Transcript Chronic anxiety in ICD patients: A multi

CoRPS
Center of Research
on Psychology
in Somatic diseases
Psychosocial support
Susanne S. Pedersen, Professor of Cardiac Psychology
CoRPS
Disclosures
None
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Affiliations
Prof.dr. Susanne S. Pedersen
• CoRPS - Center of Research on
Psychology in Somatic diseases, Tilburg
University, The Netherlands
• Thoraxcenter, Erasmus Medical Center,
Rotterdam, The Netherlands
• Department of Cardiology, Odense
University Hospital, Denmark
Phone: + 31 (0) 13 466 2503
E-mail: [email protected]
www.tilburguniversity.nl/corps
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Overview
• Why bother about psychosocial support?
• Interventions: Do we know what works?
• E-health: New kid on the block
• Clinical practice tips
• Take home message
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Overview
• Why bother about psychosocial support?
• Interventions: Do we know what works?
• E-health: New kid on the block
• Clinical practice tips
• Take home message
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Anxiety
Depression
Type D
Vital exhaustion
Type A
Social isolation
PTSD
Hostility
Stress
Anger
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PCI patients - Minimal symptoms and
mortality/MI
PHQ-2* cut-off ≥2 (range 0-6)
%
10
HR: 1.89; 95% CI: [1.06-3.35]
21/240
N = 796
8
6
26/556
4
2
0
Depressed Non-depressed
* 1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
Pedersen et al. J Gen Intern Med 2009;24:1037-42
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ICD patients - Posttraumatic stress
symptoms and mortality
N = 147
Ladwig et al. Arch Gen Psychiatry 2008;65:1325-30
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Type D personality - burden of increased
negative emotions and inhibition
No!!
I do not want to
share my emotions
with others…
Type D ?
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ICD patients - Anxious Type D patients and
ventricular arrhythmias
N = 391
van den Broek, Denollet et al. JACC 2009;54:531-7
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ICD patients - Type D personality and preimplantation ICD concerns and mortality
N = 371
2-year mortality (%)
HR: 3.65; 95%CI: 1.57-8.45; p = .003
20
18
16
14
12
10
8
6
18.2%
5.2%
4
2
0
Type D and concerns
Pedersen et al. Europace 2010;12:1446-52
None or one risk marker
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Peripheral arterial disease: Depression
and mortality
Cherr al. 2008;23:629-34
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Chronic heart failure: Depression,
anxiety, social isolation and mortality
Cumulative hazard functions:
Friedmann et al. Am Heart J 2006;152:940.e1-940.e8
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Prevalence of psychological distress in
patients with heart disease
A subset of patients: 1 in 4 (25%)
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Why would depression be bad for the heart?
CAD
Healthrelated
behaviours
Elevated
blood
pressure
Hemostatic
changes
Endothelial
damage
Depression
Activation
of the
HPA-axis
 HRV
Noncompliance
Risk factor
clustering
Release
of stress
hormones
Inflammation
Poor
prognosis
Also effects on QoL, adherance, and compliance !!!
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Disclosures
Kotseva et al. Lancet 2009;373:929-40
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ICD shock - the paradox
Safety?
Danger?
Braunschweig, Boriani, ... Pedersen et al., Europace 2010;12:1673-90
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Overview
• Why bother about psychosocial support?
• Interventions: Do we know what works?
• E-health: New kid on the block
• Clinical practice tips
• Take home message
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Key questions
• How do we get emotionally
distressed patients into
interventions?
• How do we keep them in
interventions?
• What to offer patients what works for whom?
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Possible interventions
Drug Therapy
Counseling
Stress Reduction Techniques
Cognitive Behavioral
Therapy
Psychotherapy
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Major intervention trials in CAD
Trial name
Sample
Risk factor
Treatment
Endpoint
SADHART (2003)
369 MI/UAP
Depression
Sertraline vs.
placebo
LVEF (safety)
ENRICHD (2003)
2481 MI
Depression/
poor support
CBT (+SSRI)
vs. UC
Recurrent MI/death
(all-cause)
EXIT (2005)
710 PCI
Exhaustion
BI vs. UC
Exhaustion/MACE
CREATE (2007)
284 CAD
Depression
Citalopram vs.
