icd by WlT6NY

VIEWS: 28 PAGES: 37

									ICD and new cardiac populations:
psychological issues

Bob Lewin




    CARE AND EDUCATION RESEARCH GROUP
Psychological issues
Psychopathology
8-17% acute episodes of anxiety, treatable with medication, or cognitive
therapy - should have service available
  anxiety and depression 30-40%
Clinically important anxiety 13% depression 10%
Direct causal relationship to number of shocks

HRQOL
same as other symptomatic cardiac groups e.g.. heart failure NYHA 1,2
worse in high shock population
major impact on activity levels, sexual activity

Relationship to implantation
HRQOL
        neurological problems

Behaviour
       avoidance of activity
       sexual difficulties
Psychological issues - Psychopathology

Series of 35 implants followed over 5 years, florid episodes of
psychopathology in 17% all following shocks – all severe anxiety
focussed on fear of future shocks, depression in 3 and 2 had become
housebound. Bourke JP, Heart 1997
Anxiety and depression - in 30% after implantation with 63% still anxious or
depressed at 1 year . Hegel MT, Int J Psychiatry Med, 1997

Using Hospital Anxiety & Depression Scale 13% were above the cut-off for
treatment for anxiety and 10% for depression, 15% said they wanted ‘special
psychological support’. No sig. Difference compared to CAD group with no


In ICD patients depression of moderate severity was identified in 35% of
cases using the Beck depression inventory (BDI).


Heart. 2001 Apr;85(4):375-9. How different from pacemaker patients are recipients of implantable cardioverter-defibrillators with respect to
psychosocial adaptation, affective disorders, and quality of life? Duru F, No different from pacemker patients
Effect on HRQOL

Conclusion Quality of life is better with ICD therapy than with amiodarone
therapy. The beneficial quality-of-life effects from an ICD are not evident in
patients who receive numerous shocks from their device. (Irvine J, Am Heart J
2002;144:282-9.)
relationship to implantation
neurological problems
Mean Hospital anxiety and depression (HAD) scores for anxiety and depression for 11
patients who completed the comprehensive cardiac rehabilitation programme and all the
exercise tests. Error bars = SD.

67% were cases at baseline, 42% at the end of the programme and 25% at 12 weeks



A Fitchet, Heart,
                 decreasing frequency of
                 angina, higher
                 ischaemic threshold
                                                               “Angina
 development of
                                                           doesn‟t do any
 collateral blood
                                                            lasting harm”
 supply to
 ischaemic area




                       Keep active - repeated
                        ischaemic challenge



Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462
                         angina at lower level of
                         activity


                                                               “angina is a
                                                                mini heart
deconditioning                                                   attack”
less efficient
use of oxygen in
myocardium




                 reduce activity to prevent angina
                    & further damage to heart


Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462
Guiding principle
Cardiac care should include attention to
• the patients‟ understanding of their illness
• the patients‟ own behaviour
• the coping measures they adopt
• their emotional status
• the influence of family and friends
• the social setting
Because these are determinants of treatment success,
treatment costs, disability and further ill health.
Cardiac Misconceptions
Heart has been worn out by „stress‟, „worry‟ or „overwork‟


There is a dead part in my heart that could burst if it were
put under too much pressure

Once you‟ve had one heart attack you‟ll have more and
one will get you, there‟s not much you can do

Rest restores the heart


effect - reconditioning, feeling of loss of control, anxiety,
depression
How could beliefs lead to weaker relationships
between impairment and disability?
                       increasing frequency
                       of angina at lower
                       level of activity            “angina is a
                       (correlation between          mini heart
deconditioning
less efficient use
                       ischaemia and
                       blockage increasingly
                                                      attack”
of oxygen in           weakened)
myocardium




                reduce activity to prevent angina
                   & further damage to heart


Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462
How do beliefs lead to weaker relationships between
impairment and disability?
                                                      “Angina
                     decreasing frequency of      doesn‟t do any
                     angina (correlation           lasting harm”
                     between ischaemia and
development of       blockage increasingly
collateral blood     weakened)
supply to
ischaemic area




                   repeated ischaemic challenge



Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462
Angina Management Programme: 1st trial

Crossover - waiting list to treatment - 82 patients

Main findings at 1 year after treatment;
       30% no angina
       70% reduction in episodes of angina
       57% improvement in exercise duration
       72% reduction in self reported disability (SIP)
       50% of patients taken off CABG list

no patient looking for further treatment,
at 5 years all but 2 still alive, only 4 been back to
cardiology.

