• Fri. Jul 19th, 2024

A look at cardiac psychology


Jul 8, 2024 #cardiac, #Psychology

Margery Quackenbush was attending a board meeting of the nonprofit where she served as executive director when she felt a sharp, stabbing pain in her chest. As the organization’s president yelled at a board member, Quackenbush — then age 69 — noticed her heart tightening and felt terrified.

After that day more than 15 years ago, her cardiologist began a series of tests. The results showed a blocked artery and she got a stent put in, becoming one of more than 600,000 people in the United States who have a stent placed each year, according to the American Heart Association.

“The whole thing came as a shock. I like to tell people I didn’t know I had a heart,” said Quackenbush, who was then the executive director of the National Association for the Advancement of Psychoanalysis. Years later, at age 85, the therapist lives in New York City’s Upper East Side in an apartment she shared with her husband of almost 50 years, children’s book author Robert Quackenbush, who died of cancer in 2021.

She became more mindful of her heart, and its needs, by attending regular support groups over the last 15 years. Today, she credits her health in part to the psychological and behavioral support she’s received while navigating heart disease — an area that’s all too often neglected in the U.S. health care system.

One in three heart patients live with anxiety, depression, and ongoing stress, according to a 2023 meta-analysis of over 100 studies. But even in the age of 24/7 monitoring via implantable loop recorders and wearables, many patients are without professional support for the mental and emotional social aspects of coping with heart disease.

“The technology of cardiology is locked down. People get that. What’s not locked down is the patient experience,” said Sam Sears, professor of health psychology at East Carolina University, and the author of over 200 research studies on psychological interventions for heart health. “The human factors in all this just don’t get addressed as a standard of care.”

Q uackenbush, however, got lucky. Reeling from surgery and seeking community with others who’d been through similar experiences, she asked her cardiologist about support groups for heart patients. In 2007, she showed up at the office of cardiac psychologist Robert Allan, whose group she still attends to this day.

On a recent Tuesday evening, Quackenbush put her feet up in her living room and logged onto Zoom from her iPad for her biweekly cardiac support group with Allan. A few members are still there from 2007, while many others have come and gone. The goal has remained the same throughout: to support each other in recovery from heart disease.

Margery Quackenbush attends Dr. Allan's virtual support group. -- health coverage from STAT
Quackenbush attends cardiac psychologist Robert Allan’s virtual support group from her home. Olivia Falcigno for STAT

“Getting older is scary,” Quackenbush said of the group. “If something upsets you, you have a place you can go. You know that every other week, you are able to talk about whatever it is.”

The group offers support for healthy habits, too. Since her heart issues were first diagnosed, Quackenbush has embraced exercise, first participating in cardiac rehab, then going to a gym after the rehab center closed, then doing at-home workouts. Her current routine includes sitting down and standing up repeatedly, pelvic floor exercises, clamshells, and weight lifting. The group’s support has helped her reinforce her exercise regime and healthy cooking habits (she loves making salmon and chicken) and taught her to avoid extra stress on the heart by not eating large meals or having dinner too close to bedtime.

On this night, Quackenbush shares the impact that heated discussions about Israel and Palestine seem to be having on her physical and emotional health.

“In a [separate] discussion group I’m in, I noticed some chest pain when the group’s discussion veered toward the war in the Middle East,” Quackenbush, who lives with anxiety, shared with the group.

That was the cue for Allan to interject and ask how the news was impacting everyone. “Are you taking care of yourself while you monitor the Middle East?” he asked the group.

One member said he can’t bring himself to exercise these days. Another member said she hasn’t been getting much work done, but was OK with that considering the circumstances.

Allan aims to keep the tone of the group inclusive and encouraging even in the midst of deep discussions, posing open-ended questions and asking people to respond who haven’t had a chance to talk yet.

“I try to let the group do its own work. I sort of feel like an orchestra leader. You want to let the musicians play, you want to give them some direction,” Allan said.

For the next hour and a half, eight members shared other dispatches from their personal lives: falls, strokes, knee replacements, and even a looming cardiothoracic surgery. The group shared knowing nods and swapped experiences. One person with knee surgery on the horizon said they know they could get through it knowing another member had done it successfully in the past.

Allan has a long history in cardiac psychology. Every Tuesday and Thursday for three decades, Allan ran a psycho-educational group at Weill Cornell Medical Center’s cardiac care step-down unit for survivors of recent cardiovascular events. He worked with over 15,000 patients and family members until the Covid-19 pandemic shut the program down.

Also a member of the voluntary faculty at Weill Cornell College of Medicine, he ran pro-bono psychoeducational programs in stress and anger management at Weill Cornell’s cardiac rehabs in Manhattan, which closed in 2015, and in Queens, which closed during the pandemic. In addition to having a private practice, Allan also served as a guest instructor with the 92nd Street Y’s former cardiac rehab, where the group Quackenbush belongs to first began.

“I did this because of my own interest,” said Allan, who hasn’t had heart trouble himself. But he got into the field because he wanted to help people live differently than his father, who had his first heart attack at age 46, and whom he described as an “angry, primitive, Type A man.”

