1. CoRPS Center of Research on Psychology in Somatic diseases ICD patients with anxiety: what to do? Susanne S. Pedersen, Professor of Cardiac Psychology

2. CoRPS Disclosures Moderate speaker or consultancy fee from: Cameron Health Medtronic Sanofi-Aventis St. Jude Medical

3. CoRPS Affiliations Prof.dr. Susanne S. Pedersen CoRPS - Center of Research on Psychology in Somatic diseases, Tilburg University, The Netherlands Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands Department of Cardiology, Odense University Hospital, Denmark Phone: + 31 (0) 13 466 2503 E-mail: s.s.pedersen@uvt.nl www.tilburguniversity.nl/corps

4. CoRPS Overview Prevalence of anxiety in ICD patients Which patients are at risk of anxiety? Why bother about anxiety in ICD patients? What to do about anxiety in ICD patients? Take home message

5. CoRPS Overview Prevalence of anxiety in ICD patients Which patients are at risk of anxiety? Why bother about anxiety in ICD patients? What to do about anxiety in ICD patients? Take home message

6. CoRPS Anxiety ≈ 25%-33% Posttraumatic stress ≈ 12%-19% A high level of chronicity of anxiety at 12 months post implantation → 51.8% (115/222) of patients anxious prior to ICD implantation Prevalence of anxiety in ICD patients Kapa et al. PACE 2010 33;198-208; Versteeg et al. Int J Cardiol 2011;146:438-9; Pedersen et al. Int J Cardiol 2011;147:420-3

7. CoRPS Prevalence of anxiety in ICD patients A subset of patients: 1 in 4 (25%)

8. CoRPS Overview Prevalence of anxiety in ICD patients Which patients are at risk of anxiety? Why bother about anxiety in ICD patients? What to do about anxiety in ICD patients? Take home message

9. CoRPS Prevalence of anxiety and depression in patients stratified by Type D and shocks Pedersen, Jordaens, Theuns et al. Psychosom Med 2004;66:714-9 % N = 182

10. CoRPS Von Känel et al. J Affect Disord 2011;131:344-52 Predictors of posttraumatic stress at baseline and follow-up N = 107

11. CoRPS Correlates of anxiety and depression Johansen, Pedersen et al. Europace 2008;10:545-51 AnxietyDepressionOR [95% CI] Female gender 2.38 [1.32-4.29]† ns Age ns ns Living with a spouse ns ns Non-ischaemic etiology ns ns Symptomatic CHF 5.15 [3.08-8.63]‡ 6.82 [3.77-12.39]‡ Co-morbidity ns ns ICD-related complications ns ns ICD shocks 2.21 [1.32-3.72]† 2.00 [1.06-3.80]* Years with ICD therapy ns ns Current smoking ns ns Amiodaronens ns Other antiarrhythmic medication ns ns Psychotropic medication ns 2.75 [1.40-5.40]† * P < 0.05; † P < 0.01; ‡ P < 0.001 N = 610

12. CoRPS Overview Prevalence of anxiety in ICD patients Which patients are at risk of anxiety? Why bother about anxiety in ICD patients? What to do about anxiety in ICD patients? Take home message

13. CoRPS Anxious Type D patients and ventricular arrhythmias van den Broek, Denollet et al. JACC 2009;54:531-7 N = 391

14. CoRPS Posttraumatic stress symptoms and mortality Ladwig et al. Arch Gen Psychiatry 2008;65:1325-30 N = 147 HR: 3.45 (95%CI: 1.57-7.60; p =.003)

15. CoRPS Pedersen, Erdman et al. Europace 2010;12:1446-52 Type D personality and high ICD pre- implantation concerns and mortality N = 371 HR: 3.65 (95%CI: 1.57-8.45; p =.003) 18.2% 5.2%

16. CoRPS ICD shock - the paradox Shock Braunschweig, Boriani,... Pedersen et al., Europace 2010;12:1673-90 Stressed out… Me ???!!

17. CoRPS ICD shock - the paradox Cardiac psychology has something to offer to patients Reduce catastrophic thinking Alleviate symptoms of anxiety and depression Improve quality of life Effect on survival? Pedersen et al. PACE 2007;30:1546-54; Lewin et al. Heart 2009;95:63-9 Irvine et al. Psychosom Med 2011;73:226-33

18. CoRPS Overview Prevalence of anxiety in ICD patients Which patients are at risk of anxiety? Why bother about anxiety in ICD patients? What to do about anxiety in ICD patients? Take home message

19. CoRPS 1. Screen and monitor

20. CoRPS Braunschweig, Boriani,.... Pedersen et al. Europace 2010;12:1673-90

21. CoRPS Pedersen, Theuns, Jordaens et al. Am Heart J 2005;149;664-9 ICD Patient Concerns questionnaire We want to know what things worry you about living with your ICD. It is important that you answer every question. Don’t spend too long thinking about your answers. For each question please circle one number. Please don’t leave any out. 0 = Not at all 1 = A little bit 2 = Somewhat 3 = Quite a lot 4 = Very much so I AM WORRIED ABOUT...... 1.My ICD firing01234 2.Doing activities/hobbies that may cause my ICD to fire01234 3.Time spent thinking about my ICD firing01234 4.Working too hard/overdoing things causing my ICD to fire01234 5.Having no warning my ICD will fire01234 6.The symptoms/pain associated with my ICD firing01234 7.Not being able to prevent my ICD from firing01234 8.Getting too stressed in case my ICD fires01234

