This chapter describes the structured psychosocial intervention carried out by the Cardiac Rehabilitation Unit, which includes therapeutic counselling, group intervention, treatment of anxiety and depression, a 24-hour helpline and social support. The chapter provides specific proposals for action to provide psychosocial support in practice.
Anxiety and depression
Patients with myocardial infarction can experience crises, but the fact that heart disease increases the risk of depressive and anxiety disorders and that not treating them can complicate the course of disease and produce new heart problems and death is less well known.
About 11–25% of patients with ischaemic heart disease have depressive disorder. A further 30% develop mild depressive episodes, and 9% of outpatients with heart disease and 10–50% of patients with acute coronary syndrome have anxiety disorder (1–6). A few more recent epidemiological studies (7–10) even indicate that mental factors can increase the risk of ischaemic heart disease, and studies (11–13) have shown that depression and anxiety are underdiagnosed in heart disease.
Depression and anxiety complicate the course of heart disease. Developing depression not only influences the patients’ subjective health but also adversely affects the results of treatment and reduces survival in some cases. Among patients with ischaemic heart disease, those with untreated depression have 3–4 times as much morbidity and mortality as those without depression (2). Similarly, among patients who have had coronary artery bypass grafting, those with moderate to severe depression have excess mortality compared with those with no depression (14).
Studies indicate that the effect of exercise training supplements the pharmaceutical treatment of mild and moderately severe depression. Exercise training is not recommended as the sole treatment but should be used to supplement pharmaceutical treatment (15;16). Knowledge on how to master illness is an important aspect of psychosocial support, but knowledge cannot stand alone (17).
Patients with ischaemic heart disease treated for anxiety and depression tolerate treatment well, have less depression and seems to have fewer complications related to heart disease (18–21). A study of 2481 people who had myocardial infarction (22) showed that treating depression did not influence survival.
Studies (23–26) have shown that people who live alone and lack a social network have a higher risk of ischaemic heart disease and death. Other studies (27–29) show that social isolation is associated with reduced survival and health for patients with cardiovascular diseases. No study has shown that intervening in the lives of socially isolated people with heart disease can improve health and survival. Nevertheless, studies have shown that intervening in the lives of socially isolated people with heart disease increases the quality of life (30;31) and mental well-being (32). In addition, depression can reinforce social isolation (33).
About 20–25% of patients with myocardial infarction in Denmark are employed at admission. Many are concerned about whether they can resume employment. A study of employment prospects after myocardial infarction in Denmark (34) showed that the short-term employment prospects were good: about 90% of the employed patients had resumed working within the first six months. Studies (34–36) indicate that patients’ age, educational level, socioeconomic status, psychosocial well-being and self-confidence that they could return to work are more important for continuing employment than their physical functioning (34–36). Continuing employment is an important goal of cardiac rehabilitation (37). Nevertheless, the extent to which cardiac rehabilitation has an effect is still uncertain, since this area has been little studied (34;35).
There is a consensus on cardiac rehabilitation in Denmark that psychosocial support should be a component of comprehensive cardiac rehabilitation (37–39).
The purposes of psychosocial support in the comprehensive cardiac rehabilitation programme are to guide patients in mastering their illness and reactions to their illness; to identify and treat mental disorders such as depression and anxiety; and to strengthen patients’ social skills and guide patients in social matters, including supporting patients in continuing to work.
Many people who get a life-threatening disease get into a state of crisis. Nearly everyone who gets heart disease is in crisis at some point during the course of illness. The crisis can be catalysed by a combination of several factors. In addition to pain and impaired physical functioning, they have to find a new role both for their personal lives and work lives. Most patients are very anxious that a new acute heart event will take place.
The crisis can be divided into four phases: shock, reaction, adaptation and reorientation (40–42). The course and outcome of the crisis depend on patients’ physical, mental and social resources. Two crises are seldom identical and do not follow a set pattern but alternate between various phases.
The nurse is especially attentive to patients’ psychosocial well-being in the comprehensive cardiac rehabilitation programme. At the initial consultation, the nurse asks patients how they experience their role as patients, how they live with their illness in daily life and how the illness has influenced their relationships with their surroundings. This allows patients to express how they feel about the events, and the nurse can assess whether the patient is in crisis. The assessment is based on the nurse’s professional knowledge of the phases of crisis and their content and duration.
