Written by Jonathan Gallagher, Senior Psychologist, Beaumont Hospital, Dublin – Dr Elizabeth O’Brien, Senior Clinical Psychologist, St Vincent’s University Hospital and Dr Sinead Mulhern, Principal Clinical Psychologist, Mater Hospital
Meeting of Hearts & Minds – The Practice of Cardiac Psychology.
PSYCHOLOGICAL FACTORS & CARDIOVASCULAR DISEASE (CVD)
A cardiac event such as a heart attack can be a psychologically devastating experience, with profound and enduring consequences. Frequently its onset is sudden, distressing and potentially life-threatening. Even if this is not the case, mere knowledge of this new disease status can trigger strong and frequently long-term emotional reactions as well as prompting significant lifestyle changes.
Perhaps unsurprisingly, psychological distress is highly prevalent in patients with cardiovascular disease (CVD). Anxiety, depression and insomnia disorder affect approximately one-third of people with CVD, and up to one in four cardiac patients experience clinically significant levels of posttraumatic stress (PTSD) 1-4 . Furthermore, psychological distress is linked to increased future cardiac events and mortality, poorer quality of life, increased suicide risk, greater healthcare costs and poorer long-term psychological adjustment 5 . Unfortunately, there is also evidence that during the COVID-19 pandemic psychological distress has increased in cardiac patients and this has been exacerbated by social isolation, treatment nonadherence, physical inactivity, and an increase in unhealthy lifestyle behaviours 6,7 .
COMMON PSYCHOLOGICAL RESPONSES TO CVD
In the initial aftermath of a cardiac event, the focus is understandably on the patient’s physical recovery, and many people feel relief or even gratitude for having survived. However, once a person begins to feel better physically, the emotional distress they have been holding at bay can surface. It may feel safer for this to emerge after things appear to have stabilised medically. Although this can be a normal part of the recovery process it can be quite frightening if the person hasn’t experienced this kind of emotional vulnerability previously.
After the initial sense of shock subsides, emotional vulnerability can manifest in different ways for cardiac patients:
- Anxiety and fear of having another heart attack is very common, and this typically eases for people as they begin to re-engage with their lives. However, for many their fear can be so great that they restrict their activities (e.g. avoiding exercise) to the point where this interrupts their lives and compromises their health.
- Many people experience panic attacks after a cardiac event and need help understanding why this happens and figuring out how to respond differently to the triggers for panic (e.g. abdominal breathing).
- Low mood, depression or hopelessness affects many patients with heart disease. This is often accompanied by a feeling of grief about what’s been lost (e.g. a sense of immortality, physical limitations), and can lead to a sense of disconnect with life and its sense of purpose or meaning. Depression is common, and can be compounded by fatigue which limits the individual’s ability to fully engage in life.
- Social isolation and/or lack of perceived support can deepen the impact of depressed mood. If an individual doesn’t have an emotional connection with another person to process the grief they’re experiencing, they may need to look externally to see who can support them with this challenge. Social support is hugely important in helping cardiac patients to adjust to sometimes multiple lifestyle changes (e.g. exercise, dietary patterns, smoking, alcohol reduction).
- Sleep problems are especially common in newly diagnosed cardiac patients, and many patients are afraid to close their eyes at night for fear they may not wake up. Improving one’s ability to unwind and slow down can be important here, and brief psychological treatments for insomnia (CBT-I) are particularly effective.
- Some people may even feel traumatised by their cardiac event. For example, if they nearly died or were shocked on the way to hospital; or if their implantable device (ICD) went off. Or maybe they were very distressed in ICU and were convinced they were going to die. Sometimes in the aftermath of such an experience people develop symptoms of posttraumatic stress disorder (PTSD) which can include reliving the trauma or having flashbacks or nightmares, feeling very alert to future risk and feeling very anxious. These symptoms often resolve but at times can remain very frightening.
- People may feel anger if they believe their cardiac issue was not identified in time, or even towards others (e.g. employer, family members) whom they perceive to have contributed to their high stress levels. Personality traits such as hostility place patients at additional cardiovascular risk, and outburst of anger have been shown to serve as triggers of acute cardiovascular events 8 .
- Where stress has been ongoing, people may be placing high demands on themselves which result in an overly demanding lifestyle. Now, this can lead to feeling overwhelmed by pressures that feel unchangeable, and this may need to be addressed.
- Mental and behavioural habits that perpetuate the stress cycles people are caught in can add additional suffering and impede physical recovery. For example, people often need help getting unstuck from thinking traps that drive automatic or unhelpful behaviour. This may include guilt about previous lifestyle choices made, regrets, self-blame or self-criticism. These common thinking styles can hold people back and lower mood, particularly in those patients who had a lot of negative selftalk before their cardiac event.
