UNC HOSPITALS CARDIAC REHAB PROGRAM CHAPEL HILL, NC

Turning Challenges Into Opportunities: From Surviving To Thriving

Janet Garvey Baradell, PhD, RN, CSBoard Certified, Psychiatric-Mental Health

Clinical Nurse Specialist

PSYCHOSOCIAL INTERVENTIONS

Screening tools

Psycho-education

Skills training

Social support

Individual meetings

Motivational interviewing

Referrals

Support group

Collaboration with health care providers

PSYCHOSOCIAL ASPECTS

OF HEART DISEASE FOR PATIENTS & FAMILIES:FROM SURVIVING TOTHRIVING

Janet Garvey Baradell, PhD, RN, CSBoard Certified,

Psychiatric-Mental HealthClinical Nurse Specialist

Adapted from Mayo Clinic .com

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OUTLINE

• What brings you to cardiac rehab?

• Impact of heart illness on you & your family

• Psychosocial risk factors

• Reducing your risk factors

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WHY ARE YOU HERE?

My doctor referred meMy spouse/family want me hereI want to prevent another heart eventI want to feel betterI want to reduce risk factorsI want to improve my quality of lifeI want to reduce stress

ILLNESS AND REHAB ARE STRESSFUL FOR EVERYONE IN THE FAMILY

YOU Crisis!

impact, turmoilresolution

Griefdenial, anger, bargaining,depression, acceptance

Guilt Face own mortality Fear/distrust body Stress

new demands, cost, time, role change: dependent, burden, powerless,role reversal

SPOUSE/PARTNER“Caregiver Strain “: many of the same feelings you

felt, plus hub of communication vigilant, protective role changes:

insecure about the future, new responsibilities, role reversal

Caregiver Strain IndexInconvenient, time consuming,

physically exhausting, disagreements about care, daily schedule, other family/work demands, etc.

CAREGIVER STRAIN INDEX (CSI)By M. Terry Sullivan, RN, MSW, MSN, CMC

Permission is hereby granted to reproduce this material for not-for-profit educational purposes only, providedThe Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source.

Available on the internet at www.hartfordign.org. E-mail notification of usage to: hartford.ign@nyu.edu.

• Sleep is disturbed• Inconvenient• Physical strain• Confining• Family adjustments• Change in personal

plans

• Demands on my time• Emotional adjustments• Behavior is upsetting• Upset by changes from

his/her former self• Work adjustments• Financial strain• Feel overwhelmed

REACTIONS: FAMILY & FRIENDS

May be : helpful or disappointing clingy, withdrawn,

indifferent afraid

of what they don’t understand

to ask questions

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WHICH PSYCHOSOCIAL ISSUES ARE RELEVANT FOR HEART PATIENTS?

Smoking>PSYCHOSOCIAL RISK FACTORS>Hypertension>Obesity>Sedentary, etc.

Psychiatric ProblemsDepressionAnxiety

Personality TraitsType A Behavior PatternType D Behavior Pattern

Stress

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20-40% OF HEART PATIENTS WILL EXPERIENCE DEPRESSION OR ANXIETY

DepressionAnxiety

Neurologic Disorders

10-20%Cancer10-20%

Chronic Pain

40-60%

Heart Disease20-40%

Diabetes 10-20%

SubstanceDisorders

20-40%

www.apm.org/unutzger

PSYCHIATRIC PROBLEMSPozuelo, L. et al. 2009 Cleveland Clinic Journal Of Medicine. 76(1), 59-70. McGrady

A, McGinnis R, Badenhop D, Bentle M, Rajput M. Journal of Cardiopulmonary Rehabilitation and Prevention. 2009;29:358-364.

Depression and Anxiety reduce adherence to cardiac rehab

prescriptions

exercise, meds, nutrition, smoking cessation, stress management

increase the likelihood of not completing rehab

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle your response.)

1. Little interest or pleasure in doing thing? 0 1 2 3

2. Feeling down, depressed, or hopeless? 0 1 2 3

3. Trouble falling or staying asleep, or sleeping too much?

0 1 2 3

4. Feeling tired or having little energy? 0 1 2 3

5. Poor appetite or overeating? 0 1 2 3

6. Feeling bad about yourself – or that you area failure or have let yourself or your family down?

0 1 2 3

7. Trouble concentrating on things, such as reading the newspaper or watching television?

0 1 2 3

8. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?

