ICD and new cardiac populations:

psychological issues

Bob Lewin

CARE AND EDUCATION RESEARCH GROUP

 Psychological issues
Psychopathology
8-17% acute episodes of anxiety, treatable with medication, or cognitive
therapy - should have service available
↑ anxiety and depression 30-40%
Clinically important anxiety 13% depression 10%
Direct causal relationship to number of shocks

  HRQOL
  same as other symptomatic cardiac groups e.g.. heart failure NYHA 1,2
worse in high shock population
major impact on activity levels, sexual activity

Relationship to implantation
HRQOL
neurological problems

Behaviour
avoidance of activity
sexual difficulties
Psychological issues - Psychopathology

Series of 35 implants followed over 5 years, florid episodes of

psychopathology in 17% all following shocks – all severe anxiety
focussed on fear of future shocks, depression in 3 and 2 had become
housebound. Bourke JP, Heart 1997
Anxiety and depression - in 30% after implantation with 63% still anxious or
depressed at 1 year . Hegel MT, Int J Psychiatry Med, 1997

Using Hospital Anxiety & Depression Scale 13% were above the cut-off for
treatment for anxiety and 10% for depression, 15% said they wanted ‘special
psychological support’. No sig. Difference compared to CAD group with no

In ICD patients depression of moderate severity was identified in 35% of

cases using the Beck depression inventory (BDI).

Heart. 2001 Apr;85(4):375-9. How different from pacemaker patients are recipients of implantable cardioverter-
defibrillators with respect to psychosocial adaptation, affective disorders, and quality of life? Duru F, No different from
pacemker patients
Effect on HRQOL

Conclusion Quality of life is better with ICD therapy than with amiodarone
therapy. The beneficial quality-of-life effects from an ICD are not evident in
patients who receive numerous shocks from their device. (Irvine J, Am Heart J
2002;144:282-9.)
relationship to implantation
neurological problems
Mean Hospital anxiety and depression (HAD) scores for anxiety and depression for 11
patients who completed the comprehensive cardiac rehabilitation programme and all the
exercise tests. Error bars = SD.

67% were cases at baseline, 42% at the end of the programme and 25% at 12 weeks

A Fitchet, Heart,
 decreasing frequency of
angina, higher
ischaemic threshold
“Angina
doesn’t do
development of
any lasting
collateral blood harm”
supply to
ischaemic area

Keep active - repeated

ischaemic challenge

Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462

 angina at lower level of
activity

“angina is a
mini heart
deconditioning attack”
less efficient
use of oxygen in
myocardium

reduce activity to prevent angina

& further damage to heart

Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462

Guiding principle
Cardiac care should include attention to
• the patients’ understanding of their illness
• the patients’ own behaviour
• the coping measures they adopt
• their emotional status
• the influence of family and friends
• the social setting
Because these are determinants of treatment
success, treatment costs, disability and further
ill health.
Cardiac Misconceptions
Heart has been worn out by ‘stress’, ‘worry’ or
‘overwork’

There is a dead part in my heart that could burst if

it were put under too much pressure

Once you’ve had one heart attack you’ll have more

and one will get you, there’s not much you can do

Rest restores the heart

effect - reconditioning, feeling of loss of control,

anxiety, depression
How could beliefs lead to weaker relationships
between impairment and disability?
increasing frequency
of angina at lower
level of activity “angina is a
deconditioning
(correlation between mini heart
ischaemia and attack”
less efficient use blockage increasingly
of oxygen in weakened)
myocardium

reduce activity to prevent angina

& further damage to heart

Lewin, B. 1997, Journal of Psychosomatic Research

43:453-462
How do beliefs lead to weaker relationships
between impairment and disability?

“Angina
decreasing frequency of doesn’t do
angina (correlation any lasting
between ischaemia and harm”
development of blockage increasingly
collateral blood weakened)
supply to
ischaemic area

repeated ischaemic challenge

Lewin, B. 1997, Journal of Psychosomatic Research

43:453-462
Angina Management Programme: 1st trial

Crossover - waiting list to treatment - 82 patients

Main findings at 1 year after treatment;

30% no angina
70% reduction in episodes of angina
57% improvement in exercise duration
72% reduction in self reported disability (SIP)
50% of patients taken off CABG list

no patient looking for further treatment,

at 5 years all but 2 still alive, only 4 been back to
cardiology.