“I learned about the risk factors, and I started changing my lifestyle dramatically to avoid the same fate as my dad.”

Robert Allan, cardiac psychologist

“I learned about the risk factors, and I started changing my lifestyle dramatically to avoid the same fate as my dad,” Allan said. Then, through therapy, support groups, and psychoeducational programming, he started to teach other people to protect their hearts and minds too.

Earlier in his career, Allan came across cardiologists Meyer Friedman and Ray Rosenman’s seminal 1959 study linking type A behavior — characterized by anger and joyless striving — with an increased risk of heart attacks in men.

In the 1980s, public health specialists found type A personalities actually survived their heart attacks “better” than those with type B, results that stirred controversy in the field. Over the last 40 years, the landscape shifted from emphasizing the health risks of type A personalities to looking at the impact of other psychosocial factors — such as anxiety, depression, stress, and loneliness — on the heart. This growing body of research led Allan to discover the power of psychosocial support groups.

Support groups, Allan said, “help motivate people to change … They support healthy living through communication and validation.” When one group member says they went to the gym three times in the last week, the rest will cheer them on; if a member confesses to one too many bacon cheeseburgers, the others will groan and suggest healthier alternatives.

Psychologist Robert Allan runs a biweekly cardiac support group out of his home. -- health coverage from STAT
Psychologist Robert Allan runs a biweekly cardiac support group out of his home. Olivia Falcigno for STAT

Research suggests that psychosocial factors play a role in both developing and coping with heart disease.

Depression is both a risk factor for developing cardiac disease and a risk factor after heart surgery. Worsening depression puts people at even greater risk of recurrence of heart disease, with a landmark 1993 study finding that depression can impact cardiac mortality. Research from 2017 also found depression to be a predictor of death in the first decade following a heart disease diagnosis.

Meanwhile, according to a 2022 statement from the American Heart Association, social isolation and loneliness are associated with a 30% percent increase in heart attack and stroke. Stress, too, is a concern: In a 2021 study of over 900 patients, researchers found the presence of mental stress-induced blood flow reduction, compared with no mental stress-induced reduction in blood flow, is significantly associated with an increased risk of cardiovascular death or nonfatal heart attacks.

And in a 2016 analysis of 46 studies spanning more than 2 million participants, researchers found anxiety was linked with higher risk of heart disease, stroke, and cardiovascular mortality.

“If you’re depressed, if you’re anxious, if you’re isolated, if you’re angry, you can work on those behavior patterns.”

Robert Allan, cardiac psychologist

But depression, anxiety, loneliness, and stress are not inevitable. “If you’re depressed, if you’re anxious, if you’re isolated, if you’re angry, you can work on those behavior patterns,” said Allan, who emphasizes the power of groups to reduce isolation.

In November of 2023, the American Heart Association hosted a symposium that included findings from two preliminary studies — one on how depression may accelerate cardiovascular risk factors, and one on the link between cumulative stress and plaque build-up in arteries. Cardiologist Glenn Levine emphasized in a statement the importance of screening patients for depression and anxiety: “These are things we want to aggressively refer people to mental health professionals.”

While the data on psychological risk factors for heart disease is strong, more research on what psychological interventions work in terms of health outcomes and impact on behavioral changes in the long term is needed.

That said, a meta-analysis of 14 randomized controlled trials published in 2023 found cognitive behavioral therapy, delivered individually or within a group, effectively reduced depression in patients with heart disease. And a 2017 review of 35 randomized controlled trials with a total of 10,703 participants with coronary heart disease found that people who received psychological treatment had a reduced rate of death from cardiac events, and their symptoms of depression, anxiety, and stress were alleviated. However, the review did not find evidence that psychological interventions impacted all-cause mortality.

“I’ve been struck by how, despite these positive results, how little has really found its way into the routine care of cardiac patients,” said James Blumenthal, professor in psychiatry and behavioral sciences at Duke University, speaking of his and others’ research on the profound relationship between the mind and heart.

Research by Blumenthal and his team has found that cardiac rehab programs enhanced by group stress management training resulted in lower stress and greater improvements in medical outcomes compared to standard cardiac rehab, which generally includes exercise programs and lifestyle education.

“For whatever reason, there’s been a general lack of acceptance when people say, ‘Oh, yeah, we think it’s important,’ but it has never actually made its way into the care of patients with heart disease,” Blumenthal said.

Blumenthal developed behavioral interventions delivered in group settings as an approach to psychologically-informed cardiac rehab, working with Duke’s preventive cardiology program in the 1980s on the cardiac rehab team conducting stress management groups and providing stress management via federally funded research program in the 1990s.

“Because the intervention was not covered by insurance — and was offered to patients at no cost — it was never incorporated into the routine care of patients,” Blumenthal explained via email. Duke’s cardiac rehab still evaluates patients for psychosocial risk factors for heart disease and employs a health psychologist, though it hasn’t offered formal stress management training and groups in over a decade.

