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Psychology Better Living, Better Coping, Fewer Deaths

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Psychosomatic Medicine, 1982; 44:519-527. Dracup, Walden, Stevenson, & Brecht. ... Psychosomatic Medicine 67:393-397(2005) Recent HF Studies ... – PowerPoint PPT presentation

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Title: Psychology Better Living, Better Coping, Fewer Deaths


1
Psychology Better Living, Better Coping, Fewer
Deaths
25th April 2007
  • Jim McManus, CPsychol, MFPH
  • Public Health Lead
  • Chartered Psychologist

2
Key Points
  • Not just about Palliative care Living with HF
  • About stopping us from getting there for as long
    as possible
  • Costs to the NHS of HF in 2000 were 1 million bed
    days
  • Straw Poll - How many deaths from HF are
    avoidable with a proper model of care?

3
Old Concept
death
Treatment
Aggressive Care
Palliative Care
Time
4
Better Concept and a clearer role for psychology
death
Disease-modifying curative
Treatment
Symptom management palliative
Time
Bereavement
5
Identity, security and ontological challenge
  • Letwin List
  • Frightening, life threatening event (MI, major
    surgery)
  • A chronic illness, reduced life expectancy,
    symptoms
  • Altered identity an invalid, walking time
    bomb
  • Fears for family and partner being left alone
  • Threat to employment and financial status
  • Medication side effects (lethargy, impotence)
  • Being treated differently by other people
  • Neurological impairement (esp. cardiac arrest
    pats.)
  • Making lifestyle changes, smoking, diet, activity

Self Efficacy, Social Support, Resilience
6
Misconceptions
  • Letwin et al
  • Misconceptions strongly predictive of outcomes in
    some conditions
  • Misconceptions related to onset of bad spells
    and hospitalisation
  • Patient self-efficacy, not just patient education

7
The Biopsychosocial Pathway
8
Psychosocial risk factors for distress in cardiac
patients (Young et al)
  • Depression (strong support)
  • Anxiety (strong support)
  • Stress (strong support)
  • Poor social support (strong support)
  • Anger / hostility (inconsistent)
  • Life stress (inconsistent)
  • Job strain (inconsistent)

Rozanski et al. Circulation. 1999992192-2217.
Rozanski et al. J. of American College of
Cardiology. 2005
9
Epidemiological Estimates
  • In general CAD/CHD population 20-50
  • In heart failure, as many as 58 72 patients
    have been found to be depressed at clinical
    levels (Beck, SF-36,DSMIV)
  • Blumenthal, Williams, Wallace, Williams,
    Needles. Psychosomatic Medicine, 1982
    44519-527.
  • Dracup, Walden, Stevenson, Brecht. J Heart
    Lung Transplant 1992,11273-9.
  • Freeland, Carney Rich. J Griatr Psych 199124
    (1) 59-71.
  • McDermott, Schmidt Wallner. Arch Intern Med
    19971571921-1929.

10
Psychological illness post MI (Letwin)
11
Can Depression Kill?
  • Contributes to development, progression,
    morbidity and mortality.
  • The risk is linear, with even sub-clinical levels
    of hopelessness imparting risk (RR btwn 1.5 and 2
    for fatal IHD or MI from 6-27 years)
  • Anda et al. Epidemiology 19934285-94
  • Barefoot et al. Circulation 1996931976-80
  • Ford et al. Arch Intern Med. 19981581442-1426
  • Pratt et al Circulation. 1996943123-3129
  • The depression-related risk of cardiac mortality
    over 6-18 mos post-MI is higher, RR btwn 3-6
    (controlling for disease severity).
  • Frasure-Smith et al. Circulation 199591999-105
  • Ladwig et al. Eur Heart J 199112959-64

12
US-NHSANES1
  • National Health and Nutrition Examination Survey.
    Followed 5007 women and 2886 men prospectively.
    Ferketich et al. Arch Intern Med. 2000
    1601261-1268
  • Found that depression at time 1 predicted the
    development of CAD at time 2
  • WOMEN RR of CHD incidence in dep was 1.73. No
    effect on CHD mortality.
  • MEN RR of CHD in dep was 1.71. Depressed men
    had an increased risk of CHD mortality (RR
    2.34).

