Carroll Allison
Allison J. Carroll, PhD
Research Associate
Center for Prevention Implementation Methodology (Ce-PIM) for Drug Abuse and HIV
Department of Psychiatry and Behavioral Sciences
Northwestern University Feinberg School of Medicine
Dating back to the 1970s, it was observed that patients with cardiovascular disease have higher than expected rates of depression, anxiety, and behavioral concerns (Cassem and Hackett, 1971; Cay et al., 1972). By the 1990s, it had become clear that cardiac patients with depression had poorer prognosis than their non-depressed counterparts (Frasure-Smith et al., 1993). Decades of research culminated in 2014 when the American Heart Association officially designated depression as an independent risk factor for poor outcomes among patients with acute coronary syndrome (Lichtman et al., 2014).
More recently, a focus has emerged on prevention of cardiovascular disease – and, importantly, on promotion of cardiovascular health. The American Heart Association formally defined parameters to assess cardiovascular health in 2010, known as “Life’s Simple 7”: blood pressure, total cholesterol, blood glucose, cigarette smoking, body mass index, physical activity levels, and diet (Lloyd-Jones et al., 2010). This shift to focus on cardiovascular health developed from an evolved understanding that cardiovascular functioning is typically maximized at birth and declines with age (Perak et al., 2018). Numerous studies have since shown that depression is associated with poorer cardiovascular health even among adults without cardiovascular disease (e.g., Kronish et al., 2012).
So, as one might imagine, the influence of psychological and behavioral factors does not begin at the point of a cardiac diagnosis. Across the continuum of cardiovascular health (Figure 1), there are myriad potential points for health psychology interventions to assist in promoting cardiovascular health and reducing risk for cardiovascular disease.
Figure 1. Continuum of cardiovascular health promotion and disease prevention.
Preserving cardiovascular health/low cardiovascular disease risk
Prevention efforts at this stage are largely focused on the public, such as faith-based communities, primary care clinics, and schools. There is an emphasis on family-based approaches among pediatric populations that are designed to “extend the health span” of children and maximize cardiovascular health as they develop through adolescence and young adulthood (Perak et al., 2018).
For example, the prevalence of pediatric hypertension has significantly increased over the few decades (Flynn et al., 2017). Managing hypertension often involves behavioral modification, including such measures as diet, exercise, and medication adherence, yet few behavioral interventions for pediatric hypertension have been developed or tested among pediatric hypertension patients. In general, the most successful lifestyle interventions for children and adolescents are multi-factorial, family-based approaches (e.g., Coppock et al., 2014), an endeavor for which health psychologists are naturally suited.
Controlling increased cardiovascular disease risk
Similar to cardiovascular health promotion and cardiovascular disease risk reduction, this stage emphasizes healthy behavior change such as smoking cessation, diet adherence, increased physical activity and reduced sedentary behaviors, etc. These behaviors often cluster together, especially among those with mental health conditions such as depression or anxiety (Vermeulen-Smit et al., 2015), and this convergence is an ideal point of intervention for health psychologists.
In addition to community-based interventions, preventive cardiology clinics have developed in response to the shift in focus from treating to preventing cardiovascular disease (Lloyd-Jones et al., 2010). Further integration of health psychologists into cardiology clinics more generally, and preventive cardiology clinics in particular, can assist in the management of increased cardiovascular disease risk. Given health psychologists’ successful integration into medical clinics, most notably the primary care behavioral health integration (Hunter et al., 2018), this integration may take many forms, including co-located individual behavioral health services, support groups, or shared medical appointments.
Detecting and treating acute cardiovascular events
The point of intervention at this stage is brief but essential, and includes helping patients to identify and change cardiac-related lifestyle factors and promote healthy adjustment to new disease or illness. For example, smoking cessation treatment during and following hospitalization for cardiovascular disease is only effective if patients are followed for at least one month after discharge (Rigotti et al., 2012). Physicians often do not have the time or capacity to conduct this follow-up, whereas health psychologists are most likely better equipped with the time and skills to perform the necessary follow-up to promote long-lasting behavior change.
Reducing risk of recurrent cardiovascular events
Between 20-60% of patients develop depression after a myocardial infarction, cardiac surgery, or a heart failure diagnosis. Depression is a risk factor for poor prognosis, above and beyond medical factors and health behaviors (Lichtman et al., 2014). Health psychologists working with cardiac patients can assist with adjustment to disease and illness, management of psychosocial barriers to physical and mental wellbeing, and maintenance of healthy lifestyle behaviors. Unfortunately, despite a wide variety of psychological interventions tested among cardiac patients, none have yet found to improve cardiac outcomes as a result of improved psychological functioning (Richards et al., 2017), making this an important area for further study.
