By Serena Agusto-Cox | News & Views

Cardiovascular health has a bidirectional relationship with mental health, specifically, depression, anxiety, stress, and loneliness. Sharon Y. Lee, PhD, assistant professor in the Department of Psychiatry and Human Behavior at Warren Alpert Medical School of Brown University, says that not only can a person’s mental health adversely impact their cardiovascular health, but inversely, cardiovascular well-being can have a negative effect on mental status.

“Stress, depression, and anxiety are factors that elevate one’s risk for developing cardiovascular disease and worsening its progression. On the other side, we also know that folks who have experienced a cardiac event or who live with cardiovascular disease often struggle with their mental health,” says Dr. Lee. “There’s also data to show that these mental health concerns, if left untreated, can increase the cardiac patient’s risk of rehospitalization and death.” She adds that these struggles with mental health can persist for many years after a cardiac event occurs.

Cardiac Rehab Can Address Physical and Emotional Health

Many cardiac rehab programs already administer the Patient Health Questionnaire-9 (PHQ-9) to assess depressive symptoms, the Generalized Anxiety Disorder-7 (GAD-7) form to evaluate anxiety symptoms, or other screening tools to identify patients in need of additional mental and behavioral health care. Providing patients with the language and tools they need for mental and physical health recovery is proven to improve patient outcomes.

According to Dr. Lee, “providers and staff can play a key role by engaging patients in conversations about how they manage their stress.” Oftentimes, patients are wary of talking about anxiety and depression, but they can easily relate to stress and how to manage it.

“While exercise physiologists or nurses are not necessarily trained mental health professionals, they can provide patients with the basic statistics to make better informed decisions, as well as outline some ‘light touch’ interventions that patients can do on their own to address mental health concerns,” explains Dr. Lee. “Just because we're all trained in different disciplines, doesn't mean that we can't play an important role in screening for mental health disorders. Staff also can provide emotional support to patients in the moment.”

Dr. Lee estimates that approximately 33 percent of CR patients have anxiety and that another third have depression. For CR patients, staff can ask specific questions to elicit responses that point to a need for mental health care, such as when a patient expresses a loss of pleasure or interest (called anhedonia) in activities they loved before their cardiac event. Some of these might include no longer deriving joy from attending a baseball game with a grandchild or losing the desire to take walks in the park. “This is really different from not being able to do the activities because they are recovering from a cardiac event and have specific activity restrictions or limitations,” Dr. Lee underscores.

What can be tricky to uncover is whether physiological changes, such as weight loss, weight gain, loss of appetite, or a rise in sleep disruption are due to the cardiac event and prescribed medications or if they are rooted in mental health issues. Dr. Lee recommends that CR staff tease out the crux of the problem by asking follow-up questions. For instance, if patients say they are having trouble sleeping, CR staff can ask simple questions to determine if the cause is physiological or emotional:

• What is causing you to wake up?
• Do you wake up feeling a certain way?
• Do you know why you're waking up?
• Is there a specific thought that pops into your mind after you wake?

When a patient answers these questions, they may talk about the next day’s checklists or upcoming doctor appointments. “This would sound more like anxiety than something physically related to the cardiac event or the patient’s medication,” she said. “If a patient is depressed, they may express feeling ‘worthless’ or like ‘a burden’ to others.”

Psychoeducation in Cardiac Rehab

Once CR staff are aware of a patient’s mental health, they can ease the stress of CR by providing tidbits of information that normalize the impact of cardiovascular problems on mental health. “I might say to patients, ‘most of my patients report feeling nervous about exercising again after a cardiac event.’ This normalizes the anxiety they may feel,” explains Dr. Lee. “In fact, a third of people who come through here will develop anxiety after a cardiac event.” This is the moment where Dr. Lee lets patients think about it and then express themselves.

According to Dr. Lee, research conducted by other scientists — like the VIRGO study — show that female patients younger than age 55 who experience a cardiac event often fare worse in terms of mental health, exhibiting higher rates of symptoms of anxiety, depression, and even post-traumatic stress disorder. Providing patients with information about similar situations can ease stress levels and normalize a patient's response to an atypical or traumatic experience.

Dr. Lee also points out that patients and providers should start thinking about the connections between mental and heart health. “Taking care of your mental health is a way of taking care of your heart,” she advises. “Patients with cardiovascular or mental health concerns should walk themselves away from drinking, smoking, and poor dietary behaviors and walk toward behaviors like increased physical activity, good quality sleep, and adherence to medical regimens.”

Developing healthy habits for dealing with stress before a cardiac event also provides a solid foundation to work from after those situations happen and patients are engaged in CR. “After a cardiac event, it is harder to build new mental health care habits and better behaviors to improve physical health,” says Dr. Lee. With older adults, CR staff and providers should also look for signs of social isolation and loneliness, which can impact recovery. Dr. Lee adds that CR staff can have conversations with patients on the treadmill and from those talks gauge how lonely or isolated they are feeling.

Patients benefit greatly when they see their feelings and stressors as normal, and CR staff can help demystify what mental health treatment looks like by having a psychologist or therapist briefly visit a CR group. Referrals to mental health professionals or clinics may be the best way to help patients in need of greater intervention.

“CR is a beautiful space because it lends itself to interdisciplinary cross talk. It’s really where the mind meets the body,” Dr. Lee explains. “For instance, when a dietician reviews a patient’s food log or performs a cooking demonstration, it’s another opportunity to provide psychoeducational content to patients. They can point to how depression or stress can impact food cravings and how those cravings can affect food choices.”

Dr. Lee explains that “through these micro-interventions and team-based care, which already happens in CR, patients and staff become champions for not only cardiac care, but for mental health.”

A recording of Dr. Lee's 2024 live webinar on the bidirectional relationship between cardiovascular health and mental health is available at the AACVPR Learning Center.