program at both sites. Research using the BDI has shown a dose-dependent relationship between BDI scores and patients’ survivability post-MI.4 The inventories are administered to patients by nursing staff or other allied health professionals at each site during the first day of CR classes. They are electronically scored and a preliminary analysis is conducted to identify which individuals are at risk for psychological adjustment problems. The criteria for determining psychological risk include psychometric data and/or the patient’s endorsement of suicidal thoughts (Table 1). A psychologist from the Cardiac Psychology Service reviews the psychometric (including Brief Symptom

BDI & BSI Screening

Criteria met, Assessment Triage

Criterianot met

DiagnosticInterview

Staff/patientrequest referral

8 Psychosocial Issues in Cardiac Rehabilitation

Inventory subscale scores) and demographic data on

individuals deemed at risk, and writes a triage report. This

report indicates the priority level at which patients need

to be seen for psychological follow-up and is submitted

to the sites. All patients screened as “at risk” are scheduled

to see the psychologist based on the recommendations

contained in the triage report. Patients can also be referred

to the psychologist by CR staff based on their observations

of the patient or in response to a patient’s request for a

psychological consultation. When patients make a request

for services, CR staff informs them that the consultation

will only address issues related to their cardiovascular event

and that other problems are dealt with through community-

based resources. Patients are given information about these

resources and are assisted in connecting with them.

Table 1: Screening Criteria for Identifying Patients as “At Risk”

Any one of the following:

1. Patient reports suicidal ideation (BDI 9 and/or BSI 9)

2. BDI ≥20

3. BSI Global Severity Index (GSI) ≥ Tscore of 64

4. Two BSI subscales ≥ Tscore of 64

The follow-up session with the psychologist consists of a

60- to 85-minute interview to review screening information

with the patient, obtain consent, develop a diagnostic

impression based on criteria from the Diagnostic and

Statistical Manual for Mental Disorders, and provide the

patient with a treatment plan. The treatment plan outlines

strategies for addressing psychological distress, problems with

adherence to lifestyle-change recommendations, and issues

related to returning to baseline psychosocial functioning.

Analysis of screening data from the fall of 2002 to the

end of 2003 (n=1,154) indicated that approximately 29%

of patients entering CR at the two sites met psychological

risk criteria.14 More precisely, between 250 and 300 CR

participants in the Winnipeg region each year experience

clinically significant levels of psychological distress and

require psychological intervention. This is consistent with

results reported in the literature on the psychological sequelae

of cardiovascular disease.7 In the aforementioned analysis,

at-risk patients were most likely to be diagnosed with an

adjustment disorder or major depression. Twenty-two

percent of this group had suicidal thoughts and 53% were

on medication or were determined as needing it to address

their psychological problems. Only 4% had a specific plan

or intent to do self-harm. Nevertheless, the prevalence of

suicidal ideation found in this group resulted in the two CR

sites, in consultation with the Cardiac Psychology Service,

establishing a specific protocol for addressing varying levels of

risk for self-harm and harm towards others. At-risk patients,

in comparison to those not meeting risk criteria, were also

found to be younger (52% vs. 40% <60 years old) and more

likely to have a previous personal and/or family psychiatric

history (48% vs. 18% and 31% vs. 20%, respectively). In

addition, they differed with regard to their attitudes towards

lifestyle change. More precisely, they had less self-efficacy

in making healthy dietary changes, increasing their activity

levels, and losing weight. Similarly, at-risk patients tended to

be more in the contemplative and preparatory stages rather

than the action and maintenance stages of making necessary

modifications in lifestyle behaviours.15

Table 2: CBI Components of Stress/Depression Management Seminar

Mind-body information Developing a prioritized self

Self-monitoring Learning to behave like an optimist

Basic self-care strategies Cognitive restructuring

Behavioural activation tips Social-support building

Goal-setting Self-efficacy building

Table 3: Arousal Reduction Procedures

Diaphragmatic breathing Visualization techniques

Progressive muscle relaxation Combo techniques

Autogenic training Sleep hygiene strategies

A stepped approach to treatment is employed (Figure 2)

for patients requiring psychological intervention. Patients

who are evaluated to be mildly distressed receive a basic

treatment package consisting of two 3-hour group seminars

dealing with cognitive-behavioural therapy (CBT) strategies

for stress and depression management, and relaxation training

(Tables 2 & 3), respectively, and a follow-up appointment

with the psychologist. The seminars are conducted on a

monthly basis by the psychologist and are accompanied

by extensive handouts on CBT strategies. Patients with

moderate levels of distress and those who do not respond

to the initial intervention receive an additional three

sessions of individual CBT as well as the basic treatment

package to address their illness and lifestyle adherence

concerns. The individual sessions build on and tailor the

strategies introduced to patients during the group seminars.

Individuals experiencing moderate levels of distress may also

be considered for specialty services offered by the CHPP

of the WRHA (e.g., groups for depression, various anxiety

disorders, and insomnia), a more extended course of CBT

at the Cardiac Psychology Service, as well as community-

based resources if they fail to respond to their initial course

Psychosocial Issues in Cardiac Rehabilitation 9

of treatment. The individual CBT sessions are conducted at the CR sites, whereas specialty services are located at various hospitals in the Winnipeg area. Finally, patients with severe levels of distress receive on-site crisis intervention and the basic treatment package, and are referred to the Cardiac Psychology Service at St. Boniface General Hospital for more extensive individual CBT (6-8 sessions) to address their illness adjustment problems. They are often linked to other specialty groups in the CHPP and the community. Psychotropic medication is often recommended for these individuals.