Lewin, B. 1995, British Journal of Cardiology, 2, 219-26
Angina Management Programme: 2nd trial
      Episodes of Anxiety Depression Disability   Treadmill
        Angina     (HAD)    (HAD)      (SIP)      workload
                                                   (METS)
  4
  2                                                     *
  0
 -2
 -4                     *         †
 -6
 -8
                *
-10
                                             †
-12
-14
      Control       Exercise      AMP


6 months post treatment (* = p<0.01, †= p<0.001)
Disability in Angina
570 new angina patients.
Multiple regression to predict outcome at 6 months
101 cardiological variables and a personality questionnaire
Best model had one significant factor hypochondriasis
In the next 200 patients the model predicted by name
61% of patients with satisfactory angina relief
85% of patients failing to get sufficient relief from medical treatment
Williams, R. 1986, Psychosomatic Medicine, 48, 200-210


Angina Misconception Scale
angina is a kind of mini heart attack that damages your heart
angina is cured by rest
Furze G, Journal of Health Psychology 2001; 6:501-510
Taking the HM further
update treatment – improved understanding of self-
management and cognitive-behavioural methods
more inclusive - needs to incorporate CABG and PTCA
rehab
make training cheaper and more accessible, possibly
distance learning
make it a complete package - including assessment and
audit tools
build in the „triage model‟ and primary care handover into
the process
exploit IT better – use tailoring for more „individualised‟
programme based on assessed needs
The Angina Plan
70 page manual, relaxation tape, trained facilitator

angina misconceptions - complete questionnaire and discuss
relaxation and breathing techniques - on audio tape
controlling acute angina attacks - thought insertion, distraction
over activity rest cycle - explanation & how to avoid
goal setting and pacing - at initial session then by phone
exercise - daily walking goal, self paced increase
secondary prevention - diet, exercise,

Method
30 minutes introduction session, with partner present if possible
followed by 4, 10-15 minute phone calls, weeks 1,4,8,12 to set further
goals, praise progress, encourage adherence
I
M
P
A
    The relationship of impairment and disability
I
R
M
E                                Impairment causes
N
T                                disability
           D IS A B IL IT Y
recruitment & randomisation Angina Plan RCT

                  398 identified and written to by GP
     96 no reply, 52 had angina > 12 months, 33 no angina, 1 died, 4 terminal illness, 7 mental
                                 confusion, 18 refused to take part

                     187 present at assessment clinic
 Excluded from study - 25 angina > 12 months, 8 no angina, 2 atypical presentation, 4 urgent referral
                  for treatment, 1 terminal illness, 4 withdrew, 1 underwent CABG
                        142 randomised to treatment

     68 to Angina Plan                                              74 to education
 4 Dropped out, 1 no 6mth questionnaires                           5 Dropped out, 2 Died

                     130 (90%) at 6 month
       Angina Plan 63                educational session 67
a psycho-biological understanding of illness

physiological differences alone cannot explain
    •   disability (including anxiety and depression)
    •   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
to predict all of these you also need to measure
   •    anxiety & depression
   •    health beliefs
   •    personality
   •    patients‟ own attempts to cope
   •    social support & social class

Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462
A biopsychosocial understanding of disability

 physiological differences alone cannot explain
      •   disability (including anxiety and depression)
      •   the extent of the symptoms reported
      •   the success or failure of medical treatments or surgery
      •   the number of acute medical events and readmissions
      •   medical costs
 to predict all of these you also need to measure
     •    anxiety & depression
     •    health beliefs
     •    personality
     •    patients‟ own attempts to cope
     •    social support & social class

 Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462
Health beliefs - Cardiac misconceptions
if you’ve had a heart attack you are bound to die of heart
disease
any excitement or shock could cause another heart attack
sex is too exciting and especially dangerous
heart disease is caused by ‘stress’ ‘worry’ or ‘overwork’ (80%)
angina is a mini heart attack and damages the heart*
there is a dead part in my heart that could burst if put under too
much pressure*

*Maeland & Havik, Wynn, *Alan Goble, 1965
UK National Institute for Clinical Excellence
systematic review of the use of ICDs recommended increased use

BUT
also found to be associated with - poor quality of life, anxiety,
depression, unnecessary avoidance, poor return to work

Although the ICD relieves fear of dying prematurely, in some
patients it evokes a number of device related fears so that the
overall effect on anxiety is neutral.

