Meeting the psychological needs of cardiac patients – an integrated stepped-

care approach within a Cardiac Rehabilitation setting

Professor Myra HunterInstitute of Psychiatry, KCL

Consultant clinical psychologist, South London & Maudsley Trust

Depression and cardiac disease

Prevalence of depression in cardiac patients

3 times higher than general population 25-30% persistent anxiety/depression Depression in cardiac patients is a significant

and independent predictor of mortality, increased cardiac events, reduced quality of life, poorer self-management and greater health service use

Depression: pathways to CHD

Depression/ Anxiety (Stress)

Health behaviours (e.g. exercise)

Biological changes

Biological changes (e.g. heart rate variability)

CHD

(Adapted from Brunner, 2002)

Indirect

Direct

Depression and cardiac disease

Socio-economic disadvantage associated with depression and CHD

The death rate from CHD is 38% higher for men and 43% for women born in the Indian sub-continent

Living alone, being socially isolated, low emotional support, lack of a confidante additional independent predictors of morbidity and mortality

Services may not meet women’s needs

Cardiac Rehabilitation: meeting the needs

Cardiac rehabilitation (CR): multidisciplinary group based sessions aimed to improve physical and emotional recovery

Typically includes: health education (smoking, diet, exercise), stress management, exercise, delivered by cardiac specialist nurses, physiotherapists, dieticians - 6 weeks

NSF recommends that 85% attend a CR programme Depression, lower SES associated with lower take

up and higher drop out rates

Cardiac Rehabilitation: meeting the psychological needs

Psychosocial interventions advocated by NSF (2001) and NICE (2007)

Evidence for psychological and medical interventions for depression in cardiac patients: mixed generally no effect on cardiac outcomes

Enrichd trial 2003: CBT reduced depression after 6 mths but not sustained at 30 mths - one size fits all CBT…

Cochrane review 2004: CBT no effect on mortality but some effect on anxiety/depression

Meta-analysis 2007: CBT in first 2 years reduced mortality in men but timing important no effect if offered immediately after cardiac event

British Heart Foundation audit of UK CR 2009

4% reduction in anxiety/depression (HAD) following CR

33% of UK CR programmes have some psychology

3% included psychological interventions

Meeting Psychological Needs of Cardiac Patients

Funded by Guys & St Thomas’ Charity to GST and SLAM

3 year project Service innovation to integrate psychology within

multi-disciplinary cardiac rehabilitation programme Provide & evaluate a stepped care approach with

interventions that are individualised and acceptable and accessible for patients

To carry out service evaluation

Alison ChildCardiac Liaison Sister Jane SandersCardiac Rehabilitation Sister Paul Sigel Consultant Clinical Psychologist

Myra Hunter IOP/SLAM

B J Cardiology 2010;17:175-9.

Clinical psychologists role

Specialised psychological interventions

Improving access to and acceptability of psychological interventions

Input to CR programme

Multidisciplinary work - collaboration with physicians, nurses & therapists (including prevention)

Training, supervision, research

Access points to clinical psychology during the patient journey

Psychological assessment & treatment

Home VisitS2

Hospital Discharge

S1

Heart Failure

teamCardiac

OutPatients

S4

Cardiac Rehab

S3

Cardiac Event

GPs Liaison with

IAPTCMHT

Psychological Interventions Stepped-care Approach

Psycho-education sessions

Group Workshops/ Brief

1:1 therapy

Individual Therapy

Intervention

Mild

Moderate

High

Patient need

Psychological interventions

Psycho-education sessions within the cardiac rehabilitation, addressing on behavioural risk factors and adjustment issues. Co-facilitated with other members of the MDT

Brief individual therapy 1-6 sessions. This included cardiac-focused/ engagement focussed interventions and included people with severe SMI

Individual therapy 4-26 sessions CBT for anxiety, depression and adjustment to adverse life events

Group workshops consisting of eight sessions for small groups (3-8 patients)

Adjustment, depression, anxiety and behavioural risk factors

Concerns about the meaning and impact of symptoms Disbelief and non acceptance of cardiac problem Health beliefs and catastrophic interpretations about

impact of cardiac disease on their lives and in the future Coping and engaging in everyday activities Adherence to treatments Modifying behavioural risk factors smoking, alcohol,

exercise, weight Changes in roles, relationships and interactions with other

people The re-emergence or intensification of pre-morbid

psychological difficulties Noticing some benefits

Results: accessibility and acceptability

103 (82%) of the 125 patients referred accepted interventions from the psychologist

Gender (62% male and 38% female) and ethnicity (70% White, 10 Black, 8% Asian, 7% other and 6% not recorded) was similar to that of patients attending cardiac rehabilitation.

Psychological interventions delivered to patients

Mean scores on the BDI showing changes in mood after psychological interventions

Results

Audit data for 460 patients attending CR during the two years of the study (2005-2007) showed a reduction of 19% for anxiety and 13.5% for depression (HADS) following the CR compared to a 4% national average (National Audit of Cardiac Rehabilitation, BHF, 2009)

Overall satisfaction rates (Client Satisfaction Questionnaire) on discharge of 86% for all intervention types, ranging from 83 to 93%.

Psychological input acceptable and accessible Depression reduced in those treated (BDI)

Conclusions

Integration of psychology within the MDT in the acute setting enabled increased accessibility and acceptability

This also reduced possible stigma and normalised the focus on psychological issues

The psychologist provided the team with supervision and support in addressing psychological issues

The flexible timing and the emphasis on patient choice of the level of intervention were felt to be important elements of the service.

Future directions

IAPT Community Evaluation of groups (Tylee et al in progress) Collaborative care (Katon et al New Eng J Med

2010) Cardiac settings: non cardiac chest pain,

anxiety in people with implantable cardiac defibrillators (ICDs), input to heart failure and Cardiac Rehab teams