The higher prevalence of depression and anxiety in post-myocardial infarction populations, in comparison with the general population, is well documented.1 Research indicates that individuals and their networks report different effects of, and ways of adjusting to a myocardial infarction—while some adjust well, others experience a sense of shock and ongoing uncertainty regarding their treatment and future health.4,5 Some patients can also have an altered sense of self and experience loss due to a change in their health.6 This commentary reviews the benefits of providing psychological support for patients who experience emotional distress after having a myocardial infarction.
It is important to identify when a patient is experiencing negative thoughts after having a myocardial infarction because such thoughts are associated with an increased risk of anxiety and/or depression.3 Furthermore, identifying and treating depressive symptomatology, in particular, is vital because depression is an independent risk factor for a second myocardial infarction. This increased risk relates to a variety of biological, behavioural and psychological factors, including high platelet activity, reduced adherence to cardio-protective medications and social isolation.7 Anxiety and depression symptoms are associated with poorer self-management and health outcomes, and greater health service use.8
Both anecdotal and published evidence8 indicate that, after a myocardial infarction, patients commonly present with symptoms of cardiac-related anxiety. For example, they may experience frequent and extreme fear that they will have another heart attack or may take excessive steps to avoid what they believe are “potential triggers” of a heart attack (such as “stressful situations”). Patients may also feel that they are a “burden” to their families because they “cannot do what they used to do” or struggle to adjust to how the myocardial infarction has affected their daily functioning—ie. feeling that they are not able to be the parent that they were because they are not able to be as active etc.
Psychological therapy has been shown to improve long-term physical and mental health outcomes and to decrease mortality rates—particularly for men and those starting psychological therapy two months or more after a myocardial infarction.9–11 Cognitive behavioural therapy (CBT), for instance, targets problematic beliefs and behaviour that are maintaining psychological symptoms, using W Cognitive restructuring to help patients to develop more balanced perspectives and behavioural exercises to reduce unhelpful patterns of avoidance. For example psychologists can encourage patients to question their beliefs by asking them to examine if their belief is true for all situations or to review what they would say to a friend or relative who had the same thought. Patients are also asked to consider the effects of adhering to certain “rules for living”—ie. “preventing” negative consequences by living by “just in case” rules, such as not doing strenuous exercise so as “avoid” having another heart attack. Behavioural exercises involve asking patients to test out their negative predictions, using graded hierarchies (eg. gradually increasing physical activity, consistent with cardiac team recommendations, to test their belief that they will have another heart attack if they exercise). Relaxation exercises are also used to reduce the physical symptoms of anxiety.
There is also a growing evidence base for the use of “third-wave” CBT techniques: mindfulness based therapy and acceptance and commitment therapy for people with long-term physical health conditions, including coronary artery disease.12 Third-wave techniques encourage the development of value-based goals; for instance, promoting self-care or focusing on alternative ways of being a supportive parent (if they are distressed that they cannot provide the same level of active parenting they did before the heart attack). These goals may change over time (eg. exercise goals increasing in frequency and intensity over time), but are based on the same underlying value—ie. promoting self-care. Third-wave therapies also use mindfulness meditation, to encourage a non-judgmental awareness of the present moment and greater acceptance of physical changes and/or diagnoses.
Patients in our clinical practice report that seeing, as part of the overall cardiology service, a psychologist who has an understanding of common cardiac-related concerns is useful. This is also supported by the evidence base.10,11 The presence of a psychologist embedded within the team allows patients to access appropriate psychological support promptly and helps to normalise seeking psychological support relating to cardiac concerns. We therefore encourage the discussion of common cardiac concerns and associated psychological difficulties within cardiology clinics to help identify patients with such concerns and, if and when they arise, refer patients for psychological support (with the patients’ consent).
- Lane et al. British Journal of Health Psychology 2002; 7: 11–21.
- Stafford et al. Journal of Psychosomatic Research 2009; 66: 211–20.
- Foxwell et al. Journal of Psychosomatic Research 2013; 75: 211–22.
- Jensen et al. Patient Education and Counseling 2003; 51(2): 123–31.
- Hutton et al. Psychology, Health & Medicine 2008: 13: 87–97.
- Astin et al. BMC Cardiovascular Disorders 2014: 14: 96.
- Wuslin (2007). Treating the aching heart: A guide to depression, stress and heart disease. Vanderbilt University Press. In: Dornelas, E. A. (2012). Stress Proof the Heart: Behavioural interventions for cardiac patients. Springer.
- Child et al. The British Journal of Cardiology 2010: 17: 175–79.
- Linden et al. European Heart Journal 2007; 28: 2972–84.
- National Institute for Health and Clinical Excellence (2007). MI secondary prevention. Secondary prevention in primary and secondary care for patients following a myocardial infarction. London
- Department of Health (2001). National service framework for coronary heart disease.
- Prevedini et al. Italian Journal of Occupational Medicine and Ergonomics 2011; 33: 53.
Elizabeth Banwell and Katie Murray, clinical psychologists, Cardiac Rehabilitation, Charing Cross and St Mary’s Hospitals, London, UK