Patient’s family members, especially spouses or cohabitants, are also influenced by the situation, and some spouses react more strongly that the patients themselves. Several patients report that their spouses are unnecessarily worried in daily life and are insecure when patients have to perform simple tasks they previously performed without problems. These spouses are therefore asked to participate in patient education and in the individual consultations. Nevertheless, patients should have an opportunity to cope with their new role before spouses are involved. Spouses should be involved in accordance with the situation of each patient.
This section describes several techniques that can be used in counselling patients (43):
Let patients describe the situation: Therapeutic counselling is based on letting patients describe the course of illness and treatment. This ensures that the nurse gets a detailed sense of how patients experience their own situation. For example, if professionals are uncertain whether a patient’s palpitation is caused by arrhythmia or anxiety, the patient’s description can determine the nature of the problems. The nurse further determines whether a patient has understood the relationship between disease and the treatment initiated, both pharmaceutical and non-pharmaceutical.
Most patients need to discuss the same topics many times as part of adapting to the situation. Lack of knowledge and uncertainty about what has happened may result in anxiety. Professionals should therefore carefully balance the amount of information provided with the patients’ resources.
Repeat the last few words the patient says: Among patients who are not used to expressing their feelings or seem inhibited, the professional can encourage patients to continue their story by repeating the last few words they said. This gives patients the sense that the professional considers what they are saying important. The professional may conclude by summarizing the main topics discussed, which is subsequently recorded in the joint electric patient record, to ensure that the patient remembers the main content of the discussion.
Allow natural pauses in the conversation: Professionals may be tempted to fill in the small pauses in the conversation with conclusions or new questions. This may make patients feel that they are not permitted to finish talking or that the professional is not listening to what they are saying. If pauses are a natural part of the conversation, the patient will make new associations and have new thoughts and will relax and open up. Many patients have difficulty in abandoning their defence mechanisms for fear of collapsing: they attempt to suppress their anger, doubt, guilt feelings and insecurity. Patients’ defence mechanisms can include both exaggerating and downplaying the disease.The professional can help patients in abandoning their defensiveness and viewing their situation in an appropriate perspective by showing them that the professional has lots of time and is listening to what they are feeling and thinking.
Do not necessarily answer questions during the consultation: Anxious patients usually ask many questions since they want to be comforted that their symptoms are not lifethreatening. Patients who say that they wake up at night with palpitation expect the professional to respond in the hope that the explanation is physiological. If the professional suspects that the problem is mental, the professional should be cautious in answering the patients’ questions, since the professional risks preventing patients from recognizing their own problems. Patients asked for a possible explanation often say that they speculate considerably about their disease at night. If patients recognize by themselves that the symptoms are mental, this helps them in adapting to the situation. For patients who seem helpless and desperate, professionals may tend to give advice, but the best help may be to avoid giving advice. Patients in shock may need to have professionals take over, but later the professional can easily delegate more responsibility to patients.
The comprehensive cardiac rehabilitation programme emphasizes social interaction between patients, and many of the components of the programme are carried out as group intervention, such as smoking cessation, exercise training and patient education.
People in the same life situation sharing experience reveals and de-individualizes their problems and they begin to understand their own and other people’s problems in a larger context. In such a process with group dynamics, the group members use one another’s experience, and patients who have been through the same events often have greater trust in other such patients than a professional. The process of group dynamics focuses on social interaction and human resources. The professional is responsible for taking advantage of the group’s overall resources so that each individual achieves the greatest possible support and insight. Such serious topics as anxiety about death and anxiety about life often arise.The comprehensive cardiac rehabilitation programme emphasizes that professionals should not exceed their competencies and thus do not practise group therapy (44).
The comprehensive cardiac rehabilitation programme offers patients telephone counselling 24 hours per day. When the Unit is open, the secretary answers the telephone and assesses, together with the patient, the professional the patient would benefit by consulting. When the Unit is not open, personnel in the inpatient ward of the Department of Cardiology answer the telephone. Patients can get answers to acute questions. All contacts are registered and referred to the Cardiac Rehabilitation Unit, and the staff there follow up (the registration form is available in Danish at www.CardiacRehabilitation.dk).
In practice, the helpline is little used and therefore requires few resources, but patients express that they feel more secure knowing that they can contact the Department of Cardiology at any time.
