Psychology – Better Living, Better Coping, Fewer Deaths

1. 25th April 2007 Psychology – Better Living, Better Coping, Fewer Deaths 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. 1999;99:2192-2217. 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; 44:519-527. Dracup, Walden, Stevenson, & Brecht. J Heart Lung Transplant 1992,11:273-9. Freeland, Carney & Rich. J Griatr Psych 1991;24 (1): 59-71. McDermott, Schmidt & Wallner. Arch Intern Med 1997;157:1921-1929.

10. 90% 60% depression 40% ANXIETY LEAVE HOSPITAL RETURN WORK ACUTE EVENT IN HOSPITAL AT HOME 30% 35% 15% 1 MONTH 3 MONTHS AFTER DISCHARGE 5 YEARS AFTER MI TIME 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 1993;4:285-94 Barefoot et al. Circulation 1996;93:1976-80 Ford et al. Arch Intern Med. 1998;158:1442-1426 Pratt et al Circulation. 1996;94:3123-3129 • 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 1995;91:999-105 Ladwig et al. Eur Heart J 1991;12:959-64

12. US-NHSANES1 • National Health and Nutrition Examination Survey. Followed 5007 women and 2886 men prospectively. Ferketich et al. Arch Intern Med. 2000; 160:1261-1268 • 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. 1994:89;1992-1997 Kawachi et al. Circulation. 1994:90;2225-2229. 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 67:393-397(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 • Don’t just “Buy a psychologist” • Commission for the whole system • It’s more cost-effective • A tiered typology (1,2,3) makes it everybody’s role • It will provide more choice • It will be more mainstream