IPT vs. UC
Depression
(HAM-D/BDI)
MIND-IT (2007)
91 MI
Depression
Mirtazapine vs.
placebo
MACE (safety)
Bypassing
the Blues (2009)
302 CABG
Depression
Phone-delivered
collaborative care
vs. UC
Mental health-related
QoL
BI = behavioural intervention; IPT = interpersonal psychotherapy; UC = usual care
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SADHART – some results
Glassman et al. JAMA 2002;288:701-9
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SADHART – some results
Glassman et al. JAMA 2002;288:701-9
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SADHART – some results
Swenson et al. Am J Cardiol 2003;92:1271-6
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SADHART – some results
Swenson et al. Am J Cardiol 2003:92:1271-6
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ENRICHD - some results
Berkman et al. JAMA 2003;289:3106-16
ENRICHD:
Relative
survival
benefits
in
preCoRPS
planned subgroups
Berkman et al. JAMA 2003;289:3106-16
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Lessons learned from ENRICHD
• CBT may be harmful for women
• May be less effective to target depression immediately post-MI
 Perhaps better to focus on those with chronic levels
• Is CBT the appropriate intervention for cardiac patients?
 Assumes that patients have distorted cognitions…
• Inclusion of less severe cases?
 Patients with co-morbid conditions, such as physical illness, personality
disorders etc. were excluded… (seen in RESEARCH registry)
• UC had an unusually high recovery rate
 Some patients may have had transient depression related to MI
Jiang et al. Am Heart J 2005;150:54-78
Martens et al. J Affect Disord 2006;94:231-7
EXIT
trial:
Worked
in
patients
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without previous cardiac history
Intervention reduced the odds of exhaustion at
18 months:
• Without history of CAD: 55% reduction (OR: 0.45;
95% CI: 0.30–0.68; p .00)
• With a history of CAD: 7% reduction but ns (OR:
0.93; 95% CI: 0.56 –1.55; p .78)
Appels et al. Psychosom Med 2005;67:217-23
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Cognitive behavioral therapy in CHD
20 two-hour
sessions
of
•• Nonfatal
first recurrent
CVD
events:
0.59 [95%
0.42CBT inHR:
groups
(5-9)CI:
during
0.83]
41% reduction
one –year
•• Recurrent
myocardial
separateacute
for men
and
infarctions:
women HR:0.55 [95% CI:
0.36-0.85] - 45% reduction
• focusing on stress
• All-cause mortality: HR: 0.72
management of emotional
[0.40-1.30] - 28% reduction (NS)
factors
Gullikson et al. Arch Intern Med 2011;171:134-40
N = 362
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Collaborative care in CABG patients with
depression
• 8-months telephone- and
nursing-delivered
collaborative care
• Real world treatment
package (e.g. education
about illness, selfmanagement, etc. and
consideration of patient
preferences)
Rollmann et al. JAMA 2009;302:2095-103
N = 302
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Collaborative care in CABG patients with
depression
N = 302
Rollmann et al. JAMA 2009;302:2095-103
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Chronic heart failure: Self-management
Heart Failure Adherence and Retention
Randomized Behavioral Trial (HART)
• 18 two-hour group meetings
(10 patients) during one year
• Heart failure education and
counselling
• Problem-solving format
patients identifying barriers to
implementation
Powell et al. Arch Intern Med 304:1331-8
N = 902
p = .46
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Chronic heart failure: Self-management
Heart Failure Adherence and Retention
Randomized Behavioral Trial (HART)
Time by treatment (p = .02)
Powell et al. Arch Intern Med 304:1331-8
N = 902
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Depression and cardiac rehabilitation (CR)
paradox
CR does lead to reductions in psychological morbidity
Hevey et al. Psychosom Med 2007;69:793-7
Depression
and
cardiac
rehabilitation
(CR)
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paradox
... as corroborated by others
Egger et al. Eur J Cardiovasc Prevention Rehabil 2008;15:704-8
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Depression and cardiac rehabilitation (CR)
paradox
... but paradoxically non-completers and early
dropouts have more distress and poorer quality of life
McGrady et al. J Cardiopulm Rehab Prevention 2009;29:358-64
Depression
and
cardiac
rehabilitation
(CR)
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paradox
... as corroborated by others
Lavie et al. Arch Intern Med 2006;166:1878-83
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The role of the patient’s attitudes and
motivation
Dunlay et al. Am Heart J 2009;158:852-9
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The role of type of cardiac rehabilitation
N = 225 depressed
CAD women
Group by time interaction: F(2, 466)=4.42, p = .013
Beckie et al. Int J Nurs Studies, In Press
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CoRPS
Overview
• Why bother about psychosocial support?
