Heart Disease

Sad Hearts Have Hope: Biology Meets Psychotherapy There is widespread public understanding that heart disease is highly prevalent and a leading cause of death. Less well recognized by the general public is the fact that behavioral and psychosocial issues underlie many of the disease mechanisms that produce heart disease. How to make use of this psychosocial link in recovery and management of disease is the focus of Heart Disease: Advances in Psychotherapy Evidence-Based Practice, by Judith A. Skala, Kenneth E. Freedland, and Robert M. Carney. Although biomedical and psychological factors are components of heart disease and recovery, treatment may proceed in biomedical care or in psychological treatment without full appreciation of relevant factors in the reciprocal realm. This volume represents a natural extension of psychology in the health professions and builds on developments of the past 30 years. Emerging in parallel with the field of behavioral medicine, Health Psychology was formed as Division 38 of the American Psychological Association in 1978. These developments were partly inspired by the growing recognition that behavior is a major contributor to the leading causes of death, particularly heart disease and smoking. Within only a few years, a national conference on health psychology identified educational and training needs (Olbrisch, Weiss, Stone, & Schwarz, 1985). It was also a time when Congress was seeking ways to contain the growth of health care costs, now a national priority. The possibility that psychological interventions might reduce the overall burden of illness to individuals and their families was and remains a central theme for the discipline (Matarazzo, 1980). Since these beginnings, there has been increasing recognition of psychology as a primary health care profession having natural alliance with other health professions (DeLeon, 2002). Recent work has expanded this interface to include, for example, the promotion of wellness lifestyles in diet, exercise, and weight control; the design of smoking cessation programs; and psychological treatments for depression, anxiety, and anger concomitant with heart disease and for social and behavioral problems associated with heart disease. Indeed, the National Institutes of Health Heart, Lung, and Blood Institute managed a randomized clinical trial to assess the efficacy of cognitive-behaviorial therapy for depression and low perceived social support following a myocardial infarction that documented the beneficial effects of concomitant psychological treatments over usual treatment protocols (Berkman et al., 2003). The guide offered by Skala, Freedland, and Carney provides a useful tool in the implementation of these important findings. It makes a very beneficial contribution to bridging potential gaps and is likely to make treatment in both biomedical and psychological realms more pertinent to the lives of heart patients. Every now and then, academic practitioners communicate in a clear, straightforward manner, and these authors have managed the task exceptionally well. Readers will find an extremely useful guide that can be repeatedly mined as a valuable resource. The volume, part of the series Advances in Psychotherapy: Evidence-Based Practice, is designed for practitioners who may be called on to help patients with coronary heart disease or congestive heart failure. Psychotherapists will appreciate the short tutorials on key medical terms and how to find additional scholarly articles specific to them. The page design and text layout make it easy to identify key points through the use of bolding and notations in the margins. Additional checklists, tables, and references make this volume especially useful. Where other texts might be ponderous or obtuse, this one cuts straight to the chase. In an early section, the authors admonish therapists to take a thorough medical history, not only to clarify the diagnosis and critical events but also to note how the patient understands and interprets the information. A particularly relevant suggestion is to record the various drug prescriptions and, of equal importance, to assess the extent to which these are taken regularly as prescribed. The book makes clear that symptoms discussed in a therapy session may or may not be psychogenic. For example, patient reports of lethargy, dizziness, and limited activity days may reflect psychological malaise but also may reflect haphazard adherence to pharmaceutical guidelines. Practitioners are encouraged to recognize motivation as an important precursor to long-term change and to meet the patient's family and significant others. These individuals may be important partners in the therapeutic process. The focus is on cognitive-behavioral therapy as it has emerged in more recent years from the work of Aaron Beck. Guided discovery, mutual exploration, and nonjudgmental reflection are intended to secure a working psychotherapy relationship. Cognitive approaches recognize various types of problematic cognitions. Heart patients should be reasonably and appropriately concerned, but they may have the additional burden of negative and intrusive thoughts that ultimately contribute to a deeper depression. Such thoughts may in part be due to distortions and an incomplete understanding of basic information about their condition. Fragile patient agency and efficacy may underlie the arbitrary imposition of rules and conditions that weaken recovery. Preexisting patterns of dealing with stress may compound difficulty in coping during a serious illness. A higher, incipient level of anxiety and anxious thoughts