- Relationships and sexual health are also significantly impacted in the aftermath of a cardiac diagnosis and individuals need to feel confident in having a safe space to speak openly about these important concerns should they need to.
MECHANISMS: HOW PSYCHOLOGICAL FACTORS AFFECT CARDIOVASCULAR HEALTH
The mind and body are inextricably linked, and psychological well-being has direct effects that mediate improvements in cardiovascular health. Better psychological well-being is associated with lower blood pressure, a lower prevalence of metabolic syndrome, a more favourable lipid profile, a lower likelihood of smoking, increased exercise levels and greater adherence to a hearthealthy diet 9-11 . Conversely, anxiety and chronic stress have been shown to increase inflammation, increase blood pressure and stress hormones such as cortisol which can impact coronary arteries and increase the risk of cardiac events. Similarly, depression has also been shown to be linked with increased inflammation, reduced physical activity, continued smoking, weight gain and poorer adherence to secondary preventive medications (SPMs). While psychological components are clearly linked with both health behaviours and factors that are directly related to cardiovascular health, improving the psychological wellbeing of cardiac patients is key to optimising their health outcomes.
PSYCHOLOGICAL CARE FOR CARDIAC PATIENTS DURING CARDIAC REHABILITATION (CR)
In many respects, cardiac rehabilitation (CR) is the ideal setting in which to address the psychological needs of cardiac patients. CR is a comprehensive, multi-disciplinary chronic disease management programme that incorporates core components such as patient assessment, supervised exercise training with continuous ECG monitoring (telemetry), nutritional counselling, management of cardiac risk factors (lipids, diabetes, blood pressure, weight) and psychological management. To ensure comprehensive cardiac care, some CR programmes have a psychologist on staff as a fully integrated member of the MDT. Systematic reviews demonstrate that the psychological component drives the benefits achieved by CR, and that psychological interventions not only improve psychological distress and quality of life, but also reduce cardiac events and hospitalizations 12,13 .
From a psychological standpoint, cardiac patients experiencing psychological difficulties present to CR in broadly two different ways: their distress is ‘new’ following their recent cardiac event; or they’ve had ongoing stress prior to their health issues which is now adding to their current distress (e.g. health anxiety). Many of these patients also have other psychological and behavioural problems and have never encountered a mental health professional before.
Participating in CR is a process of recovery where patients grow together in their confidence to re-engage with their lives after a cardiac event. Because they are monitored during exercise, they feel safe to push themselves physically and this helps them to restore a sense of trust in their bodies and the expectation that they will recover well This process is reinforced by targeted education on behavioural risk factors (e.g. diet, medications, smoking) which enhances the patient’s understanding of their heart condition and their sense of control over their health. The group context has a normalising effect as it enables people to share their experiences with others. This allows patients to both benefit from the support of their peers and to learn that they are not the “only ones” to feel this way. CR can also be a good time for people to pause and re-evaluate what’s important to them in life and where they wish to spend their time and attention going forward. Cardiac patients are often acutely aware of the opportunity to review and improve their quality of life that is not afforded to those who die suddenly. This can sometimes come to be seen as a ‘silver lining’ that accompanies a recent realisation of life’s fragility.
THE ROLE OF THE PSYCHOLOGIST IN CR
The psychological benefits of exercise training (ET) are wellestablished 14 and ET is proven to be a highly cost-effective intervention for improving depressed mood in cardiac patients 15 . This can be particularly effective when allied to the social support received by staff and/or peers during CR. However, international guidelines continue to recommend that comprehensive CR programmes also provide psychological interventions delivered by appropriately trained mental health professionals, and that patients with psychological difficulties are followed in a stepped manner through to remission 16-18 .
Psychologists working in CR provide a range of psychological treatments to meet the needs of cardiac patients. Where possible, a matched or stepped care model is employed allowing treatment complexity to be matched to patient need. This allows for simpler low-intensity psychological interventions initially but also provides for specialist mental health care to be available to those patients requiring it. This model has been shown to be both accessible to patients and associated with increased satisfaction with cardiac care 19 .
In parallel with exercise training (ET), many patients during CR benefit psychologically from brief interventions such as supportive counselling, motivational interventions to assist with changing health behaviours and/ or targeted psychoeducational group sessions (e.g. adjusting to adverse life events, managing depressed mood, resuming sexual activity after a cardiac event, managing fatigue).
Stress management training (SMT) – when fully integrated with CR – not only helps patients to reduce stress but is proven to deliver an incremental benefit on cardiac outcomes (e.g. recurrent events, hospital readmissions) when compared to CR alone. Similarly, many psychologists are also trained in the delivery of mindfulness-based interventions (MBI) which can help CR patients to learn an effective coping strategy for managing stress and a way of approaching psychological distress differently. For patients with insomnia, Cognitive Behavioural Therapy for Insomnia (CBT-I) is the recommended first-line treatment, is highly effective, and its benefits are proven to persist at 10-year follow up 20-22 .