0 1 2 3

9. Thoughts that you would be better off dead, or of hurting yourself in some way?

0 1 2 3

10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all _____ Somewhat difficult _____ Very difficult _____Extremely difficult______

PATIENT HEALTH QUESTIONNAIRE: Depression

Adapted from PRIMEMD, developed by Drs. R.L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. ©1999 Pfizer Inc. Used with permission by Dr. Kurt Kroenke, MD Nov. 15, 2009.

WNL (0-4) Mild (5-9)

Moderate (10-14)

Moderately severe (15-19)

Severe (20-27)

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle your response.)

1. Feeling nervous, anxious or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Having trouble relaxing 0 1 2 3

5. Being so restless that it is hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful might happen 0 1 2 3

8. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all _____ Somewhat difficult _____ Very difficult _____Extremely difficult______

PATIENT HEALTH QUESTIONNAIRE: Anxiety

Adapted from PRIMEMD, developed by Drs. R.L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. ©1999 Pfizer Inc. Used with permission by Dr. Kurt Kroenke, MD Nov. 15, 2009.

WNL (0-4) Mild (5-9)

Moderate (10-14)

Severe (15-21)

NO YES1. Do you ever drink alcohol (including beer or wine)? [ ]

[ ]

2. Have any of the following happened to you more than once in the last 6 months? NOYES

a. You drank alcohol even though a doctor suggested that you stop drinking because of a problem with your health [ ]

[ ] b. You drank alcohol, were high from alcohol, or hung over while you were working, going to school, or taking care of children or other responsibilities [ ] [ ] c. You missed or were late for work, school, or other activities because you were drinking or hung over [ ]

[ ] d. You had a problem getting along with other people while you were drinking [ ] [ ] e. You drove a car after having several drinks or after drinking too much [ ]

[ ]

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all _____ Somewhat difficult _____ Very difficult _____Extremely difficult______

PATIENT HEALTH QUESTIONNAIRE: Alcohol

Adapted from PRIMEMD, developed by Drs. R.L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. ©1999 Pfizer Inc. Used with permission by Dr. Kurt Kroenke, MD Nov. 15, 2009.

WNL (0)

"Yes" to any item 2 a -e

is suggestive of abuse

ADDITIONAL QUESTIONS

What is the most stressful thing in your life right now?__________________________________________________________________________________________________________________________________________________________________

NO YES

Are you taking any medicine for anxiety, depression or stress? [ ] [ ]

Are you seeing a pastor, therapist, counselor, or psychiatrist for psychotherapy or stress management? [ ] [ ]

Adapted from PRIMEMD, developed by Drs. R.L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. ©1999 Pfizer Inc. Used with permission by Dr. Kurt Kroenke, MD Nov. 15, 2009.

Suicide Inquiry (use along with SAFE-T)http://www.stopasuicide.org/downloads/Sites/Docs/SAFE-T_One_Page_Final.pdf

I noticed that you answered "Yes" to question # 9 on the screening questionnaire regarding thoughts about ending your life. I am concerned about you.

• Ideation: Are you having these thoughts now? Have you had thoughts like this before? (If yes,) Tell me about that. How has your heart problem changed how you feel about living vs. dying?

• Plan: How did you think you might end your life? When did you plan to end your life?

Do you have _____ (whatever the means were – gun, drugs, hanging, knives)• Intent: How likely are you to carry out your plan to end your life? What might be some reasons to go on living?

family, friends, faith, pets, work, anyone who relies on this person, belief that things can get better, any significant relationship or person who cares about this person, including you How do you think this might affect your ______ (spouse, child, friend, etc.?) In my experience, this is a tragedy, very hard on those who love/care about you. I would be very sad if you ended your life…

I would be devastated.• Go to Risk Level/Intervention and follow guidelines for Level of Risk based on your

judgment.

ACCESSING MENTAL HEALTH SERVICES

If psychotherapists are not available in your community, some suggestions are:

• To access public mental health services in each county, AS OF JANUARY 2011

http://www.ncdhhs.gov/mhddsas/lmedirectory.htm• Mental health providers – volunteer support group leader• Self help groups: AA, NA, AlAnon, OA, Depression and

Bipolar Support Groups, Compassionate Friends, Survivors of Suicide

• Online sites: Mayo Clinic, NIMH, http://www.mayoclinic.com/health/DiseasesIndex/DiseasesIndex http://www.nimh.nih.gov/index.shtml http://www.adaa.org/

• Meditation groups

PERSONALITY TRAITS: COPING STYLESRazzini et al., 2008

Personality TraitsType A (Angry) Behavior Pattern:

driven, perfectionist, multitask, time pressure/deadlines, competitive

hostile, critical and unhappy with othersType D (DISTRESSED) Behavior Pattern:

Negative emotions, like anger, in response to multiple situations and over time

social isolation to avoid experiencing negative emotions that arise in social interaction

Seen in 28% of coronary artery disease patients and 53% of hypertensive patients!!