Figure 2: Stepped Treatment for Individuals Identified as “At Risk”*CHP=Clinical Psychology Program

Although controlled evaluations of the efficacy of this psychological treatment program have not been conducted, there is data suggesting it may be useful in alleviating CR participants’ psychological distress.14 Pre-post analyses conducted on a subgroup of 467 at-risk patients showed a 57% decrease in their mean BDI-2 scores over the course of treatment (Figure 3). The magnitude of this decrease is not only statistically significant (p<0.001) but also places these individuals in a BDI range associated with reduced cardiac morbidity and mortality rates.4 Similarly, these patients demonstrated a 62%, 46%, and 24% improvement on the emotional role functioning, social functioning, and

mental health scales of the SF-36,16 respectively. In addition, patients appeared very satisfied with how the CBT seminars

met their expectations and learning goals. Eighty-nine percent of individuals attending the seminars rated them as either “excellent” or “very good” in this regard. The success of the seminars is also illustrated by the fact that CR participants not classified as at-risk wanted to attend. Consequently, all patients entering CR at the two sites now have an opportunity to attend these seminars. Moreover, the stress management classes that are part of the general CR program have incorporated some of the seminars’ concepts and techniques into their instructional materials.

Figure 3: Pre-Post BDI Scores for Patients at Psychological Risk (n=467)

In summary, the WHRA, in conjunction with the two CR centres in the region, has developed a psychology service that is integrated into the CR process and serves a relatively large number of patients each year. The volume of patients served has necessitated the use of screening and treatment techniques that meet the psychological needs of

this population in a resource-efficient fashion. This includes the use of algorithmic and computer-assisted screening processes, triage protocols, a seminar format for CBT that can accommodate 30 people at a time, and a stepped approach to treatment that addresses the varying needs of cardiac patients who are having difficulty adjusting to their event. The challenge remains of ascertaining whether the addition of the psychological service to the CR program independently improves cardiac patients’ physical and medical outcomes. Similarly, it is yet to be determined whether the positive impact of the psychological interventions on CR participants’ emotional status results in improved adherence to lifestyle recommendations. Finally, the caregivers of cardiac patients are a relatively under-served group who have been shown to suffer from a number of stress-related problems.17 Their difficulty in adjusting to their partner’s cardiac event has been found to adversely affect patients’ overall recovery.

Consequently, the Cardiac Psychology Service is presently

developing a three-session group program for the caregivers of cardiac patients to address this unmet area of care.

References: 1. Rozanski A, Blumenthal JA, Davidson KW et al. The epidemiology,

pathophysiology, and management of psychosocial risk factors in cardiac practice. JACC 2005;45:637-51.

2. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for treatment. Circulation 1999;99:2192-217.

3. Musselman DL, Evans DL, Nemeroff CB. The relationship of depression to cardiovascular disease: epidemiology, biology and treatment. Arch Gen Psychiat 1998;55:580-92.

4. Lesperance F, Frasure-Smith N, Talajic M, Bourassa MG. Five-year risk of cardiac mortality in relation to initial severity and one-year changes in depressive symptoms after myocardial infarction. Circulation 2002;105:1049-53.

5. Mathews KA, Gump BB, Harris KF, Haney TL, Barefoot JC. Hostile

Mild

Moderate

Severe

Non-CVD Stress

CBT SeminarGroups (6

CBT SeminarGroups (6

CBT SeminarGroups (6

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IndividualF/U Session

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IndividualCBT

6-8 IndividualCBT

CHP*Specialty

Community-Based

Level of Distress Treatment OptionsFrom DX Interview

Pre-Treatment

16.1

6.88

20 –

15 –

10 –

5 –

0 –

Post-Treatment

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I Sc

ores

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behaviours predict cardiovascular mortality among men enrolled in the Multiple Risk Factor Intervention Trial. Circulation 2004;109:66-70.

6. Frasure-Smith N, Lesperance F. Depression and anxiety as predictors of 2-year cardiac events in patients with stable coronary artery disease. Arch Gen Psychiat 2008;65:62-71.

7. Kaoukis G. Adjusting to a cardiovascular event. Can J of CME 1999;11:73-89.

8. Linden W, Stossel C, Maurice J. Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch Intern Med 1996;156:745-52.

9. Dusseldorp E, van Elderen T, Maes S, Meulman J, Kraaij V. A meta-analysis of psychoeducational programs for coronary heart disease patients. Health Psychol 1999;18:506-19.

10. Rees K, Bennett P, West R, Davey SG, Ebrahim S. Psychological interventions for coronary heart disease. Cochrane Database Syst Rev 2004;CD002902.

11. Prior P, Cupper L. Behavioural, psychosocial and vocational issues in cardiovascular disease. In: Stone JA, Arthur HM (Eds.). Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease

Prevention. Second Edition. Canadian Association of Cardiac Rehabilitation;2004.

12. Beck A, Steer RA. Beck depression inventory manual. New York: Harcourt Brace Jovanovich;1987.

13. Derogatis LR, Melisaratos N. The Brief Symptom Inventory: An introductory report. Psychol Med 1993;13:595-605.

14. Kaoukis G. A regional psychological screening program for cardiac rehabilitation patients. Scientific paper presented at the Annual Meeting of the Canadian Association of Cardiac Rehabilitation, Calgary, Alberta, 2004.

15. Prochaska JO, Redding CA, Evers KE. The transtheoretical model and stages of change. In: Glanz K, Lewis FM, Rimer BR (Eds.). Health Behavior and Health Education: Theory, Research and Practice. San Francisco, CA:Jossey-Bass;1997.

16. Ware JE, Snow K, Kosinski M, Gandek B. SF36 Health Survey: Manual and Interpretation Guide. Boston:Nimrod Press;1993.

17. Moser DK, Dracup K. Role of spousal anxiety and depression in patients’ psychosocial recovery after a cardiac event. Psychosom Med 2004;66:527-32.