may contribute to an inflated perception of risk and to catastrophizing about the prognosis. Elaborations of traditional cognitivebehavioral therapy are offered that may be particularly useful to patients coping with serious medical problems that raise anxiety and often contribute to depression. In particular, there is more focus on problem solving, creating lists of specific problems that are troublesome for the patient, and a brief overview of how to teach self-therapy using behavioral and situational analysis. Of importance, considerable attention is given to evaluation of these overlapping approaches within cognitive-behavioral treatment and to evidence-based practice in general. Other approaches that receive mention include interpersonal therapy, stress management, crisis management, and motivational interviewing that prepares people for change. For most approaches, tables provide concrete steps and action plans. Attention to pharmaceutical treatments is unfortunately limited to antidepressant medications and their safety and potential efficacy for heart patients. Practitioners are warned, for example, that tricyclic antidepressants and monoamine oxidase inhibitors both may contribute to increased heart rate and blood pressure and to orthostatic hypotension in certain heart patients. Some hope is offered for the safety of antidepressants in the family of serotonin uptake inhibitors, but fewer studies have been conducted on this newer class of drugs. The typical pharmaceutical treatments for heart disease, such as angiotensin-converting enzyme (ACE) inhibitors and beta blockers, are not mentioned at all, yet these drugs produce significant physiological effects that may impact the sense of well-being for patients. For example ACE inhibitors, designed to control blood pressure, may also produce edema, headaches, dizziness, drowsiness, and weakness, all of which may be interpreted by the patient as continued evidence of decline and frailty and may lead to an increased sense of hopelessness and depression. Similar side effects have been noted for beta blockers prescribed to relieve chest pain, reduce heart palpitations, and control blood pressure. Information on these standard medical treatments should have been summarized early in the text along with the basic information provided about heart disease. Oddly, there is no substantive discussion of surgical treatment of heart disease. This omission is striking, as more than one million major surgical heart procedures are performed each year (DeFrances & Hall, 2002). Patients may have lived for some time with heart disease and pharmaceutical management but eventually be faced with the possibility of surgery. This may evoke a cascade of anxiety and other psychological dynamics having both specific and generalized components. When offered surgical options, some patients may in fact decline, but the process by which they reach these choices is not well understood. Further, it seems possible that options and probabilities may be communicated differentially by health care providers as a function of patient gender and race (Kressin et al., 2004; Schecter et al., 1996; Travis, 2005). The fairly common occurrence of neurological side effects from surgical interventions is another topic that is absent in the book. Anesthesia for major surgery can in itself produce memory lapses and a sense of confusion and lack of control that may continue to surface sporadically for months or even years following surgery. Similarly, whether bypass surgery is done on- or off-pump of a heart-lung machine has differential consequences for neurological sequelae. These neurological symptoms initially may be reported and primarily understood by the patient as psychogenic conditions for which she or he is somehow to blame. Notwithstanding these limitations, the book will prove highly useful. References Berkman, L. F., Blumenthal, J., Burg, M., Carney, R. M., Catellier, D., Cowan, M. J., et al. (2003). Effects of treating depression and low perceived social support on clinical events after myocardial infarction: The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) randomized trial. Journal of the American Medical Association, 289, 3106-3116. DeFrances, C. J., & Hall, M. J. (2002). National Hospital Discharge Survey: Advance data (Vital and Health Statistics, No. 342). Hyattsville, MD: National Center for Health Statistics. DeLeon, P. H. (2002). Presidential reflections: Past and future. American Psychologist, 57, 425-430. Kressin, N. R., Chang, B., Whittle, J., Peterson, E. D., Clark, J. A., Rosen, A. K., et al. (2004). Racial differences in cardiac catheterization as a function of patients' beliefs. American Journal of Public Health, 94, 2091-2097. Matarazzo, J. D. (1980). Behavioral health and behavioral medicine: Frontiers for a new health psychology. American Psychologist, 35, 807-817. Olbrisch, M. E., Weiss, S. M., Stone, G. C., & Schwartz, G. E. (1985). Report of the National Working Conference on Education and Training in Health Psychology. American Psychologist, 40, 1038-1041. Schecter, A. D., Goldschmidt-Clermont, P. J., McKee, G., Hoffeld, D., Myers, M., Velez, R., et al. (1996). Influence of gender, race, and education on patient preferences and receipt cardiac catheterizations among coronary care unit patients. American Journal of Cardiology, 78, 996- 1001. Travis, C. B. (2005). Heart disease and gender inequity. Psychology of Women Quarterly, 29, 15- 23. For personal use only--not for distribution. PsycCRITIQUES February 8, 2006 Vol. 51 (6), Article 9 1554-0138 (c) 2006 by the American Psychological Association