Meeting the psychological needs of cardiac patients – an integrated stepped-care approach within a Cardiac Rehabilitation setting Professor Myra Hunter Institute 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 Biological changes Indirect Health behaviours (e.g. exercise) Depression/ Anxiety (Stress) CHD There are potentially direct na dindirect pathways to explain the association between dep and CHD The best evidence for psychological treatment is associated with the indirect pathway, but its work remembering the potential role of anti-depressants here. Biological changes (e.g. heart rate variability) Direct (Adapted from Brunner, 2002)

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 Worse baseline characteristics do not account for total gender difference in clinical outcome Afro-Carribean populations have a lower than national average risk of CHD, but have a three fold higher risk of stroke.

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 (Kugler et al 1994) Lifestyle factors - there should be active intervention to prevent another one and maximise QoL NSF recommends 85% attend a CR programme Efficacy results (dusseldorp - SIGN) Reinfacrtion likely Maes, (1992) defines CR as: "the co-ordinated efforts of various health professionals and non professionals to help the patient return to his or her former way of life, taking into account possible limitations brought about by the incident, and secondary prevention measures for gaining control over the progression of the disease". Death rates from heart disease have fallen since ’70’s If you have CHD, you have a 30-50% chance of dying from it Reported 300,000 MIs per year, consequently, the NSF for CHD sets out a comprehensive proposal to “transform the prevention, diagnosis and treatment of CHD” More people are surviving their first MI (early detection and treatment), which leads to a role for rehabilitation. NSF recommends CR offered to 85% CR varies around country, but standard two components are exercise and education/information - Update NSF figures - leading cause of premature mortality in Western world - Advances in clinical management of an MI means that over 60% of pts will survive their MI. - Importance of secondary prevention Significant improvements demonstrated for anxiety and depression with exercise rehab alone (Kugler 1994)

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 Cochrane review 2004: CBT no effect on mortality but small effect on anxiety/depression Meta-analysis 2007: CBT in first 2 years reduced mortality in men but timing important offered immediatley afterwards no effect; Enrichd trial 2003: CBT reduced depression after 6 mths but not sustained at 30 mths one size fits all CBT… Secondary analyses suggest that worse outcoem in people with severe dep, who did not adhere to homework, severe health problems and lower social support. Some evidence that antidepressants might affect physiologic parameters that are dysregulated in depression BUT None of them, however, addresses the question of whether pharmacologic treatment of depression in patients with existing heart disease might affect cardiac function, morbidity, or mortality. Sertraline Anti-Depressant Heart Attack Trial (SADHART).not adequatley powered buut safe and some evidence but overall ns. MIND-IT trial (2007) antidepressant ns BDI 18 mths later ENRICHED dep reduced at 6 mth not 30; secondary analyses at follwoup dep still predcited mortality; and antidepressna ts were used for non repsonders.

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 The current service is a 3 year project funded by the Guys and St Thomas’ Charity. Its aims are to Integrate the service within the multi-disciplinary CR programme Provide & evaluate a stepped care approach with interventions that are acceptable and accessible for patients And Establish a mainstream psychology service 8

Alison Child Cardiac Liaison Sister Jane Sanders Cardiac Rehabilitation Sister Paul Sigel Consultant Clinical Psychologist Myra Hunter IOP/SLAM B J Cardiology 2010;17:175-9. Heirarchy in cardiology

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 Providing specialised interventions for addressing specific psychological aspects of medical conditions Improving access to and acceptability of psychological interventions And collaborating with physicians, nurses & therapists Although many of our patients will have psychological difficulties associated with their cardiac problems, they will not necessarily see their problems in mental health terms. For example, cardiac patients may readily discuss psychological factors contributing to physical symptoms but be uncomfortable acknowledging problems with anxiety or mood. I had a patient who was referred to me when I first started at St Thomas. Initially, she was sent an appointment to see me in the Psychology Department within the mental health trust. She did not attend this appointment. When one of the nurses spoke with her about this, she said something like “I may have problems, but I’m not a mental case.” Subsequently, the team were able to interest her in one of our workshops. I invited her to meet with me in the Cardiac Outpatients Clinic. She attended this appointment and has since engaged well with our service. Importantly, her primary complaint was the way that breathlessness & fatigue interfered with her everyday activities. She was not very keen to talk about her problems in terms of anxiety or depression. So we worked on strategies for coping with her physical symptoms whilst executing everyday activities. This was successful in increasing her activity levels and also improving her mood. Now I ‘ll tell you a bit more about some of the patients that I’ve been seeing. 10

Access points to clinical psychology during the patient journey Psychological assessment & treatment GPs Liaison with IAPT CMHT Cardiac Event Heart Failure team Hospital Discharge S1 All patients entering the cardiac rehabilitation programme met the clinical psychologist at their assessment and were offered psycho-education sessions. Patients were screened for psychological difficulties at four points during the year following their cardiac event. Home Visit S2 Cardiac Rehab S3 Cardiac Out Patients S4

Psychological Interventions Stepped-care Approach Mild Moderate High Patient need Psycho-education sessions Group Workshops/ Brief 1:1 therapy Individual Therapy Intervention When I say “stepped care” I am thinking primarily about frameworks that have been established by the Department of Health for working with LT conditions and with common mental health problems like anxiety and depression. [Animate] This triangle may be familiar to some of you. It describes levels of patient need. The base of the triangle represents the largest group of patients, having mild needs, progressing to higher levels of needs amongst a more select group. In developing services the aim is to provide interventions [animate] in line with these needs, from low to high levels of intensity. In our service we offer a range of interventions, including psycho-education sessions for all patients attending rehab, to group workshops and brief therapy for patients with moderate needs, to longer interventions for higher, more specialised needs. Now I should say something about clinical psychologists would be working in acute care. And some of you may be thinking “We already have services for mental health problems. What do we gain by having clinical psychologists working in the department? There are three primary reasons for having clinical psychologists in acute care [slide] 12

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 Benefits: healthier, putting other things in perspective, gaining support from others.

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 24% SMI psychosis ptsd sevre depression… and input to MDT in managing people in the CR programme – educaiotn and reducign stigma. People with heart failure also included.

Mean scores on the BDI showing changes in mood after psychological interventions 0-9 normal range 10-15 mild depression 16-19 mild-mod depression 20-29 moderate – severe dep 30-63 severe dep The results showed significant reductions in levels of depression after treatment (Pre treatment mean 24.42 (s.d.=11.70), Post treatment mean 14.98, s.d.=10.90; t=7.64 df 42, p<0.00001) and 3 months later (Follow-up mean 15.79, s.d.=11.01; t=7.74 df=38, p<0.0001). There were fewer changes for those with severe mental health problems

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) I guess for me the central questions are: Is this worth taking forward for the broader group of cardiac patients and, if so, how should we do this? I should also say that I’ve recently had a meeting with Lambeth PCT about ways to make some of these services available to local GPs. You may be aware that the new GP contracts contain specific indicators for measuring depression in patients with CHD. It was helpful in that context, to have some proposals to consider so I’ve prepared a few slides to aid our discussion

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. Advantages to this way of delivering psychology..

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 Primary care nurse 2 day training dep and beh management (problem solving and motivational interviewing) adn the depression help book (self help book) (Katon et al 20030 intervnetiosn – appts every 2-3 weeks individualise goals weekly supervision review by psychiatrist, GP and psychology team for patietns with depression and poorly controlled diatbetes, CHD or both...good outcomes for dep QOL nad medical risk factors 12 month slater.. NEJMed Group interventiosn and collaborative care recommended for dep and chronic illness