Lewin, B. 1995, British Journal of Cardiology, 2,

219-26
Angina Management Programme: 2nd trial
Episodes of Anxiety Depression Disability Treadmill
Angina (HAD) (HAD) (SIP) workload
(METS)
4
2 *
0
-2
-4 * †
-6
-8
*
-10
†
-12
-14
Control Exercise AMP

6 months post treatment (* = p<0.01, †= p<0.001)

Disability in Angina
570 new angina patients.
Multiple regression to predict outcome at 6 months
101 cardiological variables and a personality questionnaire
Best model had one significant factor hypochondriasis
In the next 200 patients the model predicted by name
61% of patients with satisfactory angina relief
85% of patients failing to get sufficient relief from medical
treatment
Williams, R. 1986, Psychosomatic Medicine, 48, 200-210

Angina Misconception Scale

angina is a kind of mini heart attack that damages your heart
angina is cured by rest
Furze G, Journal of Health Psychology 2001; 6:501-510
Taking the HM further
update treatment – improved understanding of
self-management and cognitive-behavioural
methods
more inclusive - needs to incorporate CABG and
PTCA rehab
make training cheaper and more accessible,
possibly distance learning
make it a complete package - including
assessment and audit tools
build in the ‘triage model’ and primary care
handover into the process
exploit IT better – use tailoring for more
‘individualised’ programme based on assessed
The Angina Plan
70 page manual, relaxation tape, trained facilitator

angina misconceptions - complete questionnaire and discuss

relaxation and breathing techniques - on audio tape
controlling acute angina attacks - thought insertion, distraction
over activity rest cycle - explanation & how to avoid
goal setting and pacing - at initial session then by phone
exercise - daily walking goal, self paced increase
secondary prevention - diet, exercise,

Method
30 minutes introduction session, with partner present if possible
followed by 4, 10-15 minute phone calls, weeks 1,4,8,12 to set
further goals, praise progress, encourage adherence
I
M
P The relationship of impairment and
A
I disability
R
M
E Impairment
N
T causes disability
DISABILITY
recruitment & randomisation Angina Plan
RCT
398 identified and written to by GP
96 no reply, 52 had angina > 12 months, 33 no angina, 1 died, 4
terminal illness, 7 mental confusion, 18 refused to take part

187 present at assessment clinic

Excluded from study - 25 angina > 12 months, 8 no angina, 2 atypical
presentation, 4 urgent referral for treatment, 1 terminal illness, 4
withdrew, 1 underwent CABG
142 randomised to treatment

68 to Angina Plan 74 to education

4 Dropped out, 1 no 6mth 5 Dropped out, 2 Died
questionnaires
130 (90%) at 6 month
Angina Plan 63 educational session 67
a psycho-biological understanding of illness

physiological differences alone cannot explain

• disability (including anxiety and depression)
• the extent of the symptoms reported
• the success or failure of medical treatment or
surgery
• the number of acute medical events and
readmissions
to predict all ofcosts
• medical these you also need to measure
• anxiety & depression
• health beliefs
• personality
• patients’ own attempts to cope
• social support & social class

Lewin, B. 1997, Journal of Psychosomatic Research

43:453-462
A biopsychosocial understanding of disability

physiological differences alone cannot explain

• disability (including anxiety and depression)
• the extent of the symptoms reported
• the success or failure of medical treatments or
surgery
• the number of acute medical events and
readmissions
to predict all ofcosts
• medical these you also need to measure
• anxiety & depression
• health beliefs
• personality
• patients’ own attempts to cope
• social support & social class

Lewin, B. 1997, Journal of Psychosomatic Research 43:453-462

 Health beliefs - Cardiac misconceptions
if you’ve had a heart attack you are bound to die of heart
disease
any excitement or shock could cause another heart attack
sex is too exciting and especially dangerous
heart disease is caused by ‘stress’ ‘worry’ or ‘overwork’ (80%)
angina is a mini heart attack and damages the heart*
there is a dead part in my heart that could burst if put under too
much pressure*

