Psychosocial aspects of cardiac Psychosocial aspects of cardiac rehabilitationrehabilitation

Professor Robert J LewinProfessor Robert J Lewin

CCAREARE ANDAND E EDUCATIONDUCATION R RESEARCHESEARCH G GROUPROUP

Psychological challenges for CHD patients

Frightening, life threatening event (MI, major surgery)

A chronic illness, reduced life expectancy, symptoms

Altered identity - an invalid, walking time bomb

Fears for family and partner being left alone

Threat to employment and financial status

Medication side effects (lethargy, impotence)

Being treated differently by other people

Neurological impairement (esp. cardiac arrest pats.)

Making lifestyle changes, smoking, diet, activity

Psychological illness in post-MI patientsPsychological illness in post-MI patients

TIME

AN

XIE

TY

1 MONTH

AC

UT

E

EV

EN

T

LE

AV

E H

OS

PIT

AL

RE

TU

RN

WO

RK

90%

5 YEARSAFTER MI

30%35%

60%

40%

3 MONTHSAFTER DISCHARGE

15%

depression

IN H

OS

PIT

AL

AT

HO

ME

Psychological reactions

There are no rules - every patient is different

You cannot look at a patient and know anything about them

You must assess every patient for

anxiety

depression

health related quality of life

But ………..

Generalisation about psychological reactions

30% of patients - “life is as good or better than before MI”

sex life improved - more intimacy, strong relationships are improved

have an - active coping style, optimistic personality, low anxiety, motivated to change, helpful beliefs, high ‘internal locus of control’, higher confidence (self efficacy), previous good mental health. The ones who come to rehab!

30% long-term psychological damage

anxious and/or depressed. Cardiac neurosis

poor coping behaviours, high in misconceptions, little spontaneous recovery after 6-12 weeks, poor motivation, feel always at risk of sudden death, previous problems with anxiety, stress or depression, younger age, no obvious risk factors, post MI angina

Psychological reactions

30% of patients - ‘not the same’ - reduced HRQOL

Say ‘I’m OK’ but partner says not

not ‘clinically anxious or depressed’ but -

fear of activity

fear of excitement

give up enjoyed hobbies / activities

won’t travel too far from home

reduce work output - retire early

sex life - not the same or abandoned

much quieter than before - won’t argue

won’t play actively with grandchildren

Assessing presentation in chronic illness

impairment = the lesion, the extent of the damage or disease, e.g. the size of the infarct, the extent of the blockage of the arteries, the ejection fraction, etc.

disability = the difference from age adjusted normal, Vo2 Max at exercise testing, report of angina, activities of daily living, pain, sexual problems, mobility, depression, anxiety, etc.

handicap = the additional imposition of society, eg. driving licence restrictions, health insurance, prejudice of employers, access to sports centres, etc.

International classification of impairments, disabilities, and handicaps: a manual of classification relating to the consequences of disease. Geneva: World Health Organization,

A biomedical model of rehabilitation

After an MI part of the heart muscle is scar tissue and not pumping blood as well as before

but - the rest of the muscle could be strengthened to make up for the part that is not working!! So the impairment will be removed and the patient will go back to normal!

Simple!

DISABILITY

IMPAIRMENT

The relationship of impairment and disability

Impairment causes disability

The biomedical model of rehabilitation

by 1975 it was clear that after an exercise programme many patients could achieve a better level of fitness than before their heart attack but many remained disabled and never returned to a full and active life

psychologists and psychiatrists must get involved with cardiac rehabilitation*

* Symposium of the International Society of Cardiology, Turku, 1975

The psychologists questions are ...The psychologists questions are ...

If we can find out what is If we can find out what is different between group 1 different between group 1 and 2 can we help group 2 and 2 can we help group 2 become more like group 1?become more like group 1?

DISABILITY

IMPAI

RMENT

Group 1. Why do these Group 1. Why do these individuals do so well? individuals do so well?

Group 2. And these less well Group 2. And these less well than you would predict? than you would predict?

• disability• the extent of the symptoms reported• the success or failure of medical treatment or surgery • the number of acute medical events and readmissions• medical costs

Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462

• anxiety & depression • health beliefs • personality• patients’ own attempts to cope• social support & social class

A biopsychosocial understanding of disabilityA biopsychosocial understanding of disability

impairment on its own cannot explain

to predict all of these you also need to include

Cardiac misconceptionsardiac misconceptions

Cardiac Misconception Scale (MI patients)Cardiac Misconception Scale (MI patients)any excitement or shock could cause another heart attackany excitement or shock could cause another heart attackheart disease is caused by ‘stress’ ‘worry’ or ‘overwork’ (80%)heart disease is caused by ‘stress’ ‘worry’ or ‘overwork’ (80%)there is a dead part in my heart that could burst if put under too much there is a dead part in my heart that could burst if put under too much

pressure. pressure.

Havik OE, 1987 Scandinavian Journal of Psychology, 28:281-92.