Frequently, certain cardiac patients (e.g. survivors of sudden cardiac arrest, SCAD) present with unique and complex psychological needs (e.g. device-related shock anxiety, PTSD) that are best delivered by an experienced clinician familiar with cardiology.
In the case of individual therapy (e.g. anxiety, depression, adjusting to adverse life events) the intention in exploring psychological distress is to allow its expression, to acknowledge it, and to offer the patient treatment strategies to address stress and factors currently contributing to the distress. A concurrent aim can be to focus on aspects of life that are meaningful that can be expanded upon, particularly in the case of existential difficulties experienced following a near death experience.
Additional expertise provided by cardiac psychologists includes psychological preparation for cardiac surgery, weight management, psychosexual counselling, insomnia treatment, medication adherence, family support (e.g. caregiver burden in heart failure), neuropsychological assessment, maintaining lifestyle changes, training of cardiology team members, research, clinical audit and quality improvement, and advocacy.
CARDIAC PSYCHOLOGY IN IRELAND: SERVICE EXAMPLES
Beaumont Hospital has a dedicated Cardiac Psychology service which is fully integrated with its Cardiology Department. Patients can access psychological care as required during the inpatient phase (Coronary Care) and individual psychology referrals are also received from both the CR programme and the outpatient Heart Failure Service (Supportive Heart Unit).
During CR, all patients routinely meet with the cardiac psychologist at the beginning of the programme, and this enables timely identification of patients at increased risk of psychological difficulties. As well as affording each patient the time and space to tell their individual story, patients identify the role of the psychologist as an integral component of CR. This normalises the inclusion of psychological issues in cardiac care and ensures high levels of patient engagement. At this juncture, brief individual interventions (e.g. supportive counselling, motivational interviewing) are also delivered as appropriate.
All patients are invited to attend weekly small group psychoeducational sessions which are incorporated into the CR programme. These sessions are based on a CBT-framework and address adjustment to heart disease, health-related lifestyle changes, and adaptive coping. Additional group sessions address sleep, weight management, managing depressed mood, stress and heart disease, overwork & exhaustion, treatment adherence, the psychology of eating and resuming sexual activity after a cardiac event.
As part of Beaumont’s steppedcare pathway, patients can also access a comprehensive Stress Management Training (SMT) Programme specifically designed for cardiac patients. This multicomponent intervention combines psychoeducation, group support and cognitive behaviour therapy for groups of 10-12 patients. Here patients acquire an extensive repertoire of relaxation techniques and psychological skills targeting stress, anxiety, sleep and anger/hostility.
Beaumont Hospital have also developed a comprehensive Heart Failure Self-Management Programme to support patients living with HF, including those unable to participate in exercisebased CR. The ‘UPBEAT’ programme targets the health of both patients and their caregivers (e.g. caregiver burden) and has been shown to be effective in improving HF self-management, psychological distress and medication adherence in patients living with HF.
All patients completing the CR programme are also followed up by the cardiac psychologist. For patients requiring additional support at this point, treatment options are discussed with the patient and onward referrals are made as appropriate (e.g. referral for stress management, individual therapy, GP, community mental health team and/or Irish Heart Foundation patient support group). For sensitive treatment-related issues (e.g. erectile dysfunction), a referral to the cardiology clinic is facilitated on the patient’s behalf. Psychological support is also provided to partners of patients where appropriate.
St Vincent’s University Hospital (SVUH):
The Cardiac Psychology service at SVUH has evolved over time and currently employs both a senior clinical psychologist (1.0 WTE) and a psychotherapist (0.3 WTE). SVUH also provide a stepped care model delivering a service for patients across the spectrum of cardiac disease.
Lower intensity and group-based interventions are offered for mild to moderate distress, and higher intensity interventions (e.g. individual psychological therapy) are offered where there is greater complexity to the presenting difficulties and more severe distress. All psychological interventions are evidencedbased in accordance with best clinical guidance, and encompass cognitive behavioural therapy (CBT), interpersonal therapy, mindfulness-based interventions (MBI), compassion-focused therapy, short term Kleinian psychotherapy and integrative approaches (depending on the clinical presentation).
SVUH’s Cardiac Psychology service provides input to the CR programme, and consultation is provided as required, on both an inpatient and outpatient basis. Patient assessment and individual input (e.g. formulation and intervention) can be initiated at any point of a patient’s care journey. All patients attending the CR programme can benefit from two psycho-educational group sessions where participants learn about stress, depression, how these difficulties can impact heart health, coping strategies and signposting to further help, and planning for post-CR behaviour maintenance. Mindfulness based interventions (MBI) such as mindfulness-based stress reduction (MBSR) and mindfulness based cognitive therapy (MBCT) are 8-week group interventions run by the SVUH Psychology Department and are also available to these patients. MBI have been shown to reduce stress, depression, improve quality of life and help individuals manage ongoing chronic conditions 23 .