The field of cardiology has often neglected mental health because it tends to place more emphasis on drugs and surgery, experts told STAT. Another issue is that cardiac rehab programs are not a moneymaker for hospitals, since program costs can exceed revenue as hospitals push for more streamlined at-home rehab delivery. Even for hospitals that do offer cardiac rehab, it’s unclear what percentage of the 1,337 cardiac rehab programs registered through American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) offer psychological support.

“There are pockets of successful integration of psychology and cardiology, and then there are places that are deserts,” said Sears. “Until we give everyone equal access and have equal buy-in from cardiology, it’ll be hard for us to see the full success of that type of integration. Instead, we see it center by center instead of state by state.”

Sears’ Cardiac Psychology Lab is part of East Carolina University’s Clinical Health Psychology program, one of seven graduate schools focused on the psychology of medicine. There, he trains cardiologists on building resilience and reducing burnout in their work, and shares a clinic and cardiac rehab with cardiologists at East Carolina Heart Institute.

“The needs of the patient are more than just what a physician and the nurse can deliver.”

Matthew Burg, clinical psychologist and professional of cardiovascular medicine

“We need a whole new approach to cardiovascular care. And we need the funding initiatives to develop and test those new models of care,” said Matthew Burg, clinical psychologist and professional of cardiovascular medicine at Yale School of Medicine.

Burg is a founding member of the Society of Behavioral Medicine’s Cardiovascular Disease Special Interest Group, where there are over 300 psychologists and cardiologists interested in advancing what they refer to as the field of cardiovascular behavioral medicine.

One big obstacle to greater psychological support for cardiac patients is training: Cardiologists often haven’t been trained to work in a team context with psychologists, and vice versa. That’s why psychologists such as Burg and Sears teach courses for future cardiologists and encourage psychologists to seek more training in cardiology.

“It’s not just about, we need integrated cardiovascular care so that we start to address mental health issues. It’s that we need integrated cardiovascular care, because the needs of the patient are more than just what a physician and the nurse can deliver,” said Burg.

Margery Quackenbush performs cardiac health exercises on her living room floor. -- health coverage from STAT
Quackenbush performs cardiac health exercises daily in her Upper East Side apartment. Olivia Falcigno for STAT

Some progress is underway. Last November, over 100 heart patients showed up to a conference room where the launch of a new cardiac support group at Brigham and Women’s Hospital in Boston, Massachusetts, was hosted by physician assistants Tiffany Andrade and Lauren Rousseau. Brigham and Women also recently launched a department of cardiovascular psychiatry, led by psychiatrist Margo Funk, that offers mental health resources to patients.

Sears was a featured speaker for the Brigham and Women support group launch and delivered a talk called “How to Make a Cardiac Comeback,” complete with a theme song: “Comeback Story” by Kings of Leon. His lively talk included references to Mick Jagger’s transaortic valve replacement and Christian Ericksen, the Denmark soccer star who had a defibrillator implanted after collapsing from cardiac arrest at a Euro 2020 soccer match. He showed photos of what he calls “cardiac swag” — people with tattoos of defibrillators and T-shirts with inspirational slogans like “I Survived Open Heart Surgery. What’s Your Superpower?”

Sears, who compared his style to that of a sergeant and oscillates between offering inspiration and reassurance, tries to impart his audience with motivation for resuming activity after a cardiac event.

“Cardiac arrest is a significant medical trauma,” said Sears. The goal of his work, he added, is “to transform the most threatening, scariest day of their life into something that empowers you to be stronger.”

“A core element about heart disease is that it leads people to believe that they can disengage as a self-protective response.”

Sam Sears, professor of health psychology

Sears’ cardiac rehab has been in practice for 16 years. At East Carolina, patients undergo six to 10 sessions of cognitive behavioral therapy, including discussions around how to manage the experience of shock from defibrillator implants while reducing symptoms of PTSD and building “active problem-oriented coping skills” shown to increase quality of life, such as making time for family, setting health goals, and engaging in safe exercise.

“A core element, psychologically and physically, about heart disease is that it leads people to believe that they can disengage as a self-protective response,” Sears said. “And the opposite is true. The more engaging they are about the disease, the more engaging they are about what’s going on in their life to be more deliberate in their behaviors and their emotions, the more likely they are to find peace and quality of life on the other side.”

Learning to be deliberate about, and engaged with, her emotions and health has been a major force for change for Quackenbush. Last year, her heart started to beat faster than normal and she was diagnosed with a condition called atrial flutter. Her doctor told her it wasn’t life-threatening.

“Well, when it’s your life, it’s different,” Quackenbush said of the experience when it came up in a recent support group conversation.

A grandmother of two, Quackenbush leads a robust social life, filled with lunches with girlfriends and dating. Every night, she exchanges a photo of her dinner with one of the men she dates. But her cardiac group remains a cornerstone — she even attended a support group on vacation on her iPhone, declining a dinner invitation to do so.

Reflecting on her recovery from heart disease, Quackenbush said, “What would I tell myself when I was in my late 60s? You’re going to survive. You have the support group.”

This story is the latest in a series on the U.S. mental health system, supported by a grant from the NIHCM Foundation. Our financial supporters are not involved in any decisions about our journalism.


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