• Interventions: Do we know what works?
• E-health: New kid on the block
• Clinical practice tips
• Take home message
CoRPS
ICD intervention trial - WEBCARE
Pedersen et al. Trials 2009;10:120
CoRPS Intervention – web application
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WEBCARE – Objectives
Primary:
• To investigate whether the web-based intervention is
superior to usual care in terms of reducing anxiety,
depression, and ICD concerns as well as improving ICD
acceptance and quality of life
• To investigate the cost-effectiveness of the web-based
intervention and whether the web-based intervention
is associated with reduced health-care utilization
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WEBCARE – Objectives
Secondary:
• To examine whether psychological (i.e., Type D
personality and positive affect) and clinical factors (i.e.,
cardiac resynchronization therapy (CRT)) moderate the
effect of the intervention, with a view to developing risk
profiles of patients who are less likely to benefit from the
intervention
Explorative:
• To explore whether the web-based intervention
influences physiological parameters (i.e., ventricular
arrhythmias and the cortisol awakening response (CAR))
WEBCARE – Study design
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5-10 days post implantation:
completion of baseline
questionnaire
-T1
T0
Follow-up
Intervention
T1
T2
T3
14
26
52
Usual care
Weeks
0
Hospitalisation
for ICD
implantation
2
Randomisation
to intervention
or usual care
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WEBCARE - Intervention (fixed, 3-month duration)
COMPONENTS
TOPICS DEALT WITH
• Psycho-education about the ICD
• Emotional reactions to ICD
therapy
• Problem-solving skills
• Which aspects of ICD therapy
may lead to distress
• Cognitive restructuring
• Relaxation training
• How to deal with shocks
• Disease-specific issues and fears
• How to prevent the avoidance of
• Personalized feedback by a therapist
activities
via the computer
• Interpretation of bodily
symptoms
• How to cope with uncertainty
• Help-seeking behavior
• How to cope with stress
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Reasons for refusal and quitting prematurely
Reason for initial refusal of participation:
• Too much work
• No interest in participating in a study
• Problems with the website
Reason for quitting prematurely:
• Too confronting / too personal
• Too time consuming / too much work
• Problems with the website
CoRPS
Overview
• Why bother about psychosocial support?
• Interventions: Do we know what works?
• E-health: New kid on the block
• Clinical practice tips
• Take home message
CoRPS
European Guidelines on Cardiovascular
Disease Prevention in Clinical Practice
“Interventions adding
psychosocial and
psychoeducational
components to standard
cardiological care can
significantly improve quality
of life and diminish
cardiovascular risk factors.”
Graham et al. Eur Heart J 2007:28:2375-414
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Should we routinely screen our patients?
Routine screening for depression in patients with CHD in various settings,
including the hospital, physician’s office, clinic, and cardiac rehabilitation
center. The opportunity to screen for and treat depression in cardiac
patients should not be missed, as effective depression treatment may
improve health outcomes
“No clinical trials have assessed whether screening for depression
improves depressive symptoms or cardiac outcomes in patients with
cardiovascular disease.”
