Behavioral Medicine for Patients with Heart Disease - The Case of Depression and Cardiac Rehabilitation

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Abstract

Patients with heart disease very often have behavioral and psychological concerns that create a challenge for cardiologists. Referrals are frequently necessary, but a behavioral and mental health infrastructure is often lacking. Outpatient cardiac rehabilitation, a comprehensive multidisciplinary program, is an appropriate resource for a variety of behavioral and psychological concerns. Cardiac rehabilitation staff are trained in behavioral health approaches such as motivational interviewing, which aids behavior change. Depression also exemplifies how cardiac rehabilitation can be used as a behavioral health resource while staying consistent with the recent American Heart Association (AHA) science advisory on treating depression in patients with heart disease. Large-scale trials, such as Enhancing Recovery in Coronary Heart Disease (ENRICHD), Sertaline and Depression Heart Attack Randomized Trial (SADHART), and Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE), provided information on pharmacologic and psychotherapeutic treatments for depression. The AHA science advisory also recommends exercise, such as cardiac rehabilitation, as a treatment option for depression. In addition to being as effective as antidepressants, exercise is associated with reductions in mortality among depressed patients with heart disease. Cardiac rehabilitation is an excellent option for patients who are depressed or struggling with behavior changes.

Disclosure
The authors have no conflicts of interest to declare.
Correspondence
Joel W Hughes, PhD, FAACVPR, Department of Psychology, Kent State University, PO Box 5190, Kent, OH 44242. E: jhughes1@kent.edu
Received date
29 June 2010
Accepted date
26 July 2010
Citation
US Cardiology - Volume 7 Issue 2;2010:7(2):55-60
Correspondence
Joel W Hughes, PhD, FAACVPR, Department of Psychology, Kent State University, PO Box 5190, Kent, OH 44242. E: jhughes1@kent.edu

Pages

In a recent meeting with department heads from psychiatry and cardiology, the possibility of hiring a behavioral medicine specialist (e.g. a psychologist) to work exclusively with cardiac and pulmonary patients was discussed. One cardiologist said, “I could probably refer you seven patients every Tuesday.” Whatever clinic he was referring to, it was clear to all in attendance that patients with heart disease very often have behavioral and psychologic concerns that adversely affect patient care, quality of life, and outcomes.
According to the World Health Organization (WHO), one in 500 deaths from cardiovascular disease will die solely because of genetics, but the fate of the rest is not so deterministic. That is, 80–90% of deaths from coronary heart disease (CHD) involve at least one major risk factor influenced by lifestyle. Cardiovascular disease is primarily a disease of lifestyle, and is largely a preventable disease.1 Alcohol/drug abuse, nicotine addiction, anger/hostility, anxiety, depression, chronic stress, cognitive impairment, insomnia, loneliness/social isolation, obesity, and poor patient self-management (i.e. non-adherence to medications, dietary recommendations, exercise prescriptions, and self-care activities) are some of the behavioral and psychological problems encountered routinely by healthcare professionals treating patients with heart disease (see Table 1). These problems create an enormous challenge for cardiologists, who must identify and manage a wide array of behavioral issues, making referrals to behavioral medicine providers where necessary.

Cardiac Rehabilitation for Patients with Behavioral Medicine Needs

Unfortunately, behavioral medicine infrastructure in healthcare is often inadequate and is certainly quite variable across institutions. A referral to a well-staffed psychiatry department or behavioral health service may be easy at some large university-affiliated medical centers, but many cardiologists do not have ready access to behavioral medicine services and must manage things ‘in-house’ or simply send the patient back to a primary care physician for follow-up. Obtaining the right professional referral is preferable, when possible (see Box 1). Furthermore, there is no widely accepted model integrating behavioral medicine services with the practice of cardiology.2 In this article we suggest that outpatient cardiac rehabilitation is an underutilized behavioral medicine resource that is already in place at most medical centers, to which patients can be referred for further assessment and treatment of a variety of behavioral and psychological concerns.

