By Anna Horner | News & Views

The intersection of cardiopulmonary disease and psychological distress is an emerging field with significant implications for cardiovascular and pulmonary rehabilitation (CR/PR). Laura Suarez Pardo, MD, assistant professor of psychiatry at the Mayo Clinic, says it is critical for CR and PR professionals to understand and recognize the psychosocial stressors affecting patients and complicating their road to recovery.

“We’ve learned through the years that an untreated mental illness or significant emotional response to cardiovascular or pulmonary illness can negatively impact [a patient’s] ability to recover,” explains Dr. Suarez Pardo. “A term originating in Australia, ‘cardiac blues,’ emphasizes the rollercoaster of emotions when someone experiences a cardiac event. Some patients understand that recovery will be tough but will do what’s being asked of them. But that’s not true for everyone.”

According to Dr. Suarez Pardo, identifying the psychosocial stressors that could prevent a participant from following a recovery plan is key. Otherwise, they may be at risk of developing depression or anxiety disorders and subsequently adopting maladaptive coping strategies such as smoking, abusing alcohol, avoiding exercise, and, ultimately, avoiding their health care providers. “Psychocardiology has helped us understand the additional risk factors we need to pay attention to,” says Dr. Suarez Pardo. “The earlier we identify those, the easier it is for providers to work together to improve the patient’s outcomes.”

Additionally, she continues, patients who already have a depressive illness are at greater risk of developing depression after a cardiac event or chronic illness. “For patients with schizophrenia and bipolar disorder, for example, we know that their risks of developing cardiac issues or chronic illnesses is higher because they tend to have less healthy behaviors. These patients also may be on medications that increase their weight, lipids, and sugars; and the side effects put them at risk even before they have a problem,” adds Dr. Suarez Pardo. “People also can develop psychological distress related to trauma from their medical experience, and some individuals who grew up in difficult environments or experienced trauma as a child are at risk of developing mental, cardiac, and chronic illnesses.”

Tools

There are numerous screening tools that can help detect psychological distress in patients with cardiovascular and pulmonary disease, according to Dr. Suarez Pardo. The Patient Health Questionnaire (PHQ) is widely used in most health care settings, and she says most CR and PR practices use the PHQ-9 tool to screen for depressive symptoms and suicidal thoughts. “It really alerts staff to a patient who is struggling, and in someone who's had a major illness event, it might just be that they’re thinking about their mortality but not in a way of hurting themselves,” explains Dr. Suarez Pardo. “But we have had experiences where the tool catches patients who feel incapable of going through all the changes following a cardiac event or chronic illness. Depression sets in, and they do contemplate suicide.”

Other screening tools are available to assess patients for anxiety. “If someone has excessive anxiety, they might overly worry about their problems, and now that chest pain is not chest pain related to their heart, but it's a panic attack,” Dr. Suarez Pardo says. “It helps determine how to treat a problem. Particularly for women, their cardiac symptoms often are treated as anxiety. For others, if they have anxiety that may be dismissed, and they keep seeking cardiac testing.”

Treatments

As for treatments, Dr. Suarez Pardo says cognitive behavioral therapy, acceptance and commitment therapy, and grief therapy can be helpful for patients adjusting to chronic illness. Antidepressants also have been shown to be a safe treatment for depression and anxiety. “We know that exercise alone can be an antidepressant, so it’s important to encourage patients to continue with their exercise routines,” adds Dr. Suarez Pardo. “Sometimes, following a cardiac event or chronic illness, patients lose their routines, their roles, and/or their employment, so CR and PR programs help them stay active and engaged, decreasing their risk of developing depression.”

There are mandated psychosocial screening assessments for anxiety, depression, substance use, stress management, cognitive abilities, and social networks, among other risk factors, that Dr. Suarez Pardo believes should be part of the regular screenings and evaluations for CR and PR programs. “Most programs will screen specifically for depression, for example, at the beginning and at the end,” she says. “It’s also recommended that they develop a workflow so that once a patient is identified as having severe depression or suicidality, they are referred to ensure they receive the help they need.”

Seeing a provider regularly who can assess their engagement, overall mood, and how they adjust to chronic illness is a screening tool in itself, adds Dr. Suarez Pardo. “It helps identify someone who might not be engaging or might be having problems from an emotional standpoint that prevent them from recovering from illness,” she explains. “These assessments indicate that the patient may need additional support, such as meeting with a psychiatrist for medication management and diagnostic clarification.”

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