13
Post MI Outcomes
  • More consistent than traditional measures of
    disease severity (prior MI, ST-elevation MI, and
    LVEF).
  • True for transient, new or persistent symptoms
  • Parashar et al Arch Int Med 2006

14
Does Anxiety Kill?
  • Dose-dependent relationship between anxiety and
    cardiac death.
  • Kawachi et al. Circulation. 1994891992-1997
  • Kawachi et al. Circulation. 1994902225-2229.
  • These studies did not include women, anxiety is
    actually more common in women according to
    epidemiological studies
  • In healthy population
  • RR of MI btwn 1- 4.5
  • RR of CD btwn 2 3.8
  • In CAD pop RR MI or CD 2.5 4.9

15
Social Isolation
  • Small social network 2-3x increase in CAD over
    time.
  • Low social support RR of CD 1.5 6.5
  • Again, there appears to be a dose-response
    relationship.

16
Cardiac Clinicians
  • Ziegelstein et al (2005) Evaluated the ability of
    cardiovascular healthcare workers to assess
    presence/absence of symptoms of depression.
  • Cardiovascular nurses, med residents, or
    attending cardiologists
  • Compared their assessments with the BDI
  • Found no sig correlation between BDI scores and
    provider assessments (nor sig differences between
    providers, or gender of providers)
  • False positives 30 and false negatives 75.
  • Psychosomatic Medicine 67393-397(2005)

17
Recent HF Studies
  • Miller et al (2006) Depression linked to
    inflammation and artherosclerosis. Physical and
    psychological sequelae of depression
  • Joekes et al (2007) Self Efficacy and Cardiac
    Patients important in rehab. Mainstream
    interventions for self-efficacy
  • Worcester et al (2007) Early post event
    intervention especially in women?

18
Psychological Contributions thus far
  • Screening and Assessment Tools
  • Studies of relationship between variables and
    outcomes
  • Interventions
  • Patient psychologist (where funded)
  • Clinician-Psychologist (skilling up, where
    funded)
  • Psychologist Expert Patient-Patient (where
    funded)
  • Psychologist Self management champions (almost
    non existent)
  • Angina and Rehab Intervention focusing on
    misconceptions
  • Patchy implementation and uptake.
  • Are we failing to prevent avoidable deaths?

19
Map of Interventions
20
Cost-Spread we need wide coverage given
prevalence
Increasing Spread
SkillingClinicians
Skilling Patients
Cost, Need, coverage And patient safety all Need
to be balanced Not a do one thing Strategy
but a do Several things
Patient Tier 2
Psych 3
Increasing Cost
21
Rough Idea of Costs very preliminary economic
appraisal
  • BED DAYS are the crucial issue here
  • Avoiding one depression related death
  • Low Band 489 psychol plus befr plus drugs plus
    rehab
  • High Band 876 psychol intensive plus befr plus
    hosp stay plus rehab
  • Avoiding one case of depression
  • Low band 58.60 eg using assessment plus brief
    advice lasting 30 mins in total with refer to
    support grp
  • High band 396.37 assess and patient befriender
    plus rehab
  • Costs of depressed patient to services
  • Low Band 3687 3 short spells in hospital
  • High Band 12454 multiple spells in hospital

22
Cost Benefit
High Benefit
SkillingClinicians if really implemented
Psychology Services
Skilling Patients
High Cost
Low cost
Status Quo
Low Benefit
23
Network Projects
  • Designing volunteer based interventions
  • Designing psychological interventions
  • National Expert Seminar
  • Psychology and HF Review Project this is the
    first report

24
Recommendations
  • Dont just Buy a psychologist
  • Commission for the whole system
  • Its more cost-effective
  • A tiered typology (1,2,3) makes it everybodys
    role
  • It will provide more choice
  • It will be more mainstream
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