Patients living with heart failure (HF) are at increased risk of psychological problems such as depression and anxiety, which can in turn negatively impact cardiac outcomes. Patients with HF can access SVUH’s Cardiac Psychology service at different stages of their illness from diagnosis to episodes of acute decompensated HF, disease progression through to end of life. CR is proven to be effective with this patient population, and the Cardiac Psychology Service also contribute to the 8-week multidisciplinary CR programme for patients with HF. A clinic also runs from the Heart Failure Unit offering individual therapy for those with more moderate to severe distress. MBI is a helpful follow-on for those appropriate who are discharged from CR or individual therapy, and patients with HF are accepted to this programme.
Patients with arrhythmias or an implantable cardiac device attending SVUH can also avail of the Cardiac Psychology service. Although most patients receiving an implantable cardioverter defibrillator (ICD) or pacemaker adjust without psychological difficulties, a significant proportion of patients can experience specific psychological challenges. Some patients with an ICD can develop problems with body image due to the implant, or anxiety in response to either cardiac symptoms or due to the device delivering therapy (i.e. an electric shock). Some will develop post-traumatic stress problems such as hypervigilance or feeling on edge, avoiding things that cause distress or re-living distressing experiences (e.g. nightmares). Notably, the prevalence of PTSD in patients with an ICD has been shown to be greater than that for Gulf War veterans 24 . The Cardiac Psychology service contribute to a multidisciplinary group education session for those who have been recently fitted with a device to help support patients’ awareness and independent selfcare. In addition to psychology services, psychological therapy, in particular CBT and trauma-informed cognitive therapy are available to patients requiring individual support.
As well as direct clinical work with patients, SVUH’s Cardiac Psychology service collaborate with colleagues in other settings (e.g. the Irish Heart Foundation) to highlight the psychological needs of cardiac patients and to advocate for optimum service provision. Research and the provision of training to colleagues which is cognisant of the psychological needs of patients is also core business of the service.
Mater Misericordiae University Hospital (MMUH):
In the Mater Hospital Cardiac Rehabilitation programme (CR) there is a principal clinical psychologist (WTE 0.4) appointed to the 8-week programme. All patients are invited to the 2-hour stress management talk given by the psychologist. During this talk, all patients are invited to take part in a mindfulness exercise and are then invited to participate in an 8-week mindfulness group. Mindfulness-based interventions (MBI) have been associated with improvements across a range of physical and mental health outcomes, including improved depressive symptoms, anxiety, stress, quality of life, smoking cessation, healthy eating and physical activity 25-27 . In line with these findings, evaluations of MMUH groups have demonstrated this to be an effective coping strategy for CR patients in terms of reducing anxiety and depression.
A pre-pandemic snapshot of the Cardiac Psychology service over 6 months showed that approximately 65 patients attended the stress management talk at the beginning of CR, and just over half of these patients (33) went onto to attend one of the 2 mindfulness groups run during this time. Feedback from the evaluation of the mindfulness programme has shown that patients viewed this an effective method to both manage stress and approach psychological distress differently. Additionally, patients indicated some improvements in mindfulness skills and self-compassion.
During the same 6-month period, 24 patients were seen for individual therapy sessions, and the average number of sessions received by patients was 4 (range 1 – 8 sessions). Areas of distress that were explored frequently included anxiety and depression and difficulties with adjustment to the cardiac event. In addition stress management, social and relationship difficulties were also addressed.
ACCESS TO PSYCHOLOGICAL CARE FOR CARDIAC PATIENTS IN IRELAND
As we have seen, psychological factors are strongly linked with cardiac prognosis, and there is firm evidence underpinning psychological support for patients with heart disease. Furthermore, the need for psychological support has intensified during the recent pandemic. However, psychological services for cardiac patients in Ireland are poorly resourced nationally and characterised by inequitable access.
The recent National Survey of CR services 28 conducted by Irish Heart Foundation (IHF) and the Irish Association of Cardiac Rehabilitation (IACR) showed that 80% (28/35) of CR centres had no access to psychological support for their patients. Yet, access to psychology was the highest rated service required (50% of CR Centres) to improve the quality of CR. Similarly, the IHF have deemed psychology a priority area and added: “the lack of psychological services and supports is emerging as one of the issues of greatest concern to the people in our patient advocacy network”.
CR programmes in Ireland are anxious to provide their patients with access to this essential service. The multidisciplinary team (MDT) for each CR centre should include dedicated and adequate psychology staffing. Our patients deserve nothing less.
References available on request
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