Appropriately treating anxiety and depressive disorders requires knowing how to identify them and some knowledge of classification and diagnostic criteria. There are so many possible diagnoses each with diagnostic criteria that they cannot all be known and used clinically. In most contexts, professionals can manage if they know the three levels of severity of depression and a few anxiety diagnoses such as panic disorder, generalized anxiety disorder, phobic anxiety disorders and hypochondriacal disorder.
Screening for anxiety and depression. The nurse in the Cardiac Rehabilitation Unit screens each patient for anxiety and depression using the Hospital Anxiety and Depression Scale (45;46). Patients who answer any of the questions in either category affirmatively may have depression and are referred to psychiatric assessment. Patients are informed that, because they have heart disease, they are especially vulnerable to developing depression and anxiety and that untreated depressive or anxiety disorders may exacerbate heart disease. Professionals respect the wishes of patients who do not want to consult a psychiatrist.
Determining the cause of anxiety or depression may be difficult in some cases. Causes can include the somatic illness or treatment, special mental vulnerability or previous depressive or anxiety disorders. Thus, several causative factors may be involved in any depression and anxiety associated with heart disease.
The Cardiac Rehabilitation Unit treats patients with mild depression or anxiety based on the following principles and refers patients with severe depression to psychiatric treatment.
The comprehensive cardiac rehabilitation programme focuses primarily on treating the underlying somatic illness among patients with depression or anxiety. Improving patients’ somatic state will spontaneously reduce depression and anxiety.
If the depression or anxiety is suspected of being caused by or exacerbated by pharmaceutical treatment, the programme switches patients to another type of treatment that does not promote these disorders if possible.
Depression and anxiety associated with heart disease are treated based on the same principles as any other depressive or anxiety disorder (47). Antidepressants with a low risk of interaction with somatic treatment are chosen. Older tricyclic antidepressants are not used because they have a high risk of cardiovascular complications (48).
The comprehensive cardiac rehabilitation programme emphasizes determining patients’ need for social support in the individual consultation with the nurse. The social worker from the Department of Cardiology participates in the weekly interprofessional conference (Chapter 4) at which any social problems among patients are presented. The social worker advises the clinical team on the subsidy and other social schemes available to each patient, and the team assesses whether the social worker can contribute further with individual counselling and follow-up.
The patient education in the comprehensive cardiac rehabilitation programme informs patients about the significance of a social network. The nurse or social worker informs patients about specific activities in the local area related to maintaining lifestyle changes, meet other people in the same situation, discuss illness history and establish a personal network. Information is adapted individually to each patient’s resources, desires and needs.
Local activities: The nurse and social worker in the comprehensive cardiac rehabilitation programme have visited selected activity locations in the Bispebjerg area and prepared an activity folder containing text on and photographs of fitness centres, community centres and daytime programmes. The material in this folder provides information on the user interface, price, waiting lists and heart-friendly activities in each location (selected activities from the folder are available in Danish at www.CardiacRehabilitation.dk). The activity folder is kept in the waiting room so that both patients and family members can keep up to date on local activities. The nurse and social worker take responsibility for updating the folder.
Patients with heart disease may experience financial strain because of co-payments for medicine and a potential reduction in income for those whose employment situation changes. Patients whose finances worsen may have difficulty in remaining optimistic, especially those who have had a complicated course of disease. Patients in the comprehensive cardiac rehabilitation programme are informed that Denmark’s social welfare legislation may potentially provide financial support for the co-payments for medicine used to treat heart disease (the rules for public subsidies for medicine in Denmark are available in Danish at www.CardiacRehabilitation.dk). In some cases, patients can get an individual consultation with the social worker. The social worker advises patients on various subsidy schemes, including private insurance, such as lump-sum payments from insurance policies for critical illness.
The comprehensive cardiac rehabilitation programme supports employed patients in maintaining employment either full time with optional social support schemes or part time. The social worker can offer to participate in visiting patients’ employers or contact patients’ social case workers in their municipality and suggest such measures as maintaining current employment, publicly subsidized employment for people with permanently reduced working capacity (flex job), vocational rehabilitation or partial old-age pension. Patients are supported and encouraged in maintaining employment through consultation with the social worker and indirectly through the comprehensive cardiac rehabilitation programme.
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