*Maeland & Havik, Wynn, *Alan Goble, 1965

I
M
P The relationship of impairment and disability
A
I
R
M
E Impairment causes
N
T disability
DISABILITY
UK National Institute for Clinical Excellence
systematic review of the use of ICDs
recommended increased use
BUT
also found to be associated with - poor quality of
life, anxiety, depression, unnecessary avoidance,
poor return to work
Although the ICD relieves fear of dying
prematurely, in some patients it evokes a
number of device related fears so that the
overall effect on anxiety is neutral.
Recommended - psychologically oriented
rehabilitation
Our cognitive-behavioural rehab programme
works in MI, Angina, Syndrome X, CF
 improves anxiety & depression
 improves quality of life
 reduces disability, symptom report and increases
activity levels
 improves physical fitness
 leads to fewer hospital readmissions & clinic
attendances
Would it work, suitably modified, in ICD patients?
 Randomised trial with ICD patients
mised controlled trial. Crossover - waiting treatment to treat
Anxiety post treatment 2 and at 4 months 4
6
wait
5
22 treatment
HAD Anxiety

3 follow-up
treatment
treatment
2

1
treatment follow-up
0
1 2 3 4

treatment control
Anxiety & depression Before
4 months after
HAD anxiety 4.32 3.09*
HAD depression 3.05 1.73 (50%
reduction)

Specific ‘concerns’ about the ICD

Concerns - number 11.61 8.59
Concerns - severity 19.00 11.09 (50%
reduction)

*2 outliers - 1 had psychotic episode, I had acute MI

Quality of Life * Before 4
months after
QLMI - emotional 5.60 5.96
QLMI - physical 5.22 5.86

QLMI - social 5.36 6.12

QLMI - global 5.39 5.98

QLMI - sex 3.20 3.86

Quality of life
EuroQual* (quality adjusted life years) 72.18
84.95

improvements significant beyond

Physical fitness Before
4 months after

Shuttle test* - heart rate change 16.22

23.59 Ns
Shuttle test* - perceived exertion 5.64 5.65
Ns
Shuttle test* - no. stages completed 7.03
8.45 P< 0.00
Shuttle test* - distance walked (yards) 354
463 P< 0.00
Main conclusions
• 25% of patients with ICDs were clinically anxious,
17% depressed (n=99, all surviving patients). No
evidence of spontaneous remission over time,
‘ICD concerns’ predicts anxiety as does age and
number of firings.

• Rehab programme worked well, no drop outs (50%

drop ins!)

• ICD Concerns questionnaire worked well - related

to quality of life and psychological variables and
changed after treatment
 Problems
costs money!
w numbers at any one time in any one centre

raphically dispersed patients - problem getting to rehab cent

partners - an essential element in the solution -

unable to take time off work to take part

few staff trained in CBT

nical psychologists almost totally unavailable

 A potential solution
self help, home-based ICD rehab program for
patient and partner
Previous experience
cottish Office - MI patients - The heart Manual
er - newly diagnosed stable angina - the Angina Plan

The Heart Manual

50% of post-MI rehab in Scotland, 20% in UK &

catching up fast
on trial Italy and Holland by national heart
associations
than 2000 nurses in UK trained to use it, prize winning sche
Home based cognitive-behavioural programme

Phase 1. Development of the programme 12

months
Phase 2. The evaluation of the programme in a
randomised trial
10 centres randomised to control or intervention
controlled with written materials and phone calls
60-100 patients in each arm
 Benefits

From our pilot study with ICD patients

 reduced anxiety and depression
 improved quality of life
 improved physical fitness and activity levels
 fewer events ??
The Angina Plan

142 randomised to self-help manual, relaxation tape, trained facilitator

treatment
Angina education 30-60 minutes introduction session, with partner
Plan session 74 present if possible
68 followed by 4, 10-15 minute phone calls / home
90% at 6 month follow-up
/clinic visits, weeks 1,4,8,12 to set further goals,
praise progress, encourage adherence
63 67

anxiety & depression physical activity: SAQ angina and use of GTN
40% reduction
0.6
9
8 1.0
0.4
7 0.5
0.0
0.2 6
-0.5
0 5 -1.0
-0.2
4 -1.5
3 -2.0
-0.4
2 -2.5
-0.6 1 -3.0
-0.8 0 -3.5
-1 -4.0
-1 -4.5
-2
-1.2
Angina GTN
Anxiety Depression

Lewin RJP, British Journal of General Practice, 2002, 52, 194-201