By Dr Joseph Scopelliti MAPS
Senior clinical health psychologist, Bendigo Health Care Group
Compared to otherwise healthy people, individuals who have heart disease are significantly more likely to suffer from depression. Prevalence estimates of depression following acute myocardial infarction (heart attack) range as high as 40-65 per cent (Januzzi, Stern, Pasternak, Roman, & DeSanctis, 2000). At the same time, the risk of developing heart disease is elevated in people suffering from depression (Rafanelli, 2005). This bi-directional relationship between depression and heart disease, both of which are affected by lifestyle and social factors (such as isolation and a lack of quality social support), is linked to a significantly greater risk of early illness-related (sudden cardiac) death. Despite the interest in this area over a number of years, as yet the mechanisms underlying this relationship remain unclear.
In Australia, as in other Western countries, cardiovascular disease – including heart disease – accounts for the highest number of deaths per annum. In terms of disability, depression – currently the leading cause – is projected by the World Health Organisation to become the second leading contributor to the global burden of disease.
The implications of the above are wide-ranging and need to be addressed at a number of levels. Within this context, psychology is well placed to make an important contribution by providing a range of clinical and health promotional programs for people with chronic illnesses including depression and heart disease.
One program currently operating to address this need in the Greater Bendigo region in central Victoria is the Hospital Admission Risk Program – Chronic Disease Management (HARP-CDM). This program is staffed by a multidisciplinary team of care coordinators including specialist nursing staff, occupational therapist, physiotherapist, social worker, along with clinical health psychologist and psychiatrist. The primary focus of this program is on patient self-management.
Patients are referred to HARP-CDM from a variety of sources including hospital A&E departments, acute medical units, GPs, and rehabilitation programs. If entry requirements are met, patients are allocated to the appropriate stream (e.g., cardiac) and screened with the Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983). Those scoring 10 or above on the HADS and/or where there are other significant issues (e.g., treatment non-adherence) then undertake a mental health screen carried out by the clinical health psychologist. The psychologist determines the need for a comprehensive mental health assessment, which includes developmental history, use of specific measures (such as the DASS – Depression, Anxiety, Stress Scale [Lovibond & Lovibond, 1995]), measures of functional performance, and mental status examination. Referral for psychiatric assessment, treatment or review may be indicated in some cases. A Care Plan is then constructed with identified psychological interventions.
The diagnoses of heart disease and/or depression can be highly distressing – in some cases, traumatic – and strike at the core of human experience. Grief and loss issues are common as patients confront a range of ongoing practical, emotional, social, and existential/spiritual challenges. These challenges are likely to be present over extended periods as patients and their carers navigate a complex web of medical appointments, investigations, and treatments that many find to be alienating, fragmented, and demoralising experiences (e.g., use of pacemakers, defibrillators). Within this context the psychologist occupies a privileged role by focussing less on the biological aspects of disease and its clinical management, and more on patients’ relationship to their health condition and the meaning it has in their lives. It could be argued that this broader perspective is more acknowledging of the particular social and biographical contexts in which chronic illness may be understood.
A variety of psychological interventions may be considered in working with those who suffer from heart disease and depression. These range from change-based strategies such as cognitive interventions that address negativity and other unhelpful patterns of thinking, to acceptance-based strategies (e.g., Hayes & Strosahl, 2004) which can assist patients to let go of what may seem to be an interminable struggle against their health condition. There are numerous inspirational published (including web-based) accounts from patients who have found creative ways of coping with chronic disease (e.g., Simmons, 2002) and these can be recommended to both patients and carers. Writing about one’s experience is one modality that may be beneficial to patients who suffer from a range of health conditions (DeSalvo, 2000). Most patients attending HARP-CDM will be introduced to the notion of mindfulness and are encouraged to develop skills in attentional control that may assist them with anxiety, negative ruminations, and feelings of hopelessness.
The course of chronic heart disease and depression is often a fluctuating one which requires the flexible, responsive, and creative application of a range of interventions across time. Whatever the choice of interventions, ultimately what may be of greatest value is the extent to which we as clinicians are able to attend to and be with our chronically ill patients. In so doing, we might assist them to discover dignity, meaning, and purpose in the midst of their distress and suffering.
Lorig, K., Holman, H., Sobel, D., Laurent, D., Gonzalez, V., & Minor, M. ((2000). Living a Healthy Life with Chronic Disease: Self-Management of Heart Disease, Arthritis, Diabetes, Asthma, Bronchitis, Emphysema & others (2nd Edition). Boulder, Colorado: Bull Publishing. (Chapter 5. Using Your Mind to Manage Symptoms).
Simmons, P. (2002). Learning to Fall: The blessings of an imperfect life. Sydney: Hodder.
DeSalvo, L. A. (2000). Writing as a Way of Healing: How Telling Our Stories Transforms Our Lives. Boston: Beacon Press.
Hayes, S. C., & Strosahl, K. D. (2004). A Practical Guide to Acceptance and Commitment Therapy. New York: Springer.
Januzzi, J. J., Stern, T. A., Pasternak, R. C., Roman, W., & DeSanctis, W. (2000). The influence of anxiety and depression on outcomes in patients with coronary artery disease. Archives of Internal Medicine, 160, 1913-1918.
Lovibond, S.H., & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales (2nd. Ed.). Sydney: Psychology Foundation.
Rafanelli, C. (2005). Depression, stress and the risk of heart disease. Psychiatric Times, 22, 11.
Zigmond, A. S. & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand, 67, 361-370.