Angina Misconception ScaleAngina Misconception Scaleangina is a kind of mini heart attack that damages your heart angina is a kind of mini heart attack that damages your heart if you get angina you should rest as much as possible if you get angina you should rest as much as possible it is a good idea to check how you feel before deciding what to do it is a good idea to check how you feel before deciding what to do Furze G, Journal of Health Psychology 2001; 6:501-510Furze G, Journal of Health Psychology 2001; 6:501-510

angina at lower level of angina at lower level of activityactivity ““angina is a angina is a

mini heart mini heart attack”attack”

reduce activity to prevent angina reduce activity to prevent angina & further damage to heart& further damage to heart

deconditioning deconditioning less efficient less efficient use of oxygen in use of oxygen in myocardiummyocardium

Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462

The importance of beliefsThe importance of beliefs

Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462

decreasing frequency of decreasing frequency of angina, higher angina, higher ischaemic thresholdischaemic threshold

Keep active - repeated Keep active - repeated ischaemic challengeischaemic challenge

development of development of collateral blood collateral blood supply to supply to ischaemic areaischaemic area

“Angina doesn’t do any lasting

harm”

The importance of beliefsThe importance of beliefs

Bad ideas lead to poor coping actions

Heart has been worn out by ‘stress’, ‘worry’ or ‘overwork’Coping action – avoid any excitement, worry or work, to avoid further risk

Result = a disabled lifestyle

There is a dead part in my heart that could burst if it were put under too much pressurecoping action - avoid raised heart rate, breathlessness

Result = loss of fitness, lower ischaemic threshold, increased risk of sudden death

Common mistake patients make - ‘overactivity-rest cycle

The over-activity rest cycle

TIME

AC

TIV

ITY

LEV

EL

GOODSPELL

BADSPELL

GOODSPELL GOOD

SPELL

BADSPELL

BADSPELL

disability less and disability less and less related to less related to impairmentimpairment

> anxiety> anxiety

> depression> depression

lower ischaemic lower ischaemic threshold threshold

DISABILITY

IMPAI

RMENT

What does your angina stop you doing that you would like to be able to do?

walkingwalking

gardeninggardening

GolfGolf

Week 2Week 3

How much can you do even on a bad day?How much can you do even on a bad day?

Do it every day for a weekDo it every day for a week

raisedraisedischaemic ischaemic thresholdthreshold

Goal setting and pacing

less fearless fear

less depressionless depression

week week week week week

DISABILITY

IMPAIRMENT

Assessing the risk of disability

Anxiety and depressionuse validated measure on all patients (HAD)

Low self-perceived health status

ask patient

“for your age how would you rate your health if 100 was completely healthy and 0 was very ill”

score lower than 80% indicates high risk.

Low self efficacy

ask patient, “how confident are you you will make a good recovery?” less than 80% higher risk

Beliefsattribution for problem - what caused your problem?cardiac misconceptions - use questionnaire

Biopsychosocial cardiac rehabilitationBiopsychosocial cardiac rehabilitation

TREATING ANXIETY AND DEPRESSIONTREATING ANXIETY AND DEPRESSION

Give questionnaire of cardiac misconceptions and discuss Give questionnaire of cardiac misconceptions and discuss with patient to try to change them to better understandingwith patient to try to change them to better understanding Teach relaxation and stress managementTeach relaxation and stress management Use goal setting and pacing to get patients back to Use goal setting and pacing to get patients back to abandoned pleasurable activities - (systematic abandoned pleasurable activities - (systematic desensitisation)desensitisation)

If anxious or depressed at a clinical level refer to a clinical If anxious or depressed at a clinical level refer to a clinical psychologist for cognitive therapy, or, if no psychologist treat psychologist for cognitive therapy, or, if no psychologist treat with drugswith drugs

CHECK AND IMPROVE COPING STRATEGIESCHECK AND IMPROVE COPING STRATEGIES

bad coping - resting as a ‘cure’ for heart disease bad coping - resting as a ‘cure’ for heart disease

bad coping - overactivity-rest cyclebad coping - overactivity-rest cycle

bad coping - see how I feel before I do anything bad coping - see how I feel before I do anything

Treatment = educate in better copingTreatment = educate in better coping

Treatment = use goal setting and pacing techniques. Treatment = use goal setting and pacing techniques.

Good coping - always do what I plan to doGood coping - always do what I plan to do

Good coping - don’t let angina (breathlessness) stop meGood coping - don’t let angina (breathlessness) stop me

Good coping - build up activity as each step becomes easyGood coping - build up activity as each step becomes easy

praise and encourage these coping strategiespraise and encourage these coping strategies

Biopsychosocial cardiac rehabilitationBiopsychosocial cardiac rehabilitation

GIVE PATIENT A SENSE OF CONTROL OVER THE GIVE PATIENT A SENSE OF CONTROL OVER THE ILLNESSILLNESS explain lifestyle change, and secondary prevention, stress explain lifestyle change, and secondary prevention, stress ability of patient to get control over the illness. ability of patient to get control over the illness.