Lichtman et al. Circulation 2008;118;1768-75
Thombs, de Jonge et al. JAMA 2008;300:2161-71
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CoRPS
To optimize interventions in the future
• Delineate risk profiles of patients,
reckoning with psychological factors
• These factors may interact with
demographic and clinical characteristics
and type of intervention to influence
outcome
• Match patient (psychological) profiles to
different types of interventions – what
works for whom
• ‘One size fits all’ also does not apply to
medical therapy
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CoRPS
The role of the health care professionals
in behavior change
• For patients, to initiate behavior
change is difficult
• The more difficult the behavior,
the more difficult the practice
• Learning new behaviors is easier
than breaking ‘old’ habits
• Most difficult habits to change
are those feeding physiologic
addictions (e.g., smoking)
Rozanski A. Psychosom Med 2005;67:S67-73
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Factors important for enhancing adherence
• Removing barriers to health habit change (e.g., depression
and fatigue)
 10 min of rapid walking may  energy and  tension levels for up to 2
hours later; relaxation therapy
• Providing external support for maintaining health behaviors
(e.g., social support, CR, etc)
• Motivate patients to initiate own self-management of
behavior
 patients are more likely to change and maintain behavior changes
that they ‘feel’ are meaningful to them (e.g. emotionally laden – AMI)
Rozanski A. Psychosom Med 2005;67:S67-73
CoRPS
CoRPS
Tips for dealing with high-risk patients
in clinical practice
 Establish a good rapport with patients and partners
 Know who they are – screen for psychological distress
and monitor over time
 Refer patients to cardiac rehabilitation – it works
 Look at body language and non-verbal cues
 Check if their medication and general treatment can
be optimized further
 Involve the partner – but also distress in partner
 Referral to mental health professional if available
CoRPS
Overview
• Why bother about psychosocial support?
• Interventions: Do we know what works?
• E-health: New kid on the block
• Clinical practice tips
• Take home message
CoRPS
Take home message
• Psychological factors are independent predictors of
prognosis despite state-of-the-art treatment
• A subset (25%-33%) are at risk of poor health outcomes
• Screen and monitor – we need to know who they are
• Incorporation of health status assessment in clinical
practice
• Multi-factorial psychosocial/behavioral interventions
targeted to the individual most likely to be successful
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Time for action
• Behavioral
were included
in the
guidelines
ESCfactors
press statement:
January
28,ESC
2011
forAdditional
secondaryguidelines
prevention
2003 management,
(Vienna) – talkPerk
on
oninstress
“How
to identify
depression
routine
clinical practice”
added,
will be
includedinin
the upcoming
European
Guidelines
CVD Prevention
in clinicalinpractice,
• A feeling
that on
nothing
much has changed
clinical
due to be
practice
in launched
8 years in Dublin in 2012 at the 5th Joint
European Societies Taskforce on CVD Prevention.
• We do not have all the answers yet...
• How much more evidence do we need?
• What are we waiting for?
WE CAN DO BETTER TO IMPROVE PATIENT CARE
!
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Device Conference, 3-4 November 2011,
Tilburg, the Netherlands
Living in a Device World: Focus on Recent Challenges and Tools to Improve
Clinical Care for Patients with an Implantable Cardioverter Defibrillator
Themes
Selection of invited faculty
• OVERCOMING THE SHOCK OF THE ICD
• Nico Blom (MD, PhD), Leiden University Medical Center, NL
• ICD REGISTRIES AND THE INCLUSION OF THE
PATIENT PERSPECTIVE
• Matthew Burg (PhD), Yale School of Medicine, USA
• DEACTIVATION OF THE ICD AND END OF LIFE
ISSUES
• Viviane Conraads (MD, PhD), University Hospital Antwerpen, BE
• Dorothy Frizelle (PhD), University of Hull, UK
• Jens Brock Johansen, (MD, PhD), Odense University Hospital, DK
More information available
on:
• Karl-Heinz Ladwig (MD, PhD), Helmholtz Institute, Munich, GE
• CRT SELECTION AND RESPONSE
• Mathias Meine (MD, PhD), University Medical Center Utrecht, NL
www.tilburguniversity.edu/device2011
• THE DO’S AND DON’TS OF PATIENT
• NEGLECTED SUBGROUPS
COMMUNICATION
• Susanne S. Pedersen (PhD), CoRPS, Tilburg University, NL
• SEXUALITY IN ICD PATIENTS
• Samuel Sears (PhD), East Carolina University, USA
• BEHAVIORAL INTERVENTIONS
• Steen Pehrson (MD, PhD), Copenhagen University Hospital, DK
• LOOKING INTO THE FUTURE
• Dominic Theuns (PhD), Erasmus Medical Center Rotterdam, NL