Psychology Better Living, Better Coping, Fewer Deaths

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Psychology Better Living, Better Coping, Fewer
Deaths
25th April 2007

• Jim McManus, CPsychol, MFPH
• Public Health Lead
• Chartered Psychologist

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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?

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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
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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
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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

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The Biopsychosocial Pathway
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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
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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.

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Psychological illness post MI (Letwin)
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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

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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).

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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

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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

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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.

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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)

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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?

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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?
  

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Map of Interventions
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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
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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

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Cost Benefit
High Benefit
SkillingClinicians if really implemented
Psychology Services
Skilling Patients
High Cost
Low cost
Status Quo
Low Benefit
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Network Projects

• Designing volunteer based interventions
• Designing psychological interventions
• National Expert Seminar
• Psychology and HF Review Project this is the
  first report

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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