Recommended - psychologically oriented rehabilitation
Our cognitive-behavioural rehab programme
works in MI, Angina, Syndrome X, CF
 improves anxiety & depression
 improves quality of life
 reduces disability, symptom report and increases activity levels
 improves physical fitness
 leads to fewer hospital readmissions & clinic attendances
Would it work, suitably modified, in ICD patients?
Randomised trial with ICD patients
randomised controlled trial. Crossover - waiting treatment to treatment
Anxiety post treatment 2                     and at 4 months 4
               6
                               wait
               5
                   22                             treatment

               4
 HAD Anxiety




               3                                            follow-up
                   treatment
                                            treatment
               2

               1
                        treatment                 follow-up
               0
                        1              2                3               4

                                      treatment         control
Anxiety & depression             Before           4 months after
HAD anxiety                      4.32             3.09*
HAD depression                   3.05             1.73    (50% reduction)




Specific ‘concerns’ about the ICD
Concerns - number                11.61            8.59
Concerns - severity              19.00            11.09     (50% reduction)


*2 outliers - 1 had psychotic episode, I had acute MI


                                  all changes significant beyond P< 0.001
Quality of Life *                         Before        4 months after

QLMI - emotional                          5.60          5.96
QLMI - physical                           5.22          5.86
QLMI - social                             5.36          6.12
QLMI - global                             5.39          5.98
QLMI - sex                                3.20          3.86

Quality of life
EuroQual* (quality adjusted life years)   72.18         84.95

                                improvements significant beyond P< 0.001
Physical fitness                                       Before                 4 months after

Shuttle test* - heart rate change                      16.22                  23.59 Ns
Shuttle test* - perceived exertion                     5.64                   5.65       Ns
Shuttle test* - no. stages completed                   7.03                   8.45       P< 0.00
Shuttle test* - distance walked (yards)                354                    463        P< 0.00


*Progressive exercise test, walk in circuit, 20 yards between 2 cones, cassette audio tape plays
tones, must do one circuit between tones, tones played increasingly quickly, correlates well with
Bruce protocol.
Main conclusions
 25% of patients with ICDs were clinically anxious, 17% depressed
  (n=99, all surviving patients). No evidence of spontaneous remission
  over time, ‘ICD concerns’ predicts anxiety as does age and number of
  firings.

 Rehab programme worked well, no drop outs (50% drop ins!)

 ICD Concerns questionnaire worked well - related to quality of life and
  psychological variables and changed after treatment

 ICD rehab effective and worthwhile
Problems
costs money!
low numbers at any one time in any one centre

geographically dispersed patients - problem getting to rehab centre

partners - an essential element in the solution - unable to take time
off work to take part

few staff trained in CBT

clinical psychologists almost totally unavailable
A potential solution
self help, home-based ICD rehab program for patient and partner

Previous experience
Scottish Office - MI patients - The heart Manual
Pfizer - newly diagnosed stable angina - the Angina Plan

The Heart Manual

50% of post-MI rehab in Scotland, 20% in UK & catching up fast
on trial Italy and Holland by national heart associations
more than 2000 nurses in UK trained to use it, prize winning schemes
Home based cognitive-behavioural programme

Phase 1. Development of the programme 12 months
Phase 2. The evaluation of the programme in a randomised trial

10 centres randomised to control or intervention
controlled with written materials and phone calls
60-100 patients in each arm
Benefits

From our pilot study with ICD patients
 reduced anxiety and depression
 improved quality of life
 improved physical fitness and activity levels
 fewer events ??
The Angina Plan



       142 randomised to treatment        self-help manual, relaxation tape, trained facilitator

Angina Plan             education         30-60 minutes introduction session, with partner present if
    68                  session 74        possible
                                          followed by 4, 10-15 minute phone calls / home /clinic
       90% at 6 month follow-up
                                          visits, weeks 1,4,8,12 to set further goals, praise progress,
                                          encourage adherence
         63                 67

 anxiety & depression                physical activity: SAQ        angina and use of GTN
                                                                       40% reduction
0.6
                                      9
                                      8                             1.0
0.4
                                      7                             0.5
                                                                    0.0
0.2                                   6
                                                                   -0.5
  0                                   5                            -1.0
-0.2
                                      4                            -1.5
                                      3                            -2.0
-0.4
                                      2                            -2.5
-0.6                                  1                            -3.0
-0.8                                  0                            -3.5
                                     -1                            -4.0
 -1                                                                -4.5
                                     -2
-1.2
                                                                          Angina    GTN
      Anxiety     Depression

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

								
To top