In sum, health psychologists are well-positioned to take advantage of various points of intervention along the full continuum of cardiovascular health: throughout the lifespan, among various populations, and at any point of disease state. Health psychologists are behavior change experts, particularly for facilitating multiple behavior change among patients with comorbid psychological distress. Health psychologists take a unique biopsychosocial approach that allows one to identify, understand, and address the social and economic factors that contribute to inequalities in disease prevalence, treatment, and outcomes. A health psychologist’s ability to focus on a patient’s strengths in order to promote positive psychological and physical health and wellbeing is the ultimate non-invasive, patient-centered management of cardiovascular health.
References
Cassem, N.H., Hackett, T.P. (1971). Psychiatric consultation in a coronary care unit. Ann Intern Med, 75:9-14. doi: 10.7326/0003-4819-75-1-9
Cay, E.L., Vetter, N., Philip, A.E., Dugard, P. (1972). Psychological status during recovery from an acute heart attack. J Psychosom Res, 16:425-35. doi: 10.1016/0022-3999(72)90068-2
Coppock, J.H., Ridolfi, D.R., Hayes, J.F., St Paul, M., Wilfley, D.E. (2014). Current approaches to the management of pediatric overweight and obesity. Current treatment options in cardiovascular medicine, 16:343-43. doi: 10.1007/s11936-014-0343-0
Flynn, J.T., Kaelber, D.C., Baker-Smith, C.M., Blowey, D., Carroll, A.E., Daniels, S.R., de Ferranti, S.D., Dionne, J.M., Falkner, B., et al. (2017). Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics, 140. doi: 10.1542/peds.2017-1904
Frasure-Smith, N., Lesperance, F., Talajic, M. (1993). Depression following myocardial infarction. Impact on 6-month survival. Jama, 270:1819-25.
Hunter, C., Funderburk, J.S., Polaha, J., Bauman, D., Goodie, J.L., Hunter, C.M.J.J.o.C.P.i.M.S. (2018). Primary Care Behavioral Health (PCBH) Model Research: Current State of the Science and a Call to Action. 25:127-56. doi: 10.1007/s10880-017-9512-0
Kronish, I.M., Carson, A.P., Davidson, K.W., Muntner, P., Safford, M.M. (2012). Depressive symptoms and cardiovascular health by the American Heart Association’s definition in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. PLoS One, 7:e52771. doi: 10.1371/journal.pone.0052771
Lichtman, J.H., Froelicher, E.S., Blumenthal, J.A., Carney, R.M., Doering, L.V., Frasure-Smith, N., Freedland, K.E., Jaffe, A.S., Leifheit-Limson, E.C., et al. (2014). Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: A scientific statement from the American Heart Association. Circulation, 129:1350-69.
Lloyd-Jones, D.M., Hong, Y., Labarthe, D., Mozaffarian, D., Appel, L.J., Van Horn, L., Greenlund, K., Daniels, S., Nichol, G., et al. (2010). Defining and setting national goals for cardiovascualr health promotion and disease reduction: The American Heart Association’s Strategic Impact Goal through 2020 and beyond. Circulation, 121:586-613. doi: 10.1161/circulationaha.109.192703
Perak, A.M., Marino, B.S., de Ferranti, S.D. (2018). Squaring the Curve of Cardiovascular Health From the Beginning of Life. Pediatrics, 141:e20172075. doi: 10.1542/peds.2017-2075
Richards, S.H., Anderson, L., Jenkinson, C.E., Whalley, B., Rees, K., Davies, P., Bennett, P., Liu, Z., West, R., et al. (2017). Psychological interventions for coronary heart disease. Cochrane Database Syst Rev, 4:Cd002902. doi: 10.1002/14651858.CD002902.pub4
Rigotti, N.A., Clair, C., Munafò, M.R., Stead, L.F. (2012). Interventions for smoking cessation in hospitalised patients. The Cochrane database of systematic reviews, 5:CD001837-CD37. doi: 10.1002/14651858.CD001837.pub3
Vermeulen-Smit, E., Ten Have, M., Van Laar, M., De Graaf, R. (2015). Clustering of health risk behaviours and the relationship with mental disorders. J Affect Disord, 171:111-9. doi: 10.1016/j.jad.2014.09.031