USE REINFORCERS (rewards) FOR ATTEMPTS AT USE REINFORCERS (rewards) FOR ATTEMPTS AT COPINGCOPINGpatient keeps record of progress, review it with patient and patient keeps record of progress, review it with patient and praise compliance with programmepraise compliance with programmeif appropriate involve family, ask them to praise coping effortsif appropriate involve family, ask them to praise coping efforts

Biopsychosocial cardiac rehabilitationBiopsychosocial cardiac rehabilitation

BUILD UP PATIENTS SELF EFFICACYBUILD UP PATIENTS SELF EFFICACYset small goals at 80% confidence level, success increases set small goals at 80% confidence level, success increases self efficacy increases the chance of further successself efficacy increases the chance of further success

the Angina Management the Angina Management ProgrammeProgrammeexplain the overactivity-rest cycle and how to avoid explain the overactivity-rest cycle and how to avoid ititteach goal setting and pacing, set goals every week teach goal setting and pacing, set goals every week reward reports of coping and success, applause from reward reports of coping and success, applause from the groupthe groupgroup discussions about cardiac misconceptions, group discussions about cardiac misconceptions, true causes not ‘myths’true causes not ‘myths’Discuss how to become more disabled and how to Discuss how to become more disabled and how to become less disabledbecome less disabled

Stress managementStress managementrelaxation, breathing retraining, meditationrelaxation, breathing retraining, meditationyoga sessionsyoga sessionsbring in real examples of recent episodes of stressbring in real examples of recent episodes of stressLewin, B. 1997, Journal of Psychosomatic Research 43:453-Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462462

Crossover trial - waiting list to treatment - 82 Crossover trial - waiting list to treatment - 82 patients main findings at 1 year after treatmentpatients main findings at 1 year after treatment

30% no angina30% no angina 70% reduction in episodes of angina70% reduction in episodes of angina 57% improvement in exercise duration57% improvement in exercise duration 72% reduction in self reported disability (SIP)72% reduction in self reported disability (SIP) 50% of patients taken off CABG list50% of patients taken off CABG list

no patient looking for further treatmentno patient looking for further treatment

Lewin, B, 1995, British Journal of Cardiology, 2, Lewin, B, 1995, British Journal of Cardiology, 2, 219-26219-26

the Angina Management Programme: trial 1

The Angina Management Programme: trial 2The Angina Management Programme: trial 2

Depression(HAD)

Episodes of Angina

Anxiety(HAD)

Disability(SIP)

Treadmill workload(METS)

*

* †

†

*

-14-12-10-8-6-4-2024

routine care control Exercise programme Angina Management Programme

6 months post treatment ( * = p<0.01, = p<0.001)†

226 patients randomly allocated to 226 patients randomly allocated to

Angina PlanAngina Plan 6868

142 randomised to treatment142 randomised to treatment

90% at 6 month follow-up90% at 6 month follow-up

education education sessionsession 7474

6363 6767

-1.2

-1

-0.8

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

Anxiety Depression

anxiety & depression

-4.5-4.0-3.5-3.0-2.5-2.0-1.5-1.0-0.50.00.51.0

Angina GTN

angina and use of GTN

-2-10123456789

physical activity: SAQ

40% reduction

Lewin RJP, British Journal of General Practice, 2002, 52, 194-201

The Angina PlanThe Angina Plan

home based programme, a patient held home based programme, a patient held manual & trained facilitator manual & trained facilitator

30-60 minutes introduction session30-60 minutes introduction session

and 4, 10-15 minute phone calls / and 4, 10-15 minute phone calls / home /clinic visits, to set further goals, home /clinic visits, to set further goals, praise progress, encourage adherencepraise progress, encourage adherence

RCT

misconceptions that have to changemisconceptions that have to change

Approximately 50% of the improvement in physical limitations Approximately 50% of the improvement in physical limitations was explained by the change in the was explained by the change in the total scoretotal score on the angina on the angina misconceptions scalemisconceptions scale

the items in which change predicted improvementthe items in which change predicted improvementit is very important to avoid anything that brings on angina it is very important to avoid anything that brings on angina 0.030.03an attack of angina does not do you any lasting harm an attack of angina does not do you any lasting harm 0.030.03if you get angina you should rest as much as possible if you get angina you should rest as much as possible 0.030.03it is a good idea to check how you feel before deciding what to do it is a good idea to check how you feel before deciding what to do 0.0010.001my angina was caused by having too much worry, or stress, or work my angina was caused by having too much worry, or stress, or work 0.060.06

some beliefs that did not change between groupssome beliefs that did not change between groups you should just ignore angina it is a nuisance nothing more you should just ignore angina it is a nuisance nothing more 0.980.98it is usually better to carry on even if you feel a bit under the weather it is usually better to carry on even if you feel a bit under the weather 0.270.27

significance levelsignificance level

THE ENDthis presentation will be at

www.cardiacrehabilitation.org.uk

BHF Care & Education Research GroupDepartment of Health SciencesSeebohm Rowntree BuildingUniversity of YorkY010 5DD

RJPL1@york.ac.uk +44 (0)19 04 32 13 27