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References
  1. World Health Organization, The World Health Report 2002, Geneva, Switzerland: World Health Organization, 2002.
  2. Rozanski A, Integrating Psychologic Approaches Into the Behavioral Management of Cardiac Patients, Psychosom Med, 2005;67:S67–S73.
    Crossref | PubMed
  3. King ML, Improving the Quality of Care Following and Acute Cardiac Event—The Role of Cardiac Rehabilitation in the Care Continuum, US Cardiology, 2009;6:79–82.
  4. Miller WR, Rollnick S, Motivational Interviewing, preparing people to change addictive behavior, New York: The Guildford Press, 1991.
  5. Rubak S, Sandbaek A, Lauritzen T, Christensen B, Motivational Interviewing: a systematic review and meta-analysis, Br J Gen Pract, 2005;305–12.
    PubMed
  6. Barth J, Schumacher M, Herrmann-Lingen C, Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis, Psychosom Med, 2004;66:802–13.
    Crossref | PubMed
  7. van Melle JP, De Jonge P, Spijkerman TA, et al., Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis, Psychosom Med, 2004;66:814–22.
    Crossref | PubMed
  8. Carney RM, Freedland KE, Depression, mortality, and medical morbidity in patients with coronary heart disease, Biol Psychiatry, 2003;54:241–7.
    Crossref | PubMed
  9. Rozanski A, Blumenthal JA, Davidson KW, et al., The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology, J Am Coll Cardiol, 2005;45:637–51.
    Crossref | PubMed
  10. Egede LE, Major depression in individuals with chronic medical disorders: prevalence, correlates and association with health resource utilization, lost productivity and functional disability, Gen Hosp Psychiatry, 2007;29:409–16.
    Crossref | PubMed
  11. Glassman AH, O’Connor CM, Califf RM, et al., Sertraline treatment of major depression in patients with acute MI or unstable angina, JAMA, 2002;288:701–9.
    Crossref | PubMed
  12. Frasure-Smith N, Lesperance F, Recent evidence linking coronary heart disease and depression, Can J Psychiatry, 2006;51:730–37.
    PubMed
  13. Freedland KE, Carney RM, Lustman PJ, et al., Major depression in coronary artery disease patients with vs. without a prior history of depression, Psychosom Med, 1992;54:416–21.
    Crossref | PubMed
  14. Frasure-Smith N, Lesperance F, Reflections on depression as a cardiac risk factor, Psychosom Med, 2005;67(Suppl. 1): S19–S25.
    Crossref | PubMed
  15. Carney RM, Rich MW, teVelde A, et al., The relationship between heart rate, heart rate variability and depression in patients with coronary artery disease, J Psychosom Res, 1988;32:159–64.
    Crossref | PubMed
  16. Glassman AH, Helzer JE, Covey LS, et al., Smoking, smoking cessation, and major depression, JAMA, 1990;264:1546–9.
    Crossref | PubMed
  17. McGee HM, Doyle F, Conroy RM, et al., Impact of brieflyassessed depression on secondary prevention outcomes after acute coronary syndrome: a one-year longitudinal survey, BMC Health Serv Res, 2006;6:9.
    Crossref | PubMed
  18. Carney RM, Freedland KE, Eisen SA, et al., Major depression and medication adherence in elderly patients with coronary artery disease, Health Psychol, 1995;14:88–90.
    Crossref | PubMed
  19. Rieckmann N, Gerin W, Kronish IM, et al., Course of depressive symptoms and medication adherence after acute coronary syndromes: an electronic medication monitoring study, J Am Coll Cardiol, 2006;48:2218–22.
    Crossref | PubMed
  20. Jaarsma T, Lesman-Leegte I, Hillege HL, et al., Depression and the Usefulness of a Disease Management Program in Heart Failure: Insights From the COACH (Coordinating study evaluating Outcomes of Advising and Counseling in Heart failure) Study, J Am Coll Cardiol, 2009;55:1837–43.
    Crossref | PubMed