Has a seven-fold increased risk of sudden, cardiac death

“STRESS”: LIFE EVENTSBaradell, J. Abbreviated Daily Hassles Scale. 1988; Lazarus & Folkman, 1984

Stress is anything that makes a demand on you:caused by internal or external demands

Internal Thoughts/Feelings – self generated pressure to return to work, provide care for others, be perfect, unrealistic expectations about time or effort necessary to recover or helplessness, hopelessness, despair

External stresses: time pressure /deadlines for work, school or family obligations, traffic, crime, weather

caused by positive or negative eventsPositive: births, weddings, graduations, pay raise,

promotion, new homeNegative: finances, work, marital conflicts, health problems,

death, divorce Accumulates over a lifetime

STRESSERSStress in America survey in

August by Harris Interactive for the American Psychological Association

The adults surveyed said that stress affected behavior and often had physical consequences:

• •31% say they skipped a meal.

• •40% say they overate or ate unhealthy foods.

• •44% say they lay awake at night.

http://www.usatoday.com/yourlife/health/medical/mentalhealth/2010-11-09-

apastress09_VA1_N.htmaccessed 11-10-10

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WHY ARE PSYCHOSOCIAL RISK FACTORS RISKY??? Pozuelo, et al., 2009; Razzini et al., 2008; Blumenthal, 2008; Jiang, 2008; Parissis et al.,

2007Carney, et al., 2004

Body seeks homeostasis: balance in level of arousal and relaxation

“Stress” activates the Fight or Flight Response: a defensive response that disrupts homeostasis

After stress subsides, relaxation restores homeostasis Not all stresses must induce Flight or Flight Response Chronic stress causes

hyper-arousal of the Sympathetic Nervous System, and

impairment of the Parasympathetic Nervous system to produce relaxation resulting in feeling “switched on” or “keyed up”

Stress contributes to the development of Coronary Artery Disease Endothelial Disease - a systemic disease that damages the lining of arteries

“FIGHT OR FLIGHT” RESPONSE Sympathetic Nervous System The Stress of Life (Selye, 1956, 1976, 1984)

Physical Impact Increases:

heart rate, BP, force of contraction rapid, shallow breathing blood sugar, triglycerides &

cholesterol sodium and water retention muscle tension clotting belly fat

Psychological Impact Alert Fearful Rapid thinking with impaired

memory Expect the worst Freeze

Sympathetic Nervous SystemBody reacts to stress by activating the HPA Axis:

Parasympathetic Nervous System: stimulation of Vagus nerve produces relaxation/homeostasis

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CORONARY ARTERY DISEASE

http://www.heartsite.com/html/cad.html

                                             

PROGRESSION OF CADhttp://www.heartsite.com/html/cad.html

Normal coronary artery Fatty streaksFatty streaks begin to interfere with blood flow

Fibers encase fatty streakscreating plaque; inflammation

Ruptured plaque andclot formation

Clot continues to grow,blocking artery – Heart Attack

AN INFLAMMATORY PROCESS

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REDUCING RISK FACTORSREDUCING RISK FACTORS

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EFFECTIVE TREATMENTS FOR HEART PATIENTS

Pozuelo, et al., 2009; Blumenthal, 2008; Jiang, 2008; Manzoni, et al., 2008; Razzini et al., 2008; Parissis et al., 2007; Carney, et al., 2004

• Exercise: may be the most effective at reducing all risk factors, as well as, reducing depression

• Stress Management, including relaxation training or meditation: reverses “Fight or Flight”, may reduce inflammation, and platelet stickiness – all protective

• Antidepressants: SSRI’s citalopram (Celexa) and sertraline (Zoloft); mirtazapine (Remeron) was not effective in treatment of depression in heart patients

• Psychotherapy: effective in reducing depression and anxiety and improving quality of life , has not consistently shown reduced mortality

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Relaxation Training for Anxiety: A Ten-Years Systematic Review With Meta-Analysis

Gian Mauro Manzoni; Francesco Pagnini; Gianluca Castelnuovo; Enrico Molinari BMC Psychiatry.  2008; ©2008 Manzoni et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided

the original work is properly cited.