22. CoRPS 2. Clinical practice tips

23. CoRPS Braunschweig, Boriani,.... Pedersen et al. Europace 2010;12:1673-90 Shock-induced distress – how does it work?

24. CoRPS General measures Establish trustful relationship… o with patients and partners o with mental health expert inside or outside the team Listen to patients and leave room for questions and emotions Look at patient’s body language Regularly explore beliefs, health resources and distress (both pre-existing and newly developed) Sears et al. Stress and Health 2008;24:239-48 Braunschweig, Boriani,.... Pedersen et al. Europace 2010;12:1673-90

25. CoRPS General measures Offer quick help if shocks and / or distress occur Ask for subjective effects of shock… o Sensory and emotional perception o Interpretation o Behavioral consequences o Encourage resumption of activities asap Explore patient needs for more information and support Provide reassurance Sears et al. Stress and Health 2008;24:239-48 Braunschweig, Boriani,.... Pedersen et al. Europace 2010;12:1673-90

26. CoRPS ICD specific education o How the device works, triggers of shocks, how to respond to shocks (e.g. shock plan [Sears et al. Circulation 2005;211:e380-2] ) o Everyday functioning (e.g. occupational limitations, physical and sexual activity, driving) Multidisciplinary cardiac rehabilitation o “One size does not fit all” o Demonstrate safety of customized exertion via cardiac rehabilitation approaches Sears et al. Stress and Health 2008;24:239-48 Braunschweig, Boriani,.... Pedersen et al. Europace 2010;12:1673-90 Specific measures

27. CoRPS Relaxation and stress management o Assist patients in reducing arousal via progressive muscle relaxation and diaphragmatic breathing Cognitive restructuring (CBT) o Teach patients to value the ICD as a source of protection rather than a threat to their well-being o Encourage activity planning and exposure-based exercises to teach patients to engage in activities they have reduced or avoided due to the device Sears et al. Stress and Health 2008;24:239-48 Braunschweig, Boriani,.... Pedersen et al. Europace 2010;12:1673-90 Specific measures

28. CoRPS Social support o Provide patients with social support via nursing contact, patient calls and support groups Referral to a mental health professional Prescription of pharmacotherapy (e.g. SSRIs and anxiolytics) Sears et al. Stress and Health 2008;24:239-48 Braunschweig, Boriani,.... Pedersen et al. Europace 2010;12:1673-90 Specific measures

29. CoRPS E-health the future? Pedersen et al. Trials 2009;10:120

30. CoRPS Overview Prevalence of anxiety in ICD patients Which patients are at risk of anxiety? Why bother about anxiety in ICD patients? What to do about anxiety in ICD patients? Take home message

31. CoRPS Take home message A subset (25%-33%) are at risk of psychological distress High-risk patients – symptomatic heart failure, psychological profile, shock Distress increases the risk of VTs/VFs and mortality Screen and monitor – we need to know who they are; this information cannot be extrapolated from medical records Multi-factorial psychosocial/behavioral interventions targeted to the individual most likely to be successful

32. CoRPS Living in a Device World: Focus on Recent Challenges and Tools to Improve Clinical Care for Patients with an Implantable Cardioverter Defibrillator Device Conference, 3-4 November 2011, Tilburg, the Netherlands Themes OVERCOMING THE SHOCK OF THE ICD ICD REGISTRIES AND THE INCLUSION OF THE PATIENT PERSPECTIVE DEACTIVATION OF THE ICD AND END OF LIFE ISSUES NEGLECTED SUBGROUPS CRT SELECTION AND RESPONSE THE DO’S AND DON’TS OF PATIENT COMMUNICATION SEXUALITY IN ICD PATIENTS BEHAVIORAL INTERVENTIONS LOOKING INTO THE FUTURE Selection of invited faculty Nico Blom (MD, PhD), Leiden University Medical Center, NL Matthew Burg (PhD), Yale School of Medicine, USA Viviane Conraads (MD, PhD), University Hospital Antwerpen, BE Dorothy Frizelle (PhD), University of Hull, UK Jens Brock Johansen, (MD, PhD), Odense University Hospital, DK Karl-Heinz Ladwig (MD, PhD), Helmholtz Institute, Munich, GE Mathias Meine (MD, PhD), University Medical Center Utrecht, NL Susanne S. Pedersen (PhD), CoRPS, Tilburg University, NL Samuel Sears (PhD), East Carolina University, USA Steen Pehrson (MD, PhD), Copenhagen University Hospital, DK Dominic Theuns (PhD), Erasmus Medical Center Rotterdam, NL More information available on: www.tilburguniversity.edu/device2011