  21. Lichtman JH, Bigger JT, Jr, Blumenthal JA, et al., Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association, Circulation, 2008;118:1768–75.
    Crossref | PubMed
  22. Kroenke K, Spitzer RL, Williams JB, The Patient Health Questionnaire-2: validity of a two-item depression screener, Med Care, 2003;41:1284–92.
    Crossref | PubMed
  23. Kroenke K, Spitzer RL, Williams JB, The PHQ-9: validity of a brief depression severity measure, J Gen Intern Med, 2001;16:606–13.
    Crossref | PubMed
  24. Berkman LF, Blumenthal J, Burg M, et al., Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial, JAMA, 2003;289:3106–16.
    Crossref | PubMed
  25. Mendes de Leon CF, Czajkowski SM, Freedland KE, et al., The effect of a psychosocial intervention and quality of life after acute myocardial infarction: the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial, J Cardiopulm Rehabil, 2006;26:9.
    Crossref | PubMed
  26. Carney RM, Blumenthal JA, Freedland KE, et al., Depression and late mortality after myocardial infarction in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, Psychosom Med, 2004;66:466–74.
    Crossref | PubMed
  27. Blumenthal JA, Babyak MA, Carney RM, et al., Exercise, depression, and mortality after myocardial infarction in the ENRICHD trial, Med Sci Sports Exerc, 2004;36:746–55.
    Crossref | PubMed
  28. Taylor CB, Youngblood ME, Catellier D, et al., Effects of antidepressant medication on morbidity and mortality in depressed patients after myocardial infarction, Arch Gen Psychiatry, 2005;62:792–8.
    Crossref | PubMed
  29. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators, N Engl J Med, 1989;321:406–12.
    Crossref | PubMed
  30. Lesperance F, Frasure-Smith N, Koszycki D, et al., Effects of citalopram and interpersonal psychotherapy on depression in patients with coronary artery disease: the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial, JAMA, 2007;297:367–79.
    Crossref | PubMed
  31. Davidson KW, Rieckmann N, Clemow L, et al., Enhanced depression care for patients with acute coronary syndrome and persistent depressive symptoms: coronary psychosocial evaluation studies randomized controlled trial, Arch Intern Med, 2010;170:600–608.
    Crossref | PubMed
  32. Unützer J, Katon W, Callahan CM, et al., Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial, JAMA, 2002;288: 2836–45.
    Crossref | PubMed
  33. Sherwood A, Blumenthal JA, Trivedi R, et al., Relationship of depression to death or hospitalization in patients with heart failure, Arch Intern Med, 2007;167:367–73.
    Crossref | PubMed
  34. Herridge ML, Stimler CE, Southard DR, King ML, Depression screening in cardiac rehabilitation: AACVPR Task Force Report, J Cardiopulm Rehabil, 2005;25:11–13.
    Crossref | PubMed
  35. Thomas RJ, King M, Lui K, et al., AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services, Circulation, 2007;107:1611–42.
    Crossref | PubMed
  36. American Association of Cardiovascular and Pulmonary Rehabilitation, Guidelines for cardiac rehabilitation and secondary prevention programs, 4th ed, Champaign, IL: Human Kinetics, 2004.
  37. Blumenthal JA, Babyak M, Wei J, et al., Usefulness of psychosocial treatment of mental stress-induced myocardial ischemia in men, Am J Cardiol, 2002;89:164–8.
    Crossref | PubMed
  38. Ruo B, Rumsfeld JS, Pipkin S, Whooley MA, Relation between depressive symptoms and treadmill exercise capacity in the Heart and Soul Study, Am J Cardiol, 2004;94:96–9.
    Crossref | PubMed
  39. Carels RA, The association between disease severity, functional status, depression and daily quality of life in congestive heart failure patients, Qual Life Res, 2004;13:63–72.
    Crossref | PubMed
  40. Milani RV, Lavie CJ, Cassidy MM, Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events, Am Heart J, 1996;132:726–32.
    Crossref | PubMed