• Progressive relaxation and meditation are effective in reducing anxiety (ES: Progressive Relaxation=.8 and meditation=.7, high effect)

• Homework practice improves effectiveness

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RELAXATION – RESTORES HOMEOSTASISby stimulating the Parasympathetic Nervous System

Diaphragmatic Breathing

Passive MindProgressive

Muscle Relaxation

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RELAXATION CD5 Tracks With Instructions:• Mindful Breathing - 3 minutes

Practice Mindful Breathing several times a day: mid-morning and mid-afternoon and anytime you notice negative emotions like anger or impatience; feel “fight/flight/freeze” sensations or notice rapid thinking or negative thinking (judging self or others, replaying an event, worrying about a future event, creating a story in your head about a future event – as if it were TRUE)

• Progressive Relaxation and Mindfulness MeditationPractice twice a day for 2 weeks, using 1 of these tracks, then once a day – morning practice seems most beneficial– Mindful Relaxation with Imagery - 9 minutes– Progressive Relaxation - 12 minutes– Progressive Relaxation -13 minutes– Mindfulness Meditation – 20 minutes

Mindfulness Meditation classes: Program on Integrative Medicine @ UNC-Chapel Hill: http://pim.med.unc.edu/ or call 966-8586

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STRESS MANAGEMENT STRATEGIESSTRESS MANAGEMENT STRATEGIES An Active Partnership for the Health of Your Heart (AHA & ASA)An Active Partnership for the Health of Your Heart (AHA & ASA) https://www.krames.com/OA_HTML/ActivePartnership.html#TabTop

Consider priorities Avoid unnecessary stress:

do I own it? Adapt

change the way you think or feel to reduce your suffering; get socially involved; Job redesign, transfer, or change; family communication, compromise, negotiate

Accept things you can’t change

acceptance doesn’t mean agreement

Self Actualization: lack of prejudice, creative, spontaneous, acceptance of reality, problem solving

Esteem: confidence, achievement, self respect;

respect of others

Love/Belonging: family, friends, sexuality

Security: physical and emotional safety; job/school;

adequate finances; family and social connections; organize to meet priorities; home

maintenance

Physiological: smoking cessation; exercise 5-6 times a

week for 45-60 minutes; practice daily relaxation or meditation; sleep; medications;

nutrition & alcohol

Goal: MET level ≥ 8

(Maslow adapted)

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ANGER MANAGEMENT

ANGER KILLS!

Count to 10, Breathe Think before you act – what am I angry

about? Talk it out – seated, no raised voices;

say what the problem is & how you feel; ask for what you want; compromise

If you aren’t able talk it out, get away & cool off; then, get back together

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ALCOHOL GUIDELINES

IF YOU DRINK: Men: up to 2 drinks per day Women: 1 drink per day 1 Drink = 1 oz hard liquor;

4-5 oz wine (about ½ cup); 12 oz beer

WHY? interacts with medications:

eliminating them more rapidly or slowly increases risk of bleeding causes or worsens fatigue, insomnia, anxiety & depression

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SOCIAL SUPPORTCompanions and Lovers

Sexual relations, with a committedpartner allows you to feel “normal” Ask your doctor when it’s safe Orgasm is within 80% THRR To reduce workload:

non-cardiac spouse on top use side-lying or seated positions 2 hrs after meal

When in doubt about sexual function, try it out – in private

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SOCIAL SUPPORT

Health

care

teamCardiac

Rehab

Cardiac Survivors

Support Group

Volunteering

Grocery

Store

Senior

Center

Church

Exercise

Group Garden

Club

Meditation

Group

Pets

AA

OA

NA

Prayer

Group

Parents

Siblings

Neighbors

Coworkers

Friends

Spouse

Children

You

HELPFUL REFERENCESFull Catastrophe Living. 1990, Jon Kabat Zinn. PhD.

Dr. Dean Ornish’s Program for Reversing Heart Disease. 1990, Dean Ornish, MD.

10 Simple Solutions to Stress: How to Tame Tension & Start Enjoying Your Life. 2007, Claire M. Wheeler, MD, PhD.

Instant Calm: Over 100 Easy-to-Use Techniques for Relaxing Mind and Body. 1995, Paul Wilson.

Motivational Interviewing: Preparing People for Change, 2nd ed. 2002, William Miller, PhD and Stephen Rollnick, PhD.

Motivational Interviewing in Health Settings: A Review. Britt, E. Hudson, S. Blampied, N. Patient Education and Counseling, 53 (2004) 147-155.(full text was online)

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CONCLUSIONS

“Stress management in cardiac rehab can reduce death rates in cardiac patients”

Linden W, Phillips MJ, Leclerc J. Psychological treatment of cardiac patients: a meta-analysis. Eur Heart J 2007; 28:2972-2984.