  41. Josephson E, Casey E, Waechter D, et al., Gender and depression symptoms in cardiac rehabilitation: women initially exhibit higher depression scores but experience more improvement, J Cardiopulm Rehabil, 2006;26:160–63.
    Crossref | PubMed
  42. Barbour KA, Blumenthal JA, Exercise training and depression in older adults, Neurobiol Aging, 2005;26(Suppl. 1):119–23.
    Crossref | PubMed
  43. Blumenthal JA, Babyak MA, Doraiswamy PM, et al., Exercise and pharmacotherapy in the treatment of major depressive disorder, Psychosom Med, 2007;69:587–96.
    Crossref | PubMed
  44. Freedland KE, Carney RM, Skala JA, Depression and Smoking in Coronary Heart Disease, Psychosom Med, 2005;67:S42–S46.
    Crossref | PubMed
  45. Lucini DL, Milani RV, Constantino G, et al., Effects of cardiac rehabilitation and exercise training on autonomic regulation in patients with coronary artery disease, Am Heart J, 2002;143:977–83.
    Crossref | PubMed
  46. Milani RV, Lavie CJ, Impact of cardiac rehabilitation on depression and its associated mortality, Am J Med, 2007;120:799–806.
    Crossref | PubMed
  47. Casey E, Hughes JW, Waechter D, et al., Depression Predicts Failure to Complete Phase-II Cardiac Rehabilitation, J Behav Med, 2008;31(5):421–31.
    Crossref | PubMed
  48. Hughes J, Bartley A, Casey E, Depression Symptoms are not a Major Impediment to Enrollment in Phase-II Cardiac Rehabilitation, J Cardiopulm Rehabil, 2006;26:255.
    Crossref
  49. Blumenthal JA, Williams RS, Wallace AG, et al., Physiological and psychological variables predict compliance to prescribed exercise therapy in patients recovering from myocardial infarction, Psychosom Med, 1982;44:519–27.
    Crossref | PubMed
  50. Glazer KM, Emery CF, Frid DJ, Banyasz RE, Psychological predictors of adherence and outcomes among patients in cardiac rehabilitation, J Cardiopulm Rehabil, 2002;22:40–46.
    Crossref | PubMed
  51. Lane D, Carroll D, Ring C, et al., Predictors of attendance at cardiac rehabilitation after myocardial infarction, J Psychosom Res, 2001;51:497–501.
    Crossref | PubMed
  52. Sanderson BK, Bittner V, Women in cardiac rehabilitation: outcomes and identifying risk for dropout, Am Heart J, 2005;150:1052–8.
    Crossref | PubMed
  53. Turner SC, Bethell HJN, Evans JA, et al., Patient characteristics and outcomes of cardiac rehabilitation, J Cardiopulm Rehabil, 2002;22:253–60.
    Crossref | PubMed
  54. Caulin-Glaser T, Maciejewski PK, Snow R, et al., Depressive symptoms and sex affect completion rates and clinical outcomes in cardiac rehabilitation, Prev Cardiol, 2007;10: 15–21.
    Crossref | PubMed
  55. Wang P, Bohn R, Knight E, et al., Noncompliance with antihypertensive medications: the impact of depressive symptoms and psychosocial factors, J Gen Intern Med, 2002;17:504–11.
    Crossref | PubMed
  56. Gehi A, Haas D, Pipkin S, Whooley MA, Depression and medication adherence in outpatients with coronary heart disease: findings from the Heart and Soul Study, Arch Intern Med, 2005;165:2508–13.
    Crossref | PubMed
  57. Bane C, Hughes CM, McElnay JC, The impact of depressive symptoms and psychosocial factors on medication adherence in cardiovascular disease, Patient Educ Couns, 2006;60:187–93.
    Crossref | PubMed
  58. Morgan A, Masoudi F, Havranek E, et al., Difficulty taking medications, depression, and health status in heart failure patients, J Card Fail, 2006;12:54–60.
    Crossref | PubMed
  59. Ziegelstein RC, Fauerbach JA, Stevens SS, et al., Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction, Arch Intern Med, 2000;160:1818–23.
    Crossref | PubMed
  60. Romanelli J, Fauerbach JA, Bush DE, Ziegelstein RC, The significance of depression in older patients after myocardial infarction, J Am Geriatr Soc, 2002;